Physicians, like patients and policymakers, want a Medicare system that provides better value and quality care. But experience and hard data has shown that the Merit-based Incentive Payment System (MIPS) isn’t the way to accomplish that goal.
MIPS was well intentioned, but the reporting requirements are burdensome for physician practices and the things physicians need to report are often clinically irrelevant. Centers for Medicare & Medicaid Services’ (CMS) data continues to show that practices that were penalized under the MIPS program were disproportionately small practices and rural practices.
The AMA and others in organized medicine have fervently pushed for an improved system and for more opportunities for physicians to participate in value-based care. They have championed major changes, including rewarding the value of care patients receive rather than administrative activities; encouraging innovation; offering a variety of payment models and flexible program requirements that are tailored to the distinct characteristics of different specialties and practice settings; and providing timely, actionable data that physicians can use to drive improvements.
Now Congress has a chance to make changes that would help create a system that better supports value-based care: The Patients First Act of 2026 (H.R. 9693). It is an AMA-backed bipartisan, comprehensive legislation that, if passed, would:
- Create a new simplified and clinically relevant quality measurement program that requires physician input into what they would be measured on.
- Eliminate onerous and outdated MIPS Promoting Interoperability requirements.
- Cut payment penalties to 2% during a transition period, then cap them at 5%.
- Require CMS to provide regular performance feedback, or exempt physicians from penalties.
- Require more physician input into alternative payment model (APM) development and mandate a report on current barriers to specialists joining APMs and how to overcome them. Freeze APM thresholds for three years and allow Secretary discretion to set thresholds in the future.
As previously reported in detail, the Patients First Act is the most comprehensive Medicare physician payment reform bill to date. It would reform Medicare physician payment, including establishing automatic, annual inflation-based payment updates and modernizing budget-neutrality policies.
The measure aligns with the “Characteristics of a Rational Medicare Physician Payment System” (PDF), a framework that aims to ensure financial stability and predictability, promote value-based care and safeguard access to high-quality care for patients who depend on small, rural and independent practices. The AMA and more than 120 state medical associations and national specialty societies have endorsed the framework.
“The need for reform is clear and long overdue,” wrote AMA CEO John Whyte, MD, MPH, in a letter of support for the bill. “When adjusted for inflation in practice costs, Medicare physician payment has fallen approximately 33% since 2001, even as expenses for staffing, technology and regulatory compliance have climbed steadily.”
The AMA letter (PDF) was sent to Reps. John Joyce, MD (R-Pa.), Kim Schrier, MD (D-Wash.), and Greg Murphy, MD (R-N.C.), chairs of the GOP Doctors Caucus and the Democratic Congressional Doctors Caucus. The three physician representatives introduced the bill, which amounts to a major reform of the Medicare Access and CHIP Reauthorization Act (MACRA). At this article’s deadline, the proposed legislation had 50 cosponsors.
The AMA is leading the charge to reform the Medicare payment system and is asking physicians to write their representatives to urge them to cosponsor the Patients First Act.
The AMA and state medical societies representing physicians from all 50 states and the District of Columbia last week expressed strong support (PDF) for the bipartisan Patients First Act. Also last week, the House Energy and Commerce Committee held a legislative hearing focused on strengthening the Medicare physician payment system, with significant attention devoted to the Patients First Act.
Replacing MIPS
The Patients First Act would, over a four-year transition period, replace MIPS with a new quality measure program called POINTS, short for Patient Outcome Improvement National Tabulation System.
“MIPS has imposed substantial reporting burdens and steep penalties. … POINTS puts physicians and specialty societies, rather than the government, at the center of quality measurement through a clinician-majority Quality Care Reform Task Force,” Dr. Whyte wrote in his letter to Congress that outlines the positive “reforms that will allow physicians to devote more time to patient care and less to arbitrary reporting requirements.”
Over the four-year transition to POINTS, MIPS penalties would be reduced to a maximum 2% annually, a significant reduction from where they stand now. It would incrementally increase maximum penalties by 1% annually up to a maximum of 5% thereafter, down from payment adjustment of negative 9% per year under MIPS.
The bill also would eliminate the MIPS Promoting Interoperability category, formerly meaningful use and it would also eliminate the MACRA requirement that cost measures account for a majority of Medicare spending under the physician fee schedule to enable more flexibility in cost measure design and allow for more clinically meaningful measures, rather than overly broad measures the penalize physicians for costs that are out of their control.
A new Quality Care Reform Task force would also be established. It would be comprised of a clinician majority that would recommend all of the measures to be used in the POINTS program.
Among other changes, the Patients First Act would also:
- Create three categories of measures for POINTS to focus on: quality (65%), resource use (20%) and a new care efficiency category (15%), which would aim to give physicians credit for Medicare savings they achieve. This could include things such as reducing medication burden or preventing complications from patients’ chronic diseases.
- Establish a system where measures that the majority of the task force approves would be recommended to CMS. The CMS administrator would then be required to publish responses to all the recommended metrics and submit progress reports to Congress on what is being implemented within 120 days. Any measures that the task force approved by a supermajority—75% or higher—must be accepted by the Secretary.
- Create a permanent new bonus performance program in POINTS solely for independent physicians and small practices and direct more positive POINTS adjustments to physicians in independent and small practices.
- Make approved qualified clinical data registries (QCDRs) an optional pathway to report quality data and give special consideration to them.
- Prohibit CMS, starting in 2032, from imposing penalties on physicians for any performance year that they have not received at least three timely quarterly performance feedback reports.
- Authorize the Department of Health and Human Services (HHS) to fund contracts with the clinician-led data registries for developing and testing metrics and give them access to CMS claims data to inform their work.
- Require CMS to temporarily score as pay-for-reporting (full points) new measures, measures with substantive changes, or those without a benchmark to encourage reporting of these types of measures and allow practices the opportunity to gain experience with the measures and focus on practice improvement before being held accountable.
In addition, the legislation also would require that metrics:
- Conform with relevant clinical guidelines and encompass input from the relevant specialty and subspecialty that will practice under the metric, with a guaranteed representative on the task force from the relevant specialty/subspecialty.
- For nonpatient-facing providers, consider the circumstances of their practice.
- Align across categories and directly relate to either an episode of care or across a continuum of care.
- Be capable of submission through EHR technology, administrative or billing claims or through a data registry, including a qualified clinical data registry.
APM reforms
The Patients First Act also includes several policies aimed at expanding future APM options, reflecting long-standing AMA advocacy.
“By freezing the Qualifying Participant threshold at 50% for three years, authorizing the [HHS] Secretary to set lower thresholds and requiring reports on the barriers specialists face in joining APMs, the legislation preserves meaningful incentives for physicians transitioning to value-based care,” says the AMA’s letter of support.
The bill would also require mandatory notice-and-comment rulemaking for all mandatory models and if a model is being ended early or materially changed.
Primary care demonstration
The Patients First Act also includes a five-year demonstration program for primary care physicians in independent practices.
The program would include a hybrid of per-member-per-month and traditional payments that would be funded with new money and would be exempt from budget neutrality. The program would run 2027 through 2031.
The per-member-per-month payments wouldn’t require any patient cost-sharing and would be designed to include care management services; behavioral health integration; office and telehealth visits; and follow-up care communications. Primary care physicians would still be able to submit claims that were not a part of that payment.
