Most practice managers read the CY 2027 Physician Fee Schedule proposed rule for one number, the conversion factor, and closed the file. We understand. But the same document, released by CMS on July 14, 2026 and published in the Federal Register on July 16, carries the Quality Payment Program provisions for the 2027 performance year, and this year they are not routine. The MIPS 2027 proposed changes include a required core measure, three new MIPS Value Pathways, a formal plan to end traditional MIPS after the 2028 performance year, and a rewrite of parts of Promoting Interoperability.
Comments are due September 14, 2026, and the final rule usually arrives in early November. Nothing below is final. But practices that will report for 2027 need to know what is on the table now, because some of it changes which measures they should be collecting data on starting January 1, and because a practice that has been putting off the MVP question now has a date.
Here is our reading of the QPP section for an independent practice: what is proposed, who it affects, what changes in the workflow if it is finalized, and what to do before the comment period closes.
Key takeaways
- CMS proposes to sunset traditional MIPS after the CY 2028 performance period, making MVPs and the APM Performance Pathway the only options from 2029.
- Beginning with the 2027 performance year, clinicians would have to report an applicable MIPS core measure; small practices (15 or fewer clinicians) would be exempt.
- Three new MVPs are proposed for 2027: Diabetic Disease, Hypertension and Hospitalist, and all 27 existing MVPs would be revised to include core measures.
- Promoting Interoperability would drop the Security Risk Analysis measure and add an electronic prior authorization for prescription drugs measure, optional in 2027 and required in 2028.
- The performance threshold would stay where it is through the 2028 performance year, so the payment adjustment math does not change.
MIPS 2027 proposed changes in one table
| Area | Proposal for the 2027 performance year | Who feels it |
|---|---|---|
| Traditional MIPS | Sunset after CY 2028; MVPs become the primary pathway for non-APM clinicians from CY 2029 | Everyone still reporting traditional MIPS |
| Core measures | New core measure designation; clinicians must report an applicable core measure or receive zero achievement points for one measure; small practices exempt | Groups of 16 or more clinicians first |
| MVPs | Add Diabetic Disease, Hypertension and Hospitalist MVPs; modify all 27 existing MVPs to include core measures; virtual groups may report MVPs from CY 2029 | Primary care, endocrinology, cardiology, hospital medicine |
| Quality measure inventory | 180 measures after 20 removals, 10 additions and 43 substantive changes | Anyone whose current measures are on the removal list |
| Improvement Activities | Add 6, modify 5, remove 11 | Practices that reuse the same activities each year |
| Cost | No new measures, removals or substantive changes | No change |
| Promoting Interoperability | Remove the Security Risk Analysis measure from CY 2027; add an Electronic Prior Authorization for Prescription Drugs measure; make the existing electronic prior authorization measure optional in 2027 and required in 2028; 10 optional bonus points for electronic prior authorization use in 2027 | Every MIPS reporter using certified EHR technology |
| Performance threshold | Maintained at the current level through the CY 2028 performance year | Everyone |
| Advanced APMs | QP status limited to participating TIN and NPI combinations; the 3.1 percent APM incentive payment codified for payment year 2028 | ACO participants |
| FHIR reporting | Request for comment on mandatory FHIR-based quality reporting, potentially from CY 2030 with a two-year transition starting 2028 | Everyone, eventually |
The end of traditional MIPS, dated
CMS has signaled for years that MIPS Value Pathways (MVPs, the specialty-specific bundles of quality, cost and improvement activity measures introduced in 2023) would replace the choose-your-own-measures model. The proposed rule puts a date on it: traditional MIPS would end after the CY 2028 performance period, and from CY 2029 a clinician who is not in an Advanced APM would report through an MVP or, for ACO participants, the APM Performance Pathway. Multispecialty groups, which have argued that no single MVP fits them, would be expected to report as subgroups by specialty, a mechanism that has existed since 2023 and that few groups have used voluntarily.
For a small primary care practice, this is less dramatic than it sounds. The proposed Diabetic Disease and Hypertension MVPs, together with the existing Value in Primary Care MVP, cover most of what such a practice reports today, and the MVP measure sets are shorter. For a small specialty practice in a field with no MVP, the question is whether CMS builds one in the next two rulemaking cycles; if not, 2029 becomes complicated, and this is the point to comment on. For a multispecialty group, the subgroup reporting requirement is a real administrative change: separate measure selection, separate data submission and separate scores by specialty under one tax identification number.
The core measure requirement and the small practice exemption
The core measure proposal is the most immediate change. CMS would designate certain quality measures as MIPS core measures and require every clinician, group and subgroup that is not a small practice to report at least one applicable core measure starting with the 2027 performance year. Failing to do so would result in zero achievement points for one of the six required quality measures, which in practice costs roughly 10 points off the quality category. Small practices, defined in the QPP as 15 or fewer clinicians billing under the tax identification number, would be exempt. A core measure reported voluntarily would count only if it lands among the practice's highest-scoring measures.
CMS also proposes to relax the topped-out rule for core measures: a core measure that has been topped out for two or more consecutive years would not be capped at 7 points and could score the full 1 to 10, and the same treatment would extend to 17 topped-out measures used by specialties with limited measure options. That is helpful, because several likely core measures (controlling high blood pressure, A1c control, screening measures) are exactly the ones where high national performance has been costing practices points.
Which measures are designated as core is in the rule's measure tables, and the list is the thing to check. A practice of 16 or more clinicians whose current six measures include none of the proposed core measures needs to add one for 2027 and start capturing the data on January 1, because a measure added in July has six months of denominator missing.
Promoting Interoperability: one measure out, one in
The Security Risk Analysis measure would be removed from the PI category from CY 2027. Read that carefully: CMS is removing the attestation from MIPS, not the obligation. The HIPAA Security Rule still requires a risk analysis, OCR still enforces it, and every ransomware settlement OCR announced this year cited its absence. We think dropping the attestation is a mistake for exactly that reason, and we intend to say so in comments, but a practice should not read it as permission to skip the analysis.
In its place, CMS proposes a new Electronic Prior Authorization for Prescription Drugs measure, makes the existing electronic prior authorization measure (for medical services, tied to the payer API requirements taking effect January 1, 2027) optional in 2027 and required in 2028, and offers up to 10 bonus points in 2027 for using electronic prior authorization. Together those moves tell you where CMS wants practices in two years: submitting prior authorization requests from inside the EHR through standard APIs rather than by fax and portal. Practices that have not asked their EHR vendor about electronic prior authorization support should ask now, because the 2028 requirement will not wait for the vendor's roadmap.
Measures leaving and activities changing
Twenty quality measures are proposed for removal and 43 for substantive change. Removals matter most to practices that have reported the same six measures for years; the rule's Table Group A lists them, and a practice should check each of its current measures against the list before choosing 2027 measures. In improvement activities, eleven are proposed for removal and six added; a practice that attests to the same activities each year should confirm its favorites survive.
The Cost category is quiet: no new episode-based measures and no substantive changes. After several years of new cost measures arriving each rule, a stable year is welcome, though the category still carries 30 percent of the final score and remains the one practices can least influence.
Third-party intermediaries and data submission
Two smaller proposals affect practices that report through a registry or qualified clinical data registry. Intermediaries with fewer than ten participants would have to audit all of them, and every intermediary would have to support at least six quality measures including one core measure from CY 2027. Practices using a small specialty registry should ask whether it will meet those requirements or exit the program. The deadline for practices to apply for relief when an intermediary fails would move from November 1 to December 31, which is a modest but useful change.
Finally, CMS asks for comment on a transition to mandatory FHIR-based quality reporting, possibly from CY 2030 with a two-year transition beginning in 2028. FHIR (Fast Healthcare Interoperability Resources, the current data exchange standard) reporting would replace the QRDA files most practices now export. It is a request for information, not a proposal, but it is the direction, and an EHR vendor that cannot describe its FHIR reporting plan is a vendor to worry about.
Questions we hear
We are a solo practice. Does any of this apply to us?
Some of it. You are exempt from the core measure requirement as a small practice and you may be excluded from MIPS altogether under the low-volume threshold, so check your eligibility on the QPP website. The PI changes apply if you report PI, and the traditional MIPS sunset applies to everyone who is eligible in 2029. The Security Risk Analysis remains a HIPAA obligation regardless.
Should we switch to an MVP for 2027 or wait until we are forced?
If an MVP fits your specialty, our view is to report it in 2027 voluntarily. The measure sets are smaller, the scoring is comparable, and learning the mechanics in a year when traditional MIPS is still available is cheaper than learning them in 2029 when it is not. If no MVP fits, comment on that by September 14 and keep reporting traditional MIPS.
Does the proposed rule change our 2026 reporting?
No. The 2026 performance year runs under the CY 2026 final rule, and its data is submitted in early 2027. The one exception is the proposed removal of required ONC attestations beginning with CY 2026, which CMS describes as a clean-up; watch the final rule for its exact effect.
What to do this week
- Count the clinicians under your tax identification number to know whether the small practice exemption applies.
- Compare your current six quality measures and your improvement activities against the proposed removal tables.
- Identify the MVP that fits your specialty, or confirm that none does, and decide whether to comment.
- Ask your EHR vendor in writing about electronic prior authorization support and FHIR quality reporting timelines.
- If you have anything to say about core measures, MVP fit or the Security Risk Analysis removal, submit a comment before September 14, 2026.
We help practices pick measures and build the data capture in our practice transformation work, and a short call is enough to work out whether an MVP fits your group.
