CMS Proposes Transformational Medicare Reforms: What It Means for ACOs, Physician Payment, and Value-Based Care

What CMS Is Proposing

CMS released a proposed rule representing one of the most significant Medicare modernization efforts in recent years. The proposals span three major areas: expanding ACO participation in the Medicare Shared Savings Program, modernizing physician payment through the Physician Fee Schedule, and sunsetting traditional MIPS reporting in favor of MIPS Value Pathways by 2029.

Together, these changes are designed to make accountable care easier to join and more financially rewarding, shift Medicare's focus from treating illness to preventing it, reduce administrative burden on clinicians, and ensure payment incentives reward better outcomes rather than more services.

Key Proposals and What They Mean for Your Organization

Expanding ACO Participation in the Shared Savings Program

CMS is proposing changes that would increase opportunities to share savings, create new financial incentives for first-time participants, establish more predictable spending targets, and allow ACOs to reduce beneficiary out-of-pocket costs for certain services starting April 2027. In 2024, 75% of participating ACOs earned shared savings totaling $4.1 billion, generating approximately $2.5 billion in net savings for Medicare. The proposed changes are designed to build on that record and bring more providers into accountable care.

Sunsetting Traditional MIPS in 2029

Beginning with the 2029 performance period, traditional MIPS reporting would sunset. Clinicians would transition to MIPS Value Pathways — specialty-focused reporting options that CMS says would cover approximately 98% of specialties. Three new MVPs focused on diabetes, hypertension, and hospital-based care are also proposed. In addition, new MIPS Core Measures would require every clinician to report at least one measure fundamental to their specialty beginning in 2027.

Modernizing Physician Payment

CMS is proposing updates to better align physician payment rates with the time, resources, and complexity of modern care delivery. Furthermore, CMS is proposing to close a payment loophole that could otherwise result in an estimated $2.38 billion in windfall payments to clinicians not actively participating in value-based care arrangements.

How Ensure Data Solutions Helps Organizations Prepare

The CMS proposals directly align with the capabilities built across the Ensure platform. Whether your organization is an ACO, MSO, health plan, PCP group, or health system, the Ensure platform delivers the data infrastructure, network intelligence, quality management, and care coordination tools needed to succeed in this new environment.

EnsureXcel© — High-Performance Network Intelligence ↗

As CMS expands ACO participation and pushes organizations toward high-performance, outcomes-aligned care, network strategy becomes a critical competitive differentiator. EnsureXcel© is purpose-built for exactly this moment — transforming real-world performance data into a dynamic, actionable network strategy for ACOs, MSOs, health plans, and value-based care organizations.

• Multi-dimensional specialist scoring across risk-adjusted outcomes, total cost of care, episode efficiency, readmissions, and guideline adherence
• Premium, narrow, and tiered network configuration by specialty, geography, payer contract, and population segment
• Referral pattern optimization — surfacing preferred specialists at point of referral and flagging high-cost leakage in real time
• Cost share and copay steering to align benefit design with provider performance
• PCP performance intelligence for MSO network expansion, ACO geographic growth, and CIN coordination initiatives
• AI-driven analytics engine that continuously recalibrates provider performance scores using real-world evidence

EnsureQual© — Quality & Performance Optimization ↗

With traditional MIPS sunsetting in 2029 and MIPS Value Pathways becoming the primary reporting option, organizations need quality management tools that go beyond checklists. EnsureQual© helps providers monitor, predict, and close care gaps in real time — supporting HEDIS measure performance, Total Quality Score improvement, and CAHPS/HOS outcomes across the full patient population.

EnsureCM© — Advanced Care Management ↗

CMS's push toward preventive care and reduced avoidable utilization requires proactive care management at scale. EnsureCM© uses predictive analytics to stratify patient populations into risk cohorts, trigger timely clinical interventions, and deliver real-time care management support — ensuring high-risk patients receive the right attention before problems become costly hospitalizations or quality failures.

EnsureRS© — Risk Adjustment Management ↗

As CMS improves benchmark accuracy and tightens financial accountability in the Shared Savings Program, accurate risk documentation becomes more important than ever. EnsureRS© supports prospective and retrospective condition identification, documented and undocumented condition tracking, and risk score calculation — helping organizations accurately capture disease burden and optimize performance under risk-adjusted arrangements.

EnsureFin© — Financial & Utilization Analytics ↗

With more predictable spending targets and stronger shared savings incentives proposed under the new rule, organizations need real-time financial visibility to manage performance confidently. EnsureFin© delivers utilization and cost trend analytics, medical and pharmacy cost management, service fund enablement, provider stop-loss analysis, pricing and projections, and membership and revenue analytics.

EnsureXchange© — Interoperability ↗

CMS's proposals to reduce administrative burden and simplify technology requirements reinforce the need for seamless, bi-directional data exchange. EnsureXchange© enables smooth two-way exchange of clinical data between EHR systems and the Ensure analytics platform — supporting FHIR connectivity, point-of-care alerts, chart retrieval, ADT-driven hospitalization management, and structured clinical documentation exchange across providers, payers, and care settings.

The Path Forward

The CMS proposals represent a decisive shift in the direction of Medicare. ACOs are being expanded and made more accessible. Traditional MIPS is being replaced. Physician payment is being modernized. And the entire system is being pushed toward prevention, coordination, and value.

For health plans, ACOs, MSOs, PCP groups, and health systems, the question is not whether to prepare for this environment — it is whether the organization has the infrastructure to perform in it. Consequently, the Ensure Data Solutions platform was built to support exactly this transition, helping risk-bearing organizations build the data foundation, network intelligence, quality management, and care coordination capabilities that the next phase of value-based care demands.