In this episode of Ask Dr. Mingle, Dr. Dan Mingle provides an overview of the 2025 Final Rule for the Medicare Shared Savings Program and Quality Payment Program.

Click play on the video below to listen to Dr. Mingle’s thoughts now:

2025 Final Rule Video Timestamps

Use the timestamps below to navigate to the specific subjects Dr. Mingle explains in this episode:

• 02:57 – Medicare Shared Savings Program in 2025
• 21:41 – Alternative Payment Models in 2025
• 29:57 – MIPS in 2025
• 41:23 – MIPS Value Pathways in 2025

2025 Final Rule Links

You can find the text of the 2025 Final Rule in the Federal Register here: Medicare and Medicaid Programs: Calendar Year 2025 Payment Policies under the Physician Fee Schedule >>

For a more succinct look at the changes in the 2025 Final Rule, access Medicare’s fact sheet here: Calendar Year (CY) 2025 Medicare Physician Fee Schedule (PFS) Final Rule: Quality Payment Program (QPP) Fact Sheet >>

2025 Final Rule Overview

On November 1, 2024, the Centers for Medicare and Medicaid Services (CMS) released, right on time, the Final Rule for 2025 for the Medicare Shared Savings Program (MSSP) and the Quality Payment Program (QPP).

As you may be aware by now, rules for these programs change significantly every year. There is an annual predictable rhythm to the rulemaking process.

Before rulemaking, there is legislation. Congress proposes legislation. Once it passes both houses and is signed into law by the President, it goes to the appropriate federal agency for administration.

Legislation sets the overall agenda, objectives, and boundaries. It’s up to the administrative department to translate the legislative intent into specific rules by which to operate the program.

Because the QPP and MSSP relate to Medicare’s payment for healthcare services, they are in the habit of annually updating the rules for these programs in the same set of documents they use to update the physician fee schedule and other healthcare payment related rules.

Typically, it is as reliable as clockwork. There are exceptions. There are some urgent and emergent circumstances that can warrant:

• Proposing and finalizing some rules in other rule-making processes
• Abbreviating the rule-making process
• Or skipping it altogether

In general, though, it’s pretty reliable.

A proposed rule for the Physician Fee Schedule, the Quality Payment Program, and Medicare Shared Savings program is released on or about the first of July. We are given two months to read it and submit comments. Medicare gets two months to read the comments, adjust, and finalize the rules. The final rule is released on or about the first of November.

Most of the rules go into effect January 1. Some are immediate. Some are retroactive, in a sense. Some are put in place to start in a future year.

Medicare Shared Savings Program (MSSP) in 2025

Some of the most anticipated and consequential rules in the 2025 Final Rule relate to the Medicare Shared Savings Program.

QUALITY MEASUREMENT

MSSP ACOs are required to measure the quality of their care, submit the quality measurements to Medicare, and meet minimum quality standards in order to qualify to collect a share of healthcare savings they generate.

This final rule confirms that the Web Interface mechanism of measuring and submitting quality will end after 2024 measurements are completed and submitted. The Web Interface is not so much a measurement as a sampling technique mainly done with manual chart abstractions. It’s been the predominant method of quality measurement by ACOs in use since 2013 when ACOs were introduced by Medicare as a health care delivery and payment method.

When the Web Interface sunsets after 2024 measurements and submissions, ACOs will have to use one of three mechanisms to measure and submit quality of care data via the APM Performance Pathway (APP):

• Electronic clinical quality measures (eCQMs)
• The new Medicare clinical quality measures (Medicare CQMs)
• Or, for at least two more years, MIPS clinical quality measures (MIPS CQMs)

As for Medicare CQMs, they have performance period benchmarks for their first year, 2024.

This rule finalizes a new set of measures applicable to the MSSP and to other APMs. Based on the APM Performance Pathway, (APP), the new APP Plus measure set includes additional measures that will phase in over the next few years:

• For 2025, in addition to HbA1c, depression screening, and blood pressure control, APP Plus requires breast cancer screening.
• For 2026, APP Plus will add colon cancer screening.
• For 2027, treatment of substance use disorder.
• And for 2028, the last two measures: screening for social drivers of health and adult immunization.
  • The last three measures in the list above are not supported by eCQM specifications and could be postponed if those specifications are not yet ready.

The APP Plus measure set aligns MSSP quality measurement with the Adult Universal Foundation measure set that is also the basis for the Medicaid Core sets, Marketplace Quality Rating System, and Value in Primary Care MVP. This measure set is also converging with Medicare Advantage and Part D Star Ratings.

Expect all of these measure sets, from now on, to remain coordinated through the Universal Foundation Measures.

The original APP measure set is still available for use by any MIPS APM entity, other than the MSSP. MIPS APM entities can also choose to submit the APP Plus measure set.

MSSP organizations must use the APP Plus measure set. It is intended, from now on, to be the standard for MSSPs to qualify to collect shared savings.

Neither the APP nor APP plus is available to any traditional MIPS providers or practices.

NEW COMPLEX ORGANIZATION ADJUSTMENT

This was finalized as an incentive to encourage eCQM submission.

It applies to complex organizations, ACOs, APM entities, virtual groups, and organizations in MIPS or APMs that successfully submit eCQMs for their complex organizations. The bonus is:

• One achievement point for each eCQM submitted
  • Meeting case minimums and data completeness
  • Capped at 10 points per measure
  • 100% for the quality category

Notice it applies not only to ACOs and other APMs, but also to virtual groups in traditional MIPS.

ALTERNATE QUALITY STANDARD

This was introduced with the APP to incentivize the use of eCQMs and MIPS CQMs, and was due to sunset with the Web Interface after 2024 submissions.

It is extended to incentivize the all-patient all-payer reporting of the APP Plus measure set. It applies to eCQM and MIPS CQM submitters.

It does not apply to Medicare CQM submitters.

The usual quality standard requires a composite quality score at or above the 40th percentile. The alternate standard requires one outcome measure at or above the 10th percentile and one other measure at or above the 40th percentile.

PROMOTING INTEROPERABILITY

There are no new Promoting Interoperability (PI) rules pertaining to MSSPs in the 2025 Final Rule, but one of the most consequential rule changes for MSSPs was finalized in the 2024 rule to go into effect for 2025.

Starting in 2025, all participants in MSSP ACOs must be on Certified EHR Technology (CEHRT) and must make a Promoting Interoperability submission.

There is one big, if understated exception. Providers who have a temporary or permanent exception to the CEHRT requirement get the same exception for participation in an MSSP. Small practices, non-patient-facing, hospital-based, ambulatory surgical center based providers all qualify for this exception.

An interesting sidenote on this Promoting Interoperability requirement pertains to facility-based providers:

• Medicare offers an exception to Promoting Interoperability requirements for providers who are facility-based and therefore have no control over the EHR in use at the facility.
• But the only automatic grants of that exception occur for hospital-based and ambulatory surgical center based providers. For them, it only automatically applies if one of the facilities in which they work accounts for at least 75% of their billing volume.
• Providers in other facilities, like skilled care and other long-term care facilities, or providers who serve multiple facilities with no one of them rising to 75% of their volume, must make an EUC application to be granted the exception.
  • Of course, the EUC application needs to be repeated each year that it still applies.

PREPAID SHARED SAVINGS

The Advance Investment Program, introduced last year for new low revenue MSSP ACOs seems to be popular and successful.

For 2025, Medicare finalized the rule to make advance payments of anticipated shared savings available to select renewing ACOs. There are a number of qualifying prerequisites regarding performance in prior years, but it may be a very useful tool.

It is only available at the time of renewal. But early renewal is permitted with this option.

If your first year of a new renewal is 2025, you are eligible for this in 2026 without an early renewal.

Also finalized were a couple of refinements to the Advance Investment Program:

• Voluntary termination with payback of AIP payments will now be acceptable without leaving the MSSP.
• Payback of AIP payments will be required if an ACO is involuntarily terminated by CMS.

5000 BENEFICIARY REQUIREMENT

This has been less of an issue than expected. Sliding scale minimum savings rates and minimum loss rates (MSR) and (MLR) have been effective to prevent anomalous losses or gains.

ACOs must have 5000 beneficiaries at the start and at renewal. But interim drops no longer will require a corrective action plan.

Merit-based Incentive Payment System (MIPS) in 2025

An interesting year for MIPS and somewhat consequential, but there is a smaller set of changes for MIPS than for the MSSP.

MIPS PERFORMANCE AND DATA COMPLETENESS THRESHOLDS

The performance threshold stays at 75% through at least 2027.

The data completeness threshold will stay at 75% through at least the 2028 performance year.

MEASURE INVENTORY AND CHANGES

The MIPS CQM quality measure inventory is now 195 measures, three of which are only used in MVPs.

There are six new episode-based Cost measures, and there’s an important change to the scoring methodology for the Cost category.

This new change aligns the scoring range for the Cost category to match the overall MIPS performance threshold and spread of Cost scores.

From 2025 on, the median Cost score will correspond to the performance threshold for the overall MIPS program.

Standard deviations above and below the median score will be divided to use the full 0-10 scoring scale.

Until now, an average score in the Cost category actually lowered your overall MIPS score. This change means that better than average scores will raise your MIPS score and lower than average scores will lower your overall Cost score. This will significantly improve scoring for the average practice and above.

There are no significant changes to Promoting Interoperability.

For Improvement Activities, there are some changes to note:

• CMS has eliminated weighting for Improvement Activities in the Final Rule, meaning that every Improvement Activity now carries the same weight
• Four Improvement Activities have been removed
• Two activities have been modified
• Two activities have been added
• Two Improvement Activities are required for traditional MIPS
• One Improvement Activity is required for special categories and MVPs

MIPS Value Pathways (MVPs) in 2025

CMS added six new MVP options in 2025 and combined two neurologic MVPs, bringing the total of available MVPs to 21. It’s now estimated that 80% of providers have an applicable MVP.

Each MVP requires one Improvement Activity, but weights no longer apply.

MVP submissions no longer require you to choose a population health measure.

Scoring for the Cost category for MVP submissions aligns with the new Cost scoring methodology in traditional MIPS.

Perhaps the most important thing about MVPs for 2025 is what is not in the rule. 2025 had been penciled in as the year that subgroups would be mandatory for submission of MVPs. But it looks like MVPs can still be used to score all providers in multispecialty groups of any size and any specialty composition.

And of course, it’s still a solid strategy to do both an MVP and traditional MIPS submission side-by-side and take the best score to set your MIPS Adjustment.

Send us your value-based care questions!

If you’d like to ask a question about the APP transition, MIPS, ACO quality reporting, or any other Alternative Payment Model, you can reach out to us in three ways:

You can leave your questions in a YouTube comment under any episode of Ask Dr. Mingle.

On LinkedIn, leave your questions in a comment on any of our posts.

And you can reach out directly by sending an email to hello@minglehealth.com.