- AMA-driven bipartisan legislation: Overhaul MIPS introduced in the House
- Administration reverses visa processing freeze for physicians
- Three new Medicare models have approaching May application deadlines
- CMS: Extending prior authorization transparency and interoperability framework to drugs
- More articles in this issue
AMA-driven bipartisan legislation to overhaul MIPS introduced in the House of Representatives
Since its creation following the enactment of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, the Merit-based Incentive Payment System (MIPS) has been riddled with problems. In response, Representatives Mariannette Miller-Meeks, MD (R-IA) and Herb Conaway, MD (D-NJ) introduced H.R. 8622, “the Medicare Physician Data-driven Performance Payment System (DPPS) Act of 2026,” which makes key, targeted reforms to the MIPS program in hopes of making it more efficient, useful and fair for all participating physicians.
Introduction of the Medicare Physician DPPS Act represents another cog in the AMA’s overarching, multi-pronged effort to improve the Medicare physician payment system.
AMA President Bobby Mukkamala, MD, touted the benefits of the Medicare Physician DPPS Act with a quote included in an April 30 joint press release from Reps. Miller-Meeks and Conaway:
“Physicians have grappled with a multitude of problematic issues associated with the Merit-based Incentive Payment System (MIPS) for more than a decade. The combination of steep penalties and burdensome measures that don’t lead to improved quality or patient outcomes has overwhelmed physicians, especially those in private practice. Scholarly journal articles have found that compliance with MIPS costs physicians $12,800 per physician annually and requires more than 53 hours per year on quality assurance tasks. The reality of devoting significant time to tasks that do not improve patient health and yet still result in penalties is prompting private practices to close and exacerbating the trend of care shifting to higher cost settings. We commend Reps. Miller-Meeks and Conaway for their leadership in introducing this legislation that seeks to improve the MIPS program.”
Key provisions in H.R. 8622 include:
- Freezing the current MIPS (PDF) performance threshold at 75 out of 100 for three years to promote stability in MIPS, as well as mandating GAO to conduct a study, in consultation with national medical specialty societies, to make recommendations to Congress and HHS about an alternative threshold methodology.
- Eliminating the MIPS win-lose “tournament style” payment adjustments (i.e., the +/- 9%) to ensure physicians are no longer subjected to steep penalties.
- In lieu of penalties, the legislation links physicians’ MIPS performance to a portion of their annual payment update (e.g., either the existing 0.25% under MACRA or the percentage increase in the Medicare Economic Index (MEI), should it be enacted in a separate bill).
- Mandating CMS to provide at least three-quarters worth of MIPS feedback reports and Medicare claims data to physicians during a given performance year.
- Failure by CMS to provide these quarterly reports leads to physicians automatically earning higher payments.
With CMS performance data showing (PDF) that the majority of solo, small, and rural practices are being cut at the highest levels in order to fund the 9% bonuses offered in MIPS, AMA is confident that enactment of H.R. 8622, the Medicare Physician DPPS Act, would provide a tremendous amount of relief to physicians participating in MIPS.
Administration reverses visa processing freeze for physicians
The Trump administration recently updated its visa processing freeze, exempting foreign-trained physicians from the partial and complete suspension of entry into the U.S. as indicated in Proclamation 10998, which was issued in Dec. 2025. The Department of Homeland Security has stated that it will resume processing visas and work permits for physicians. With this development, the AMA is urging the administration to also address the H-1B visas as well as the Department of Health and Human Services’ administrative pause on visas.
The AMA sent a letter (PDF) following the issuance of Proclamation 10998 urging that physicians be exempted. The letter highlighted the ways in which foreign-trained physicians play a crucial role in maintaining patient access to care in the U.S., with 64% of foreign-trained physicians practicing in Medically Underserved Areas or Health Professional Shortage areas in 2021 and nearly 46% of these physicians practicing in rural areas.
“The U.S. health care workforce relies upon physicians from other countries to provide high-quality and accessible patient care,” said AMA CEO John Whyte, MD, MPH, in the letter. “Accordingly, we must ensure that the U.S. has a fair and efficient immigration system that strengthens U.S. healthcare and advances the nation’s health security. Therefore, we urge the Administration to categorically exempt physicians from the partial and complete suspension of entry into the U.S. by finding that physicians’ work serves an important national interest.”
Three new Medicare models have approaching May application deadlines
Applications for the ACCESS (Advancing Chronic Care with Effective, Scalable Solutions) model are due May 15 for a July 5 start. Applications received after May 15 will be considered for a Jan. 1, 2027 start. ACCESS is a voluntary, 10-year model that tests the ability of novel technologies to improve the health of Medicare beneficiaries and better prevent and manage four common chronic conditions: high blood pressure, diabetes, chronic musculoskeletal pain and depression. Primary care practitioners and referring clinicians will qualify for a co-management payment for documented review of patient updates (that would not be subject to patient cost sharing). More information can be found in the ACCESS Request for Application (RFA).
Applications for the new MAHA (Make America Healthy Again) ELEVATE (Enhancing Lifestyle and Evaluating Value-based Approaches Through Evidence) Model are also due May 15. MAHA ELEVATE is a grant-based model that will provide approximately $100 million to fund three-year cooperative agreements for up to 30 proposals that promote health and prevention for Original Medicare beneficiaries. Private medical practices, Accountable Care Organizations (ACOs), Federally Qualified Health Centers, Rural Health Clinics, academic institutions, and more are encouraged to apply. ELEVATE applicants must have previously submitted a letter of interest in order to apply.
LEAD (Long-Term Enhanced Design) Model ACOs must submit applications by May 17 for a Jan. 1, 2027, start. LEAD replaces the ACO REACH Model and aims to attract more small, rural and independent practices and provide additional supports for complex and dually eligible Medicare beneficiaries, as well as optional benefit enhancements and beneficiary engagement incentives. According to the LEAD RFA (PDF), specialists will also be able to participate in optional episode-based payment arrangements with ACOs and participating primary care providers. While LEAD ACOs must apply by May 17, they are not required to sign participation agreements until after financial methodology details are released this summer. They have until Aug. 5 to add participating practices and preferred providers and until Sept. 8 to drop them.
CMS proposes extending prior authorization transparency and interoperability framework to drugs, advancing key AMA priority
On April 10, CMS released the Interoperability Standards and Prior Authorization for Drugs proposed rule (CMS-0062-P), which would extend the interoperability and transparency requirements established for non-drug items and services under the 2024 Interoperability and Prior Authorization (PA) final rule (CMS-0057-F) to drugs. These requirements would apply across Medicare Advantage, Medicaid, CHIP and Qualified Health Plans (QHPs) on the federally facilitated exchanges (FFEs), with compliance dates beginning Oct. 1, 2027. Of note, CMS cites AMA research three times in the rule’s justification, including survey data showing that 29% of physicians (PDF) report that PA has led to a serious adverse event for a patient in their care. The agency’s repeated references to AMA’s work underscore the extent to which the AMA’s longstanding efforts to reform prior authorization have shaped CMS’ regulatory priorities.
The proposal introduces parallel electronic PA requirements for drugs covered under both medical and pharmacy benefits. Impacted payers would be required to incorporate drugs covered under a medical benefit into the Fast Healthcare Interoperability Resources (FHIR)-based Prior Authorization Application Programming Interface (API), facilitating electronic PA that integrates with physicians’ electronic health record workflow. For drugs covered under a pharmacy benefit, state Medicaid and CHIP fee-for-service programs, managed care plans, and QHP issuers on the FFEs would be required to support NCPDP SCRIPT, Formulary & Benefit, and Real-Time Prescription Benefit standards—bringing these payers into alignment with existing Part D PA technology requirements. Drug PA data would also be incorporated into the Patient Access, Provider Access, and Payer-to-Payer APIs, making this information accessible to patients, providers and payers through the same infrastructure established under CMS-0057-F.
The proposed rule would also extend CMS’ existing PA reporting framework for medical items and services to drugs. Impacted payers would be required to publicly report drug PA metrics, including the total number of PA requests, approval and denial rates, appeal outcomes and decision timeframes, and to publish lists of drugs subject to PA. The agency is also proposing to require impacted payers to disclose PA criteria in electronic formats and provide specific reasons for denials. Finally, the rule would establish enforceable decision timelines for drug PA that vary by payer type. State Medicaid and CHIP programs would have 24 hours to issue a determination, consistent with existing covered outpatient drug requirements. QHP issuers on the FFEs would be required to issue decisions within 72 hours for standard requests and 24 hours for expedited requests. These provisions directly advance recommendations the AMA made in its Jan. 2026 comment letter (PDF) and reflect key priorities outlined in the AMA’s Prior Authorization and Utilization Management Reform Principles (PDF).
While the AMA broadly supports the direction of the proposed rule, the final rule should include additional safeguards and requirements to ensure these changes produce meaningful improvements in the PA process for physicians and patients. In particular, the AMA will urge CMS to establish stronger safeguards related to payer adherence to technical requirements, the clinical validity of utilization management criteria, and protections for patient continuity of care. CMS should also establish clearer expectations for the discoverability, format, and data quality of PA metrics and lists of drugs subject to PA; require disaggregated reporting by therapeutic class or drug category; and require reporting on other utilization management practices that affect patient access, including the frequency of redeterminations, step therapy protocols and quantity limits.
The AMA will submit formal comments by the June 15 deadline and will continue pressing CMS to adopt reforms that strengthen payer accountability, reduce administrative burden for providers and ensure patients receive timely access to the medications they need.
