Medicare's Quality Payment Program Is Changing, and Radiologists Need to Pay Attention

A quiet but consequential shift is underway inside Medicare's quality payment program, one that could reduce annual reimbursements for thousands of diagnostic radiologists starting with the 2026 performance year. The transition from traditional MIPS (Merit-based Incentive Payment System) to MIPS Value Pathways (MVPs) may look like a technical policy update, but for radiology practices, the financial stakes are real.

CMS is redesigning how physician specialties are measured and rewarded under Medicare's quality payment program. MVPs replace broad, flexible reporting with specialty-specific measure sets and restricted reporting vehicles. For diagnostic radiologists, this matters because it eliminates a structural advantage they have long relied on: reporting through multispecialty physician groups.

Simulation research published in the Journal of the American College of Radiology applied 2026 MVP rules to 2023 MIPS data, and the findings suggest a measurable shift toward neutral or downward payment adjustments for many radiology practices. This article breaks down what that means, why it happens, and what your practice can do now.

You will find sections covering the structural differences between MIPS and MVPs, the ExRad quality measure that anchors the 2026 radiology MVP, how independent practices compare to large health systems in terms of risk, and actionable steps to prepare before January 1.

How Medicare's Quality Payment Program Is Changing: From MIPS to MVPs

Medicare is replacing traditional MIPS with specialty-specific MIPS Value Pathways (MVPs) that restrict measure selection and eliminate multispecialty group reporting, directly reducing scoring options for diagnostic radiologists.

MIPS, the Merit-based Incentive Payment System, is the existing Medicare quality payment program framework under which eligible clinicians earn a composite final score each year. That score, calculated across four performance categories (Quality, Cost, Improvement Activities, and Promoting Interoperability), determines whether a physician receives an upward, neutral, or downward adjustment to their Medicare payments two years later.

MIPS Value Pathways are specialty-specific reporting tracks within Medicare's quality payment program. CMS designed MVPs to replace traditional MIPS gradually by narrowing measure selection to clinically relevant, specialty-aligned options. Rather than choosing from hundreds of quality measures across all categories, clinicians in an MVP report a curated set specific to their specialty and patient population.

The structural differences between the two frameworks are significant. Traditional MIPS allowed broad measure selection and permitted multispecialty groups to report collectively, a flexibility that benefited specialties like radiology whose members are often embedded within large mixed-specialty practices. MVPs eliminate that collective reporting pathway for participating groups. Each MVP also restricts which reporting vehicles are available, removing options that helped some specialties maximize their composite final scores.

The CMS regulatory framework governing MVPs has been finalized through annual physician fee schedule rulemaking. The 2026 performance year is when the diagnostic radiology MVP becomes a material compliance concern, not a future possibility, but an active policy choice that practices must respond to now.

CMS's Stated Goals for the MVP Transition

CMS's official rationale for transitioning Medicare's quality payment program toward MVPs centers on three priorities: reducing clinician burden, improving measure relevance by specialty, and aligning incentives with value-based care outcomes. In theory, a cardiologist should be measured on cardiovascular quality metrics, not on measures that have no relationship to the care they actually deliver.

MVPs also sit within the broader Medicare reimbursement reform ecosystem. They are intended as a bridge between traditional MIPS and fully developed Alternative Payment Models (APMs), where clinicians take on meaningful financial risk in exchange for greater payment flexibility. CMS views MVPs as a stepping stone, a way to build specialty-level quality reporting infrastructure before the system moves further toward value-based accountability.

The comment period for recent MVP rules has closed, and the regulatory changes are finalized. These are not proposals. Radiologists and practice administrators who have been monitoring these changes as "upcoming" need to recalibrate, the 2026 performance year data collection window opened January 1.

How MVPs Differ from Traditional MIPS: A Plain-Language Comparison

Under traditional MIPS, a radiology group embedded in a multispecialty practice could report as part of that larger group. The group's composite final score, influenced by higher-performing specialties within the same practice, provided a natural buffer against low specialty-specific scores. That buffer is gone under the MVP structure, which isolates radiology-specific performance.

The measure selection difference is equally important. Traditional MIPS offered a wide menu of quality measures. Radiologists could choose options most favorable to their reporting capabilities. MVPs replace that menu with a curated set of approximately 20 measures specific to diagnostic radiology, but six of those measures under traditional MIPS were already "topped out," meaning nearly all reporting clinicians scored at or near the maximum, leaving little room to differentiate performance or earn bonus points. The MVP framework does not solve this problem; it may concentrate it.

Why Diagnostic Radiologists Are Particularly Vulnerable Under Medicare's New MVP Rules

Diagnostic radiologists are particularly vulnerable because the MVP transition eliminates the multispecialty group reporting buffer that historically inflated their composite final scores under traditional MIPS.

Diagnostic radiologists occupy an unusual position within Medicare's quality payment program. Historically, many reported not as a standalone radiology group but as members of larger multispecialty physician organizations. This reporting structure gave radiology practices access to composite final scores that reflected the collective performance of primary care physicians, surgeons, and other specialists, often scoring well above what a radiology-only group would achieve independently.

That structural advantage is central to understanding why Medicare's quality payment program changes create measurable risk. Researchers analyzing this issue grouped radiologists into three reporting categories: multispecialty group reporters (those embedded in large mixed-specialty groups), radiology-only MIPS reporters (those reporting as a standalone radiology group), and mixed reporters (those whose reporting situations did not fit neatly into either category). Each group faces a different level of exposure under the MVP transition.

The evidentiary basis for the disadvantage claim comes from a cross-sectional simulation published in the Journal of the American College of Radiology. Researchers Rebecca Smith-Bindman, MD, of the University of California, San Francisco, and co-author Carly Stewart applied 2026 MVP rules retroactively to 2023 MIPS performance data. This methodology allowed a direct, apples-to-apples comparison of how the same cohort of radiologists would fare under the two frameworks.

Historical MIPS Performance Context for Radiologists

Before the MVP transition, diagnostic radiologists as a group performed well under traditional MIPS, but that performance was largely an artifact of the reporting structure, not a reflection of radiology-specific quality measurement. Multispecialty group reporting inflated composite final scores for radiology participants by averaging in the performance of other specialties with more quality measure options.

This created a false sense of security. A radiology group earning a top-tier composite final score as part of a large multispecialty organization was not necessarily demonstrating strong radiology-specific quality. When Medicare's quality payment program removes that reporting buffer and forces radiology-only measurement under MVPs, the underlying score potential drops significantly for many practices.

The 2026 performance year is therefore a genuine inflection point. The transition does not give practices time to gradually build new reporting infrastructure, it applies immediately to a full year of performance data. Practices that have not already assessed their standalone radiology scoring potential are already behind.

How Simulation Data Reveals the Payment Adjustment Risk

The Smith-Bindman and Stewart simulation applied 2026 diagnostic radiology MVP rules to 2023 MIPS data to project payment adjustment outcomes across the three reporter categories. The findings were consistent with the structural concern: radiology-only reporters and former multispecialty group reporters both showed a meaningful shift toward neutral or downward payment adjustments under MVP rules compared to their traditional MIPS outcomes.

The composite final score calculation shifts under MVPs because the measure set is narrower, topped-out measures limit scoring headroom, and the multispecialty group buffer is removed. Radiologists who previously earned high scores largely through group-level reporting now face scores that reflect only their specialty-specific performance, and the available measures do not always provide enough differentiation to drive upward adjustments.

This is not a marginal effect. The simulation suggests that the direction of payment adjustments, upward, neutral, or downward, shifts materially for a significant portion of the radiology cohort under the new framework. For practices operating on thin reimbursement margins, a move from an upward to a neutral or downward adjustment represents a real financial consequence tied directly to Medicare quality payment program changes.

The ExRad Quality Measure (Q494): The Sole Outcome Measure in the 2026 Radiology MVP

ExRad (Q494) is the only outcome measure in the 2026 diagnostic radiology MVP and carries disproportionate weight in composite final score calculations.

The ExRad Quality Measure, formally designated Q494, is an outcomes-based measure focused on radiation dose optimization in CT imaging. It tracks whether patients undergoing CT scans receive doses within established reference ranges, reflecting a practice's ability to deliver diagnostic-quality imaging while minimizing unnecessary radiation exposure. In the 2026 diagnostic radiology MVP, ExRad holds a singular position: it is the only outcome measure in the entire pathway.

That singularity creates performance concentration risk. Under Medicare's quality payment program, outcome measures typically carry greater weight in composite final score calculations than process measures. When a single outcome measure exists in a pathway, any compliance gap with that measure has a disproportionate impact on total scores. A practice that fails to report ExRad accurately, or cannot report it at all, faces a structural disadvantage that no other measure in the MVP can compensate for.

Reporting ExRad accurately requires specific infrastructure. Practices must have CT dose monitoring systems capable of capturing patient-level dose data, clinical workflows that ensure data completeness, and the technical capacity to submit that data through approved reporting mechanisms. These are not trivial requirements. For practices that have not yet invested in CT dose optimization infrastructure, building that capability mid-performance-year is not a realistic option.

CMS's decision to anchor the radiology MVP to a single outcome measure reflects its value-based care philosophy, prioritizing clinically meaningful, patient-centered outcomes over process compliance. But it also creates a structural bottleneck. A philosophy-driven design choice becomes a practical barrier for the practices least equipped to meet it, which are often the smaller and more independent ones.

Other Quality Measures Available in the 2026 Radiology MVP

Beyond ExRad, the 2026 diagnostic radiology MVP includes additional quality measures covering areas such as imaging appropriateness, follow-up recommendation documentation, and incidental finding reporting. Radiologists must still select and report from this broader measure set to generate a complete composite final score under Medicare's quality payment program.

The critical difference from traditional MIPS is the absence of choice. Under the old framework, radiology practices could select the measures they were best positioned to perform on. The MVP's curated set removes that flexibility. If the available measures do not align well with a practice's patient population or reporting infrastructure, there is no workaround, you report from the set provided.

Several measures within the radiology MVP carry topped-out risk, meaning the field performs so uniformly well on them that they offer minimal scoring differentiation. MedPAC has noted concerns about topped-out measures reducing the incentive value of quality reporting more broadly. For radiologists, topped-out measures within the MVP mean that even strong performance on those metrics may not translate into meaningful composite final score advantages, putting additional pressure on ExRad compliance to drive overall scores.

How Other Specialties Are Affected by Medicare's Quality Payment Program Transition

Radiology is not the only specialty adjusting to Medicare's quality payment program shift from MIPS to MVPs, but its position is notably more constrained than many others. Specialties with well-developed outcome measure sets and established quality reporting infrastructure, such as cardiology and oncology, tend to benefit more from the MVP structure. Their curated measure sets include multiple outcome measures, providing scoring flexibility that diagnostic radiology simply does not have in 2026.

Primary care specialties face their own MVP challenges, particularly around administrative burden and data reporting. But they typically enter the MVP environment with more measure options and greater experience with value-based reporting models. The structural narrowing that Medicare's quality payment program MVPs impose affects primary care differently, it is less likely to push primary care physicians toward downward adjustments than it is for radiologists.

The concern about specialties with limited outcome measures is not unique to radiology, it is a recognized policy gap in how MVPs were designed. Pathology, anesthesiology, and certain surgical subspecialties face similar measure scarcity issues. However, radiology's specific situation is compounded by the historical multispecialty group reporting advantage it is now losing.

The American College of Radiology (ACR) has been active in Medicare quality payment program rulemaking, submitting formal comments, advocating for additional radiology-specific outcome measures, and pushing back on MVP design elements that disproportionately disadvantage the specialty. The ACR's engagement represents the primary channel through which radiology's concerns enter the CMS regulatory process, and practices should monitor ACR guidance as an authoritative source on MVP compliance strategy.

Independent Radiology Practices vs. Large Health Systems: Who Faces Greater Risk?

Independent and rural radiology practices face greater financial risk under the MVP transition because they are less likely to have ExRad reporting infrastructure and have more to lose from the elimination of multispecialty group reporting.

The Medicare quality payment program transition from MIPS to MVPs does not affect all radiology practices equally. Large academic medical centers and integrated health systems generally enter the 2026 performance year with built-in advantages: existing CT dose monitoring infrastructure, dedicated quality reporting staff, and the technical resources to implement ExRad compliance at scale. For these organizations, the MVP transition is a significant administrative adjustment, but not necessarily a financial shock.

Independent and smaller radiology practices face a steeper climb. Many lack the dedicated data infrastructure required for accurate ExRad reporting. They were also more likely to benefit from multispecialty group reporting under traditional MIPS, since joining a larger physician organization was a practical way to access higher composite final scores. Under Medicare's new MVP structure, that option is no longer available, they must perform on radiology-specific measures alone.

Rural practices face an additional layer of complexity. Limited access to health IT resources and smaller patient volumes can make CT dose monitoring systems harder to justify financially, even when ExRad compliance depends on them. The reporting vehicle restriction hits rural and independent practices hardest precisely because they had the fewest alternative pathways to begin with.

The ACR and other stakeholder organizations are actively engaged in ensuring that Medicare's quality payment program reforms do not disproportionately harm smaller or rural radiology practices. Their advocacy efforts include pushing for additional measures, requesting transition period flexibility, and developing compliance tools specifically designed for independent practices. Staying connected to those resources is not just advisable, it is a practical necessity for practices navigating this shift without in-house compliance teams. You can also review Medicare cost changes in 2026 to understand the broader reimbursement environment your practice is operating in.

What Radiology Practices Should Do Now to Prepare for the 2026 MVP Performance Year

Radiology practices should immediately conduct a gap analysis, assess ExRad infrastructure readiness, and engage with ACR compliance resources before the 2026 performance year data window closes.

The actions your practice takes right now, not at the end of the performance year, will determine your payment adjustment outcome. Medicare's quality payment program changes tied to the MVP transition are not theoretical risks. The 2026 performance year is underway, and the data your practice generates today will translate into upward, neutral, or downward payment adjustments in 2028.

💡 Eddie's Pro Tip

If your practice has historically reported through a multispecialty group, do not wait for your official MIPS feedback report to find out where you stand. Model your standalone ExRad and measure-set performance right now using your own recent data, so you know your real exposure before the performance year closes instead of after. That single exercise, done early, is what separates practices that can still course-correct from those that find out too late.

Evaluating Your Reporting Vehicle: Group vs. Individual vs. MVP Track

Under Medicare's quality payment program in 2026, eligible clinicians generally have three reporting options: individual reporting, group reporting, and MVP track reporting. Each option carries different implications for which measures you are scored on and what composite final score you are likely to achieve.

If your practice currently reports as part of a large multispecialty group under traditional MIPS, you need to model what your score would look like as a standalone reporter or as an MVP participant. The reporting vehicle choice is not just administrative, it directly determines your measure options, your scoring ceiling, and ultimately your Medicare payment adjustment. Practices that delay this analysis until late in the performance year will have limited ability to course-correct. Review the broader Medicare reimbursement landscape to understand how these adjustments fit into your overall payment picture.

FAQ: Medicare's Quality Payment Program Changes and Radiologists

These are the questions radiology practices most frequently ask about the 2026 MVP transition.

Conclusion: Staying Ahead of Medicare's Quality Payment Program Evolution

Medicare's quality payment program is not standing still, and neither can radiology practices. The MIPS-to-MVP transition represents a structural shift that disadvantages diagnostic radiologists who have historically relied on multispecialty group reporting and broad measure flexibility. The 2026 performance year makes that shift tangible: real performance data, real composite final scores, and real payment adjustment consequences.

It is worth recognizing that MVPs are not a final destination. CMS's quality payment program will continue to evolve, with future rulemaking cycles likely to expand MVP requirements, add new outcome measures, and narrow traditional MIPS availability further. Practices that invest now in ExRad infrastructure, strategic measure selection, and a clear understanding of their reporting vehicle options will be better positioned for whatever the next phase of Medicare's quality payment program brings.

The path forward starts with honest self-assessment. Review where your practice stands today against what the 2026 diagnostic radiology MVP requires. Engage with ACR resources built specifically for this transition. And treat Medicare's quality payment program reforms not as a compliance burden to minimize, but as an opportunity to build stronger, more defensible quality reporting infrastructure for the years ahead. To stay current on how Medicare changes continue to shape reimbursement and reporting, make ongoing engagement with program updates part of your practice's standard operating rhythm.