CMS Proposed Rules Devalue Surgeon Services; ACS Pushes Back
The ACS is preparing to deliver extensive feedback to the Centers for Medicare & Medicaid Services (CMS) relating to two proposed regulations for 2026 that would negatively affect surgeons and their patients. The ACS remains deeply concerned about some of the proposed changes and will continue to aggressively fight on your behalf for adjustments to be made before the final rules are released later this year.
Outlined below are the key issues identified in each of these proposed regulations, plus new empirical evidence that contradicts a key CMS misperception
Medicare Physician Fee Schedule
CMS published its annual Medicare Physician Fee Schedule (MPFS) proposed rule to update policies for services furnished on or after January 1, 2026.
For 2026, CMS proposes to set the conversion factor (CF) at $33.5875 for qualifying alternative payment model (APM) participants (QPs) and $33.4209 for non-QPs. These two separate CFs under the MPFS are required by law starting next year.
Additionally, the Agency proposes applying an “efficiency adjustment” of -2.5% to the work relative value units (RVUs) and corresponding intraservice portions of non-time-based services, which would significantly devalue surgical care. This adjustment is intended to account for what CMS perceived as overinflated time assumptions built into the valuation of services that have, or will become, more efficient over time. The Agency also solicits feedback on strategies to improve the accuracy of global surgery payments.
In the Quality Payment Program (QPP), CMS proposes to maintain the performance threshold at 75 points for CY 2026. The Agency also proposes six new Merit-Based Incentive Payment System (MIPS) Value Pathways (MVPs), including a Vascular Surgery MVP and reiterates its commitment to ending traditional MIPS and making MVPs mandatory in the future. CMS also proposes revisions to the Total Per Capita Cost (TPCC) measure.
Finally, the Center for Medicare and Medicaid Innovation (CMMI) proposes the Ambulatory Specialty Model (ASM), a new 5-year mandatory model scheduled to begin in 2027, and targets specialists who treat Original Medicare enrollees with low back pain or heart failure in an outpatient setting in certain geographical areas. The ASM is built on the MIPS MVP framework, originally developed for fee-for-service Medicare payments. Physician payment adjustments under the model are based on performance across four performance categories, similar to MIPS.
The rule and related fact sheet are accessible online.
Study Contradicts CMS Misperception
After learning about the negative efficiency adjustment, surgeon leaders, including new Medical Director for Health Policy Research Thomas C. Tsai, MD, MPH, FACS, analyzed National Surgical Quality Improvement Program (NSQIP) data from 2019 and 2023. The sample included more than 1.7 million operations across 249 CPT codes and 11 surgical specialties.
They found that overall operative times increased by 3.1% in 2023, compared to 2019, and at the procedure level, 90% of CPT codes had similar or longer operative times in 2023 compared to 2019. In addition, patient complexity correspondingly increased.
The results of this study, Longitudinal Trends in Efficiency & Complexity of Surgical Procedures, available online in the Journal of the American College of Surgeons, will be used to challenge the new CMS proposed rule.
Outpatient Prospective Payment System
CMS also released its 2026 Outpatient Prospective Payment System (OPPS) proposed rule. This rule annually updates policies for hospital outpatient and ambulatory surgical center (ASC) services.
CMS proposes to eliminate the Inpatient Only (IPO) list, which specifies the procedures that Medicare will only cover when performed in an inpatient setting for patient safety purposes. The Agency would phase out this list over 3 years, starting in 2026 with the removal of 285 services, allowing them to be covered in the outpatient setting. Correspondingly, CMS proposes adding 271 of the procedures considered for removal from the IPO list—along with an additional 276 procedures—to the ASC Covered Procedures List, allowing these procedures to be eligible for payment in the ASC setting.
CMS proposes changes to the Hospital Outpatient Quality Reporting (OQR), Rural Emergency Hospital Quality Reporting (REHQR), and Ambulatory Surgical Center Quality Reporting (ASCQR) programs, including the removal of social determinants of health and health equity measures within each program. CMS also proposes to adopt the Patient Understanding of Key Information Related to Recovery After a Facility-Based Outpatient Procedure or Surgery, Patient Reported Outcome-Based Performance Measure as part of the ASCQR, with voluntary reporting beginning with the CY 2027 reporting period, followed by mandatory reporting beginning with CY 2029. CMS also proposes changes to its Star Rating methodology to emphasize the contribution of the Safety of Care measure group in hospitals’ ratings.
In addition to various program and measure changes, CMS issued a request for information seeking input on meaningful measurement and reporting for quality of care in the outpatient setting. The Agency also proposes changes to hospital price transparency rules that would require hospitals to post real, consumer-usable prices and provide data in standardized formats. CMS further solicits feedback on ways to incorporate the underlying value of software-based technologies within medical practice into payment policy.
The rule and related fact sheet are accessible online.
Inpatient Prospective Payment System
On June 10, the ACS submitted a comment letter in response to the fiscal year (FY) 2026 Hospital Inpatient Prospective Payment System (IPPS) proposed rule, published by CMS in late May. The proposed rule also included updates to the Transforming Episode Accountability Model (TEAM), an alternative payment model taking effect on January 1, 2026.
The ACS’s comments focused on proposals impacting the inpatient quality reporting programs and TEAM. The College acknowledged that TEAM is an opportunity to advance value-based care in surgery but also urged CMS to reevaluate several aspects of the program, most notably the shortfalls of the models’ quality framework.
The ACS encouraged CMS to better align quality measures with surgical episodes by including episode-specific measures centered on patient goals and clinical outcomes, such as the ACS Age Friendly Hospital Measure, which was adopted in the Hospital Inpatient Quality Reporting (IQR) Program for the 2025 performance year, and the Information Transfer Patient Reported Outcome-based Performance Measure.
Additionally, the College responded to proposed measure removals in the Hospital IQR Program. The ACS strongly urged CMS to maintain structural measures, including the Age Friendly Hospital measure, in its quality programs, as these measures work in tandem with outcome and process measures to drive measurable improvements in clinical outcomes.
Finally, the ACS replied to CMS’s Digital Quality Measurement in its Quality Programs Request for Information. The College urged CMS to ensure that digital measures align with the realities of clinical practice and patient needs and to retire or revise those measures that do not meaningfully reflect quality.
Contact QualityDC@facs.org for more information.
ACS Continues to Push for Prior Authorization Reform
The ACS has long expressed concerns about the many disruptions to care, coverage, and payment caused by insurers’ ongoing use of erroneous prior authorization requirements and has been a leading advocate in urging insurers, Congress, and the Administration to make meaningful changes in the implementation and oversight of such requirements.
Recently, Department of Health and Human Services Secretary Robert F. Kennedy Jr. and Centers for Medicare & Medicaid Services (CMS) Administrator Mehmet Oz, MD, met with industry leaders representing various health insurance markets regarding a set of six reforms aimed at increasing transparency and reducing administrative burdens associated with prior authorization.
Within days of the announcement between the health insurance companies and the Trump Administration, CMS announced a new Medicare Fee-for-Service prior authorization program—the Wasteful and Inappropriate Service Reduction (WISeR) Model. In a unified response, the ACS and 22 other surgical specialty societies sent a joint letter on July 16 to CMS expressing deep concerns with the WISeR Model. The organizations warned that the six-year demonstration project—which expands the use of prior authorization in Medicare Fee-for-Service (FFS)—would jeopardize patients’ ability to receive timely care, further burden an already strained physician workforce, and perversely incentivize claims denials for medically necessary items and services.
The coalition highlighted that the WISeR Model lacks statutory authority within the FFS program, directly contradicts the Trump Administration’s pledge to prioritize patients over paperwork, and offers no support to physicians navigating the added bureaucracy. Although CMS frames the model as “voluntary,” the organizations argued that it is effectively a mandate in disguise, as physicians would be forced to choose between undergoing either a pre-service prior authorization process conducted by third-party vendors or a post-service, pre-payment medical review conducted by Medicare Administrative Contractors. Meanwhile, participating vendors would be financially rewarded based on the volume of claims denied under the model, raising serious concerns about transparency and patient harm.
The organizations urged CMS to abandon the WISeR Model and instead work with the physician community on targeted solutions that protect patient access while minimizing risks of fraud, waste, and abuse, including strengthening existing Medicare oversight programs and exempting compliant providers from prior authorization through “gold-carding” policies.
Surgeons Urge Congress to Strengthen Military and Civilian Trauma Readiness
The ACS hosted a Capitol Hill briefing on July 8 to educate congressional staff on the importance of a National Trauma and Emergency Preparedness System (NTEPS). Committee on Trauma leaders, including Chair Jeffrey Kerby, MD, PhD, FACS, Joseph Sakran, MD, MPH, MPA, FACS, and Colonel Jeremy Cannon, MD, FACS, USAFR (Ret.), explored trauma care lessons from the battlefield, gaps in civilian access, and the role of Regional Medical Operations Coordination Centers (RMOCCs) in operationalizing trauma response and preparedness across the country.
The session drew inspiration from the 77th Scudder Oration on Trauma delivered by Brent Eastman, MD, FACS, in 2010, and explored how NTEPS can finally deliver on Dr. Eastman’s vision that “wherever the dart lands” on a map of the US, a trauma system should be there to save your life.
In addition, the panel addressed the critical role civilian trauma centers will play in managing casualties from possible large-scale combat operations with peer or near-peer adversaries overseas. Preparing to effectively manage patient care within the scale of contemporary warfare will depend on a national trauma care infrastructure that links daily care coordination with wide-scale disaster preparedness, a goal NTEPS aims to achieve.
The panelists called on Congress to examine the current state of military and civilian trauma readiness and invest in the development of RMOCCs and NTEPS. Read more in the Journal of the American College of Surgeons (JACS) article, Regional Medical Operations Coordinating Centers Promote Readiness for Daily Trauma Care and Mass Casualty Incidents. A free subscription to JACS is among your many benefits of ACS membership.
