2027 QPP Proposed Rule: What’s Changing and Why It Matters

CMS released the 2027 Medicare Physician Fee Schedule (PFS) proposed rule on July 14, 2026. The rule proposes to sunset traditional MIPS after the 2028 performance period, giving clinicians a firm timeline for the long-anticipated transition to MIPS Value Pathways (MVPs). It also includes changes to quality reporting, the Promoting Interoperability performance category, and Advanced APM participation. The public comment period closes September 14, 2026, and CMS is expected to publish a final rule later this year. Understanding what’s being proposed and how it may affect future reporting requirements is critical, particularly as the program moves toward full MVP implementation.

We’ve already published a detailed breakdown of the proposed changes specific to Medicare Shared Savings Program (MSSP) ACOs. This post covers the broader MIPS and Quality Payment Program (QPP) provisions affecting clinicians, groups, and Advanced APM participants.

MIPS Value Pathways: The Future Arrives in 2029

Traditional MIPS Is Being Phased Out

CMS has signaled for several years that traditional MIPS reporting would eventually end. The 2027 proposed rule would establish a formal timeline for that transition. CMS is proposing to sunset traditional MIPS after the 2028 performance period. Starting with the 2029 performance period, MVPs would be the only MIPS reporting option for clinicians who do not participate in a MIPS Alternative Payment Model (APM). Clinicians in a MIPS APM would continue to have the option to report through the APM Performance Pathway (APP) or APP Plus, as applicable.

Why This Matters: The countdown is now real. Clinicians would have two performance years—2027 and 2028—to identify the MVP most relevant to their specialty, build workflows to collect the required data, and establish subgroup-level reporting processes, if needed. Practices that wait until 2029 to prepare may face significant operational and reporting challenges.

Three New MVPs Proposed for 2027

CMS is proposing to add three new MVPs to the inventory for the 2027 performance period, bringing the total to 30 MVPs:

• Diabetic Disease
• Hypertension
• Hospitalist

The Diabetic Disease and Hypertension MVPs reflect CMS’s stated focus on prevention and chronic disease management—conditions that, when managed proactively, can significantly reduce downstream costs and health care utilization for Medicare patients. The Hospitalist MVP addresses a specialty that plays a critical role in care coordination and the cost and quality of care delivered to hospitalized patients.

Why This Matters: Clinicians in primary care, internal medicine, and hospital medicine would have additional MVP options to evaluate. If your practice has been holding off because no MVP felt like a good fit, the new Diabetic Disease and Hypertension MVPs, in particular, are worth a close look.

Proposed Changes to All 27 Existing MVPs

CMS is also proposing to modify all 27 previously finalized MVPs. Proposed modifications include:

• Adding MIPS core measure selections to each MVP to support the proposed new reporting requirement
• Adding measures that expand clinical concepts or capture additional specialties applicable to a given MVP
• Removing measures and activities proposed for removal from their respective MIPS inventories or replacing them with more robust alternatives

CMS is also proposing to rename the Rehabilitative Support for Musculoskeletal Care MVP as the Rehabilitative Support MVP, better reflecting the broader scope of measures and activities it includes.

Virtual Groups Could Begin Reporting MVPs in 2029

Under current policy, virtual groups cannot report an MVP. CMS is proposing to change that beginning with the 2029 performance period, when virtual groups would be eligible to report an MVP for the first time. This aligns with the proposed full MVP implementation timeline.

Why This Matters: Virtual groups that currently report traditional MIPS should begin evaluating MVP options before 2029, since the proposed policy would make 2028 their final year of traditional MIPS reporting and allow them to report an MVP beginning in 2029.

Quality Performance Category: Significant Changes Ahead

A New MIPS Core Measure Requirement

One of the more substantive structural changes in this proposed rule is the introduction of a MIPS core measure designation. CMS is proposing to apply this designation to 78 measures in the MIPS quality measure inventory.

The core measure designation would replace the existing requirement that clinicians report at least one outcome measure—or a high-priority measure when an applicable outcome measure is unavailable. Instead:

• Traditional MIPS reporters would be required to report one MIPS core measure as one of their six required quality measures.
• MVP reporters would be required to report one MIPS core measure as one of their four required quality measures.
• Small practices would be exempt from this requirement.

Traditional MIPS reporters could select an applicable core measure from the broader MIPS quality measure inventory or an applicable specialty measure set. MVP reporters would select a core measure included in their chosen MVP.

If a clinician or reporting entity does not have an applicable MIPS core measure available to report, the clinician or entity would need to attest to that fact and report another measure in its place. Clinicians who fail to report a core measure and do not qualify for the small-practice exemption or complete the required attestation and replacement reporting would receive 0 out of 10 points for one of their required quality measures.

Why This Matters: Review your current measure set and the proposed core measure list. If none of your six reported measures carry the MIPS core measure designation—and you’re not a small practice—you’ll need to either add one or attest that no applicable core measure is available and report another measure in its place. Ignoring this requirement could result in a zero for one required quality measure.

CMS Proposes to Eliminate the High-Priority Measure Designation

To align with the shift to core measures, CMS is also proposing to remove the high-priority measure designation from the MIPS quality measure inventory entirely. The high-priority designation currently helps satisfy the reporting requirement when an applicable outcome measure is unavailable and is one factor CMS may consider when deciding whether to retain a measure. Under this proposal, both of those functions would be eliminated.

Proposed Quality Measure Inventory Changes

CMS is proposing a total of 180 quality measures for the  2027 performance period, down from 190 in 2026. These totals exclude QCDR measures, which CMS approves outside the rulemaking process. Key changes to the inventory include:

• Addition of 2 new quality measures focused on prevention and chronic disease management, one of which would be delayed until 2028
• Adoption of 4 current QCDR measures as MIPS CQMs
• Replacement of 7 existing functional improvement MIPS measures with 5 new functional outcome measures for orthopedic patients, which are currently QCDR measures proposed for adoption as MIPS CQMs
• Removal of 20 quality measures from the inventory
• Substantive changes to 43 existing quality measures

The tables below list the proposed new measures and the measures proposed for removal.

The five new functional outcome measures for orthopedic patients—neck, back, upper extremity, lower extremity, and knee—are based on the PROMIS® framework and are being proposed as MIPS CQMs to replace seven older FOTO-based functional status change measures being removed from the inventory.

Looking Ahead to 2028: CMS is proposing a one-year implementation delay for the new Rate of Timely Follow-up on Abnormal Screening Mammograms for Breast Cancer Detection eCQM. If finalized, the measure would become available beginning with the 2028 performance period.

Why This Matters: If any of your currently reported measures appear on the removal list, you’ll need to identify replacements if the proposal is finalized. Review the new measures closely—several specialties, including orthopedics, cardiology, nephrology, anesthesiology, and audiology, would gain new options that may be a better fit than what they report today.

Potential Scoring Relief for Topped-Out Core Measures

CMS is proposing to apply the previously defined topped-out measure benchmarks to 17 quality measures for the CY 2027 performance period. This includes two measures that do not currently receive these benchmarks.

CMS is also proposing that topped-out MIPS core measures subject to the 7-point scoring cap would no longer be capped at 7 points. Beginning with  2027, these measures would instead be scored according to the defined topped-out measure benchmark, with a maximum of 10 points.

Why This Matters: If you consistently perform at or near 100% on a topped-out measure that receives the MIPS core designation and is currently subject to the 7-point cap, you could see a meaningful increase in your quality score under this proposal. However, the number of points earned would still depend on your performance rate under the defined benchmark.

The MIPS Performance Threshold Remains at 75 Points

CMS previously finalized a 75-point MIPS performance threshold through the  2028 performance period. The proposed rule does not change that threshold for 2027.

Why This Matters: A final MIPS score of at least 75 points would continue to be required to avoid a negative payment adjustment. However, changes to quality measure selection and scoring could affect how clinicians reach that threshold.

Promoting Interoperability: Fewer Requirements and New Prior Authorization Measures

Proposed Changes to the Definition of CEHRT

CMS is proposing to update the definition of Certified Electronic Health Record Technology (CEHRT) to align with certification criteria proposed for removal under the HTI-5 proposed rule. The change is primarily technical and would not immediately alter clinicians’ reporting responsibilities.

CMS Proposes to Remove Two ONC Attestations

CMS is proposing to remove two ONC-related attestations from the Promoting Interoperability (PI) performance category:

• The ONC Direct Review attestation, which is currently required
• The ONC-Authorized Certification Body (ONC-ACB) Surveillance attestation, which is currently optional

Both would be removed beginning with the 2026 performance period. If finalized, clinicians reporting 2026 data during the 2027 submission period would not be required to complete these attestations.

Why This Matters: This would mean fewer PI requirements to complete during the next submission cycle. Wait for the final rule before removing the attestations from your reporting workflow.

Security Risk Analysis Measure Proposed for Removal in 2027

The Security Risk Analysis measure—long a required element of the PI category—is proposed for removal starting with the  2027 performance period.

Why This Matters: This would eliminate one required PI measure beginning with the 2027 performance period. Importantly, the proposal applies only to the MIPS PI measure. It would not eliminate separate security risk analysis obligations that may apply under HIPAA.

Electronic Prior Authorization: Optional in 2027, Required in 2028

The Electronic Prior Authorization measure has a more complex trajectory under this proposed rule. It had previously been finalized as a required PI measure starting with 2027. CMS is now proposing to:

• Make it an optional bonus measure for 2027 rather than a required measure
• Require it beginning in 2028
• Require clinicians who choose to report the measure in 2027 to use specified FHIR-enabled, ONC-certified health IT modules within CEHRT
• Beginning in 2028, require CEHRT to include health IT modules certified to all three ONC electronic prior authorization criteria

CMS is also proposing a new measure, Electronic Prior Authorization for Prescription Drugs, which would become required starting with the  2028 performance period. This measure would require the use of specified FHIR-enabled health IT modules within CEHRT to complete at least one prior authorization request for prescription drugs or medications.

Why This Matters: You would have one more year before electronic prior authorization becomes mandatory under PI. Use 2027 to confirm that your EHR supports the required FHIR-enabled modules for both medical services and, if finalized, prescription drugs. If you plan to report the optional medical-services measure for bonus credit in 2027, confirm that your technology meets the proposed 2027 requirements.

Improvement Activities: Six Additions and 11 Removals Proposed

CMS is proposing the following changes to the Improvement Activities inventory for the CY 2027 performance period:

• Addition of 6 new activities
• Modification of 5 existing activities
• Removal of 11 activities

New Improvement Activities Proposed for 2027

CMS is proposing to add the following six Improvement Activities:

• Use of Data to Improve Practice Workflows
• Understand and Improve Diagnostic Performance
• Systematic Screening and Intervention for Nutrition and Other Health-Impacting, Non-Clinical Issues
• Advance Care Planning Conversations to Support Patient Wellness and Care Preferences
• Clinician Use of Artificial Intelligence (AI) to Improve Patient Care
• Lifestyle Approaches to Diabetes Remediation

The proposed activities address care coordination, diagnostic safety, nutrition and other nonclinical needs, advance care planning, responsible use of artificial intelligence, and lifestyle-based diabetes management.

Improvement Activities Proposed for Removal in 2027

CMS is proposing to remove the following 11 Improvement Activities:

• IA_BE_15: Engagement of Patients, Family, and Caregivers in Developing a Plan of Care
• IA_BMH_5: MDD Prevention and Treatment Interventions
• IA_CC_10: Care Transition Documentation Practice Improvements
• IA_CC_11: Care Transition Standard Operational Improvements
• IA_CC_12: Care Coordination Agreements That Promote Improvements in Patient Tracking Across Settings
• IA_CC_16: Primary Care Physician and Behavioral Health Bilateral Electronic Exchange of Information for Shared Patients
• IA_EPA_4: Additional Improvements in Access as a Result of QIN/QIO Technical Assistance
• IA_PM_2: Anticoagulant Management Improvements
• IA_PM_19: Glycemic Screening Services
• IA_PM_20: Glycemic Referring Services
• IA_PSPA_2: Participation in MOC Part IV

Why This Matters: The proposed additions would give clinicians new options aligned with emerging priorities such as responsible AI use, diagnostic safety, nutrition, and chronic disease management. If you currently report one of the 11 activities proposed for removal, you’ll need to select an alternative for the 2027 performance period if the proposal is finalized.

Cost Performance Category: No Major Changes Proposed

The Cost category is largely unchanged in this proposed rule. CMS is proposing no new cost measures and no removals for the  2027 performance period. The only proposed update is a non-substantive maintenance revision to the operational list of care episode and patient condition groups and codes, which CMS is required to update annually under statute.

Why This Matters: No new cost measure preparation would be required for 2027 under the proposal. That said, cost continues to carry a 30% weight in MIPS scoring for traditional MIPS reporters, so performance on existing measures remains consequential.

Advanced APMs: QP Determinations Could Move to the TIN/NPI Level

A More Targeted Approach to QP Status

Under current policy, Qualifying APM Participant (QP) determinations are made at the NPI level—meaning that when a clinician achieves QP status, the financial incentives and MIPS exemption apply across every TIN under which the clinician bills, including practices that may not participate in an Advanced APM.

CMS is proposing to change this by applying QP and Partial QP determinations at the TIN/NPI level. If finalized, clinicians would only be exempt from MIPS at the specific TIN or TINs through which they achieved QP status.

Why This Matters: Clinicians who bill under multiple TINs—only some of which participate in an Advanced APM—should evaluate how this change could affect their MIPS obligations. QP status would no longer automatically extend to every TIN under which the clinician bills.

Proposed Changes to QP and Partial QP Thresholds

As a result of the Consolidated Appropriations Act, 2026, CMS is proposing to temporarily lower the thresholds used to determine QP and Partial QP status for the 2026 performance year:

• QP thresholds would decrease from 75% to 50% under the payment amount method and from 50% to 35% under the patient count method.
• Partial QP thresholds would decrease from 50% to 40% under the payment amount method and from 35% to 25% under the patient count method.

The higher thresholds would return beginning with the 2027 performance year.

Why This Matters: Clinicians who may not meet the higher thresholds in 2025 could have an easier path to QP or Partial QP status in 2026. However, organizations should prepare for the higher thresholds to return in 2027.

Additional MSSP ACO Quality Reporting Proposals

CMS has also included several quality reporting proposals specific to MSSP ACOs in this rule, including the continued availability of MIPS CQM reporting, an extension of the MIPS CQM reporting incentive, flat benchmarks for Medicare CQMs, a new Medicare eCQM collection type based on assigned beneficiaries, and revised CEHRT requirements.

For a full breakdown, see our companion post: 2027 Medicare Physician Fee Schedule Proposed Rule: Major Changes for MSSP ACOs.

Preparing for the Next Phase of MIPS

The 2027 proposed rule represents one of the most significant proposed changes to the MIPS program since its inception. For years, clinicians have known traditional MIPS would eventually end—now CMS has proposed a date. If finalized, the 2028 performance period would be the last year traditional MIPS is available, and practices that haven’t started evaluating MVPs need to start now.

Beyond the MVP transition, the shift to MIPS core measures, the phased rollout of electronic prior authorization requirements, and the simplification of the Promoting Interoperability category all point toward a program with more standardized reporting expectations and a greater emphasis on prevention, interoperability, and clinically meaningful measures.

Because these policies are not yet final, clinicians and organizations should use the proposed rule to begin planning while remaining prepared for changes in the final rule.

CMS is accepting public comments through September 14, 2026. The final rule is expected later this year. Clinicians, groups, and organizations should review these proposals carefully and consider submitting comments electronically through Regulations.gov before the comment period closes.