The Centers for Medicare & Medicaid Services (CMS) has released the proposed rule for the 2026 Medicare Physician Fee Schedule (PFS), introducing important changes to the Medicare Shared Savings Program (MSSP) and the Quality Payment Program (QPP). For healthcare organizations and providers, these updates present both opportunities and challenges.
Should You Join an ACO? The 2026 Rule Raises the Stakes
With over 11 million Medicare beneficiaries now attributed to ACOs, the question is no longer if you should consider joining an ACO, but how you can do so strategically. The 2026 proposed rule shortens the time new ACOs can remain in one-sided risk models (from 7 to 5 years), pushing organizations to adopt two-sided risk sooner. This means greater potential for shared savings, but also increased accountability for losses.
Whether you’re considering joining an ACO, optimizing your Merit-based Incentive Payment System (MIPS) performance, or navigating the transition to Advanced APMs, Pinnacle Healthcare Consulting is your trusted partner. Our team of experts brings deep regulatory knowledge, hands-on experience, and a proven track record of helping organizations thrive in value-based care.
Pinnacle Healthcare Consulting can help you:
- Assess your readiness for ACO participation
- Understand your TIN composition and how it affects you
- Model financial scenarios under one-sided and two-sided risk
- Develop a glide path for risk adoption that fits your organization’s capabilities
- Support your MIPS strategy to optimize performance and maximize incentives
MIPS: Inside or Outside an ACO—What’s the Impact?
Whether you participate in MIPS (Merit-based Incentive Payment System) as an individual, group, or through an ACO, your quality reporting and reimbursement are on the line. The 2026 rule proposes to streamline quality reporting for ACOs, remove the health equity adjustment, and update the Alternative Payment Model Performance Pathway (APP) Plus quality measure set. For non-ACO participants, MIPS requirements remain rigorous, with performance directly impacting your Medicare reimbursement.
Key 2026 MIPS Updates:
- Performance Threshold: The threshold to avoid a negative payment adjustment remains at 75 points through 2028, providing stability for planning.
- MIPS Value Pathways (MVPs): Six new MVPs are proposed, and all 21 existing MVPs will be updated. Small multispecialty practices will have more flexibility in group reporting.
- Quality Measures: The number of available quality measures is being reduced, and the definition of high-priority measures will no longer include health equity.
- Improvement Activities: New activities are being added, some are being removed, and the “Achieving Health Equity” subcategory is being replaced with “Advancing Health and Wellness.” “Achieving Health Equity” focuses specifically on reducing disparities and ensuring fairness in healthcare, while “Advancing Health and Wellness” takes a broader approach that includes preventive care, overall well-being, and health promotion for all individuals.
- Promoting Interoperability: New requirements for EHR security risk management and updated SAFER Guides are proposed.
- CAHPS for MIPS Survey: A web-based survey mode will be added to increase response rates.
Are You a QP or Non-QP? Understanding Advanced APM Status
Qualified Participants (QPs) in Advanced Alternative Payment Models (APMs) are exempt from MIPS and receive a 1.88% incentive payment. Non-QPs, however, must continue to participate in MIPS. The 2026 rule’s push toward two-sided risk means more ACOs may qualify as Advanced APMs, but the requirements are complex.
To become a QP, eligible clinicians must receive at least 75 percent of Medicare Part B payments or see at least 50 percent of Medicare patients through an Advanced APM Entity during the QP Performance Period (January 1 – August 31).
2026 Update:
CMS proposes to add individual-level QP determinations for all clinicians in Advanced APMs, not just at the APM Entity level. The QP calculation will now use all Covered Professional Services, not just E/M services, potentially impacting your eligibility for APM incentives.
How Will These Changes Affect Your Reimbursement?
The proposed changes to the MSSP and MIPS will directly impact your Medicare Physician Fee Schedule payments. ACOs that successfully meet quality and cost benchmarks can share in savings, while those that don’t may face losses—especially as two-sided risk becomes the norm. MIPS participants face payment adjustments based on performance, and the removal of certain quality adjustments (like the health equity adjustment) may affect your scores.
Additional 2026 QPP Impacts:
- Cost Measures: No new cost measures for 2026, but modifications to the Total Per Capita Cost (TPCC) measure may affect primary care providers.
- Quality Reporting: The definition of a “beneficiary eligible for Medicare CQMs” is being revised to reduce reporting burden for ACOs.
- Improvement Activities: New activities focus on cognitive impairment detection, oral health integration, and patient safety in AI use.
Pinnacle Healthcare Consulting offers:
- Ongoing monitoring of regulatory changes and their impact on your bottom line
- Tailored strategies to improve quality, reduce costs, and maximize shared savings
Ready to take the next step in your MIPs journey?
At Pinnacle Healthcare Consulting, we specialize in guiding practices, health systems, and clinicians through every step of the Accountable Care Organization (ACO) journey—ensuring you maximize benefits, minimize risk, and stay ahead of regulatory changes. Contact Pinnacle Healthcare Consulting today to discover how we can help you succeed in the evolving world of Medicare reimbursement.
Let Pinnacle Healthcare Consulting be your guide to ACO success—so you can focus on what matters most: delivering high-quality care to your patients.
