Breaking: CMS finalizes fee disparity between facility and non-facility, sets two conversion factors

Most of the significant changes to the Medicare Shared Savings Program (MSSP) have been finalized in the rule, with a major emphasis on making it easier for new and slow-to-advance entrants to take on risk.

 

CMS proposes to reduce the length of time an ACO can participate in a one-sided model of the BASIC track from a maximum of seven performance years over two performance periods to five performance years in the first period starting in 2027. After that, the new ACO must sign up for Level E of the BASIC MSSP track for all performance years of the agreement period, or for the ENHANCED track.

 

Also, CMS will “increase flexibility” for these entrants regarding the minimum patient population of 5,000 assigned Medicare fee-for-service (FFS) beneficiaries required in MSSP benchmark years. In 2027, these ACOs can have fewer than 5,000 in their first two performance years, though they will lose some opportunities if they do. 

 

Risk-shy ACOs may also gain encouragement from a revised definition of primary care services used for purposes of beneficiary assignment. Starting in 2026, behavioral health integration and psychiatric collaborative care management add-on services will be added to the definition of primary care services.

 

Also, in a change from the proposed rule, CMS won’t pull the social determinants of health (SDOH) risk assessment code G0136 from its definition of “primary care services” used for the purposes of assignment, though its description will be revised from “Administration of a standardized, evidence-based social determinants of health risk assessment tool, 5-15 minutes” to “Administration of a standardized, evidence-based assessment of physical activity and nutrition, 5-15 minutes, not more often than every 6 months.”

 

The Alternative Payment Model (APM) Performance Pathway (APP) Plus quality measure set for Shared Savings Program ACOs will lose the Screening for Social Drivers of Health, and its Consumer Assessment of Healthcare Providers and Systems (CAHPS) for Merit-based Incentive Payment System (MIPS) Survey will change from a mail-phone administration protocol to a web-mail-phone administration protocol in 2027.

 

As in the proposed rule, CMS mandates big changes in the specialty-specific MIPS Value Pathways (MVP) model to which it hopes to transition the Quality Payment Program (QPP). The agency is adding six MVPs and also modifying all 21 of the existing MVPs. 

 

For the majority of participants who have yet to transfer to the MVP program, the Merit-Based Incentive Payment System (MIPS) threshold stays at 75 points through the CY 2028 performance period “to provide continuity and stability to program participants.” MIPS scoring weights and metrics for the 2026 period remain the same as in 2025.

 

A major shift is announced in the Advanced APM program: a modification of the methodology used to calculate QP status, which determines what clinicians can take part in that program and receive appropriate payment adjustments, will “include an individual calculation for all eligible clinicians in Advanced APMs.” Currently, CMS says, “an eligible clinician who has fully engaged with an Advanced APM may still be unable to earn QP status” due to the agency’s analysis of claims data, which may require a group to be registered as an APM entity, which may not meet program minimums even if an individual clinician within it does so.

 

In keeping with HHS’ wellness agenda, CMS is issuing “an RFI on well-being and nutrition measures in QPP.” It also authorizes other RFIs on the Prescription Drug Monitoring Program (PDMP) Measure and measures under the Public Health and Clinical Data Exchange objective (including on whether to change these from yes/no measures); on “how clinicians exchange health information”; and on digital quality measurement advances such as FHIR and how they affect electronic clinical quality measure (eCQM) reporting.

 

Advanced APM participants, defined as Qualifying APM Participants (QP) and non-QP clinicians in Advanced APMs, still have, respectively, 0.75% and 0.25% conversion factors.

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