Every December, CMS releases its Measures Under Consideration (MUC) list. It is a preview of where quality measurement, reimbursement pressure, and operational burden are heading. On December 15, 2025, CMS published 24 measures for consideration across Medicare programs.
This year's list sends a clear message. CMS is done measuring intent. It is measuring outcomes, follow-through, and whether care actually happened in a way that is digitally verifiable.
Below is a practical walkthrough of what this means for primary care, hospitals, and anyone thinking seriously about what to optimize for in 2026 and beyond.
The Big Picture: Three Signals That Matter More Than Any Single Measure
1. Digital or Nothing
Every one of the 24 measures relies on at least one digital data source. Ninety six percent rely exclusively on digital sources. CMS is no longer asking whether you documented an attempt. It is asking whether the data trail proves the loop closed.
2. Chronic Disease and Safety Dominate
Twenty nine percent of the measures address chronic conditions and related acute events. Twenty five percent address safety. These are not peripheral concerns. They represent where CMS sees the biggest and most persistent performance gaps.
3. Hospitals Are Getting More Scrutiny
The programs with the most measures submitted for specification changes are the Hospital Inpatient Quality Reporting Program and the Hospital Value Based Purchasing Program. Primary care is not off the hook, but hospitals are clearly in the regulatory spotlight.
The Complete 2025 MUC List: All 24 Measures
Here is the full list of measures CMS is considering.
Cancer Screening Follow-Up (Highest Primary Care Impact)
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Rate of timely follow-up on positive stool-based tests for colorectal cancer detection
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Rate of timely follow-up on abnormal screening mammograms for breast cancer detection
Cardiovascular and Chronic Disease Management
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Low-density lipoprotein cholesterol (LDL-C) monitoring and management
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Excess days in acute care after hospitalization for acute myocardial infarction
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Excess days in acute care after hospitalization for heart failure
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Excess days in acute care after hospitalization for pneumonia
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Excess days in acute care after hospitalization for diabetes
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Hospital 30-day, all-cause, risk-standardized mortality rate following acute myocardial infarction hospitalization
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Hospital 30-day, all-cause, risk-standardized mortality rate following heart failure hospitalization
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Hospital 30-day, all-cause, risk-standardized mortality rate following chronic obstructive pulmonary disease hospitalization
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Hospital 30-day, all-cause, risk-standardized mortality rate following pneumonia hospitalization
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Hospital 30-day, all-cause, risk-standardized mortality rate following coronary artery bypass graft surgery
Sepsis
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Adult community-onset sepsis standardized mortality ratio
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Hospital sepsis program core elements score
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Hospital 30-day, all-cause, risk-standardized readmission rate following sepsis hospitalization
Safety and Antimicrobial Stewardship
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Excess antibiotic duration for adult hospitalized patients with uncomplicated community-acquired pneumonia
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Inappropriately broad empiric antibiotic selection for adult hospitalized patients with uncomplicated community-acquired pneumonia
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Hospital harm, postoperative venous thromboembolism
Person-Centered Care
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Advance care planning
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CollaboRATE shared decision-making tool for ambulatory or outpatient surgery patients
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Dialysis facility discussion of patient life goals
Other
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Facility-level percentage of chronic hyperphosphatemia in dialysis patients
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Malnutrition care score
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Emergency care access and timeliness
Ranked by Primary Care Impact: Where to Focus First
Tier 1: Optimize Now, Direct Primary Care Impact
1. Rate of Timely Follow-Up on Positive Stool-Based Tests for Colorectal Cancer Detection
Who it impacts: Independent PCPs, MIPS clinicians, ACO-aligned practices
Why it matters most: This is a pure closed-loop measure. A positive FIT or Cologuard without a completed colonoscopy now counts against you. The failure point is not clinical judgment. It is logistics. Reaching the patient, scheduling GI, tracking completion, and documenting outcomes.
What to optimize:
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Automated patient outreach after positive results
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Referral tracking with real status visibility
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Barrier documentation when patients decline or delay
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Proof of colonoscopy completion flowing back into the EHR
If you only optimize for one thing, optimize for this.
2. Rate of Timely Follow-Up on Abnormal Screening Mammograms for Breast Cancer Detection
Who it impacts: Primary care, women's health clinics, value-based groups managing preventive care
Why it matters: This is the same operational challenge as colorectal screening in a different clinical domain. Abnormal imaging that falls through the cracks now counts against quality scores, even when imaging happens outside your system.
What to optimize:
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Result ingestion from external imaging facilities
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Patient notification workflows
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Scheduling confirmation tracking
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Clear documentation of handoff and follow-up
3. LDL-C Monitoring and Management
Who it impacts: Nearly every Medicare-focused PCP, especially clinics managing chronic disease panels
Why it matters: This looks like a simple lab measure, but it quietly expands expectations. Regular monitoring, medication adherence tracking, and treatment intensification are now implied. This pushes clinics from episodic care into true longitudinal management.
What to optimize:
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Lab tracking with automated gap identification
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Medication adherence outreach
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Protocols for treatment intensification when targets are not met
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Interval follow-up scheduling logic
Tier 2: Important but Indirect Pressure on Primary Care
4. Advance Care Planning
Who it impacts: Primary care, ACOs, health systems
Why it matters: Advance care planning is being normalized as a measurable expectation rather than a nice-to-have. This measure spans multiple programs, which signals broad adoption.
What to optimize:
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Structured ACP documentation templates
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Longitudinal updates, not one-time conversations
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Patient education workflows that fit into routine visits
This becomes much easier when done incrementally rather than during a crisis.
5. Excess Days in Acute Care Measures (AMI, HF, Pneumonia, Diabetes)
Who it impacts: Hospitals directly, PCPs indirectly through ACO partnerships
Why it matters: These measures create downstream pressure on primary care. Hospitals will increasingly look to PCP partners to reduce utilization through proactive outreach and care coordination.
What to optimize:
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High-risk patient identification
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Post-discharge follow-up within 48 to 72 hours
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Weekly or biweekly touchpoints for recently discharged patients
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Transitional care management billing and workflows
6. Hospital Mortality and Sepsis Measures
Who it impacts: Hospitals directly, PCPs during transitions of care
Why it matters: Seven of the 24 measures focus on 30-day mortality rates and sepsis outcomes. PCPs are not directly accountable, but tight transitions and communication matter more than ever. Early recognition of sepsis signs in the outpatient setting can prevent acute deterioration.
Tier 3: Lower Immediate Primary Care Impact
7. Antimicrobial Stewardship Measures
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Excess antibiotic duration for community-acquired pneumonia
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Inappropriately broad empiric antibiotic selection
Who it impacts: Hospitals and inpatient settings primarily
Why it matters for PCPs: These measures set expectations for outpatient stewardship. While not directly measured in MIPS yet, they signal where CMS is heading.
8. Dialysis and Specialty-Specific Measures
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Chronic hyperphosphatemia in dialysis patients
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Dialysis facility discussion of patient life goals
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Malnutrition care score
Who it impacts: Nephrology, dialysis facilities, integrated systems
Why it matters: This signals CMS's growing focus on whole-person care and nutrition, consistent with the MAHA (Make America Healthy Again) framework referenced in the MUC release.
9. Emergency Care Access and Timeliness
Who it impacts: Emergency departments and health systems
Why it matters: This is not directly applicable to ambulatory primary care, but it affects patients in your panel who access emergency services.
How to Use This as a Decision Framework
If you are a PCP or operations leader, here is the simplest rule.
Optimize for anything that requires proof of follow-up, not proof of intent.
That means:
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Outreach systems that actually reach patients, not just send messages
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Scheduling workflows that confirm completion
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Tracking that shows the loop closed
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Documentation of outcomes, not just referrals
What About MAHA Alignment?
CMS noted that the 2025 MUC list includes measures consistent with HHS's Make America Healthy Again priority framework, particularly around chronic illness and nutrition. CMS is also promoting early review of five developmental measures aligned with MAHA.
For value-based care leaders, this signals continued investment in:
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Chronic disease management outcomes
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Nutrition interventions, including the malnutrition care score
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Prevention and lifestyle medicine
These are areas worth watching closely as future measures are developed.
Key Dates
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Public commenting: December 16, 2025 to January 6, 2026
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Consensus-based entity recommendations due: February 2026
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Potential adoption through federal rulemaking: 2026 to 2027
Final Takeaway
The December 2025 MUC release is not about adding measures. It is about raising the bar on whether care actually happened.
Primary care is being asked to do what it has always tried to do, now with measurement attached:
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Stay connected to patients
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Close loops
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Make care between visits real
The clinics that win will not be the ones with the best reports. They will be the ones with the fewest loose ends.
For questions about how AI-powered voice agents can help automate the follow-up workflows these measures require, reach out at founders@pearcalls.com.
Sources
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CMS Measures Management System Hub, "2025 Measures Under Consideration List Now Available," December 15, 2025
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Becker's Healthcare, "CMS pitches 24 Medicare measure updates: 7 things to know," December 15, 2025
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American Hospital Association News, "CMS releases 2025 Measures Under Consideration List," December 15, 2025