CMS Advance Care Planning Infrastructure: Why the 2025 MUC List Is Being Misread

Over the past year, CMS has sent an increasingly consistent signal about the future of care delivery. Through ACCESS, LEAD, MAHA ELEVATE, interoperability mandates, and AI-enabled utilization pilots, CMS has been clear about its direction, even as details remain fluid.

Yet one of the most critical signals CMS has issued recently is being widely misunderstood.

The 2025 CMS Measures Under Consideration (MUC) list is being treated in many organizations as a technical appendix. A draft set of quality concepts. Something to monitor, but not yet operationalize.

That interpretation is a mistake.

When CMS evaluates Advanced Care Planning across more than a dozen Medicare programs simultaneously, this is no longer about documentation quality or end-of-life compliance. It is CMS signaling that advanced care planning infrastructure is becoming a core prerequisite for accountable care delivery.

This shift has significant implications for executives, clinical leaders, and boards planning for the next three to five years.

CMS is shifting care delivery

CMS Advance Care Planning Infrastructure Is the Signal, Not the Measure

CMS does not scale measures casually.

Measures that cut across multiple programs at once represent assumptions CMS believes are either already true or must become true quickly. When ACP appears simultaneously across MSSP, ACO REACH successors, dialysis models, specialty programs, and population health frameworks, it signals a belief that care organizations should already have durable, cross-setting visibility into goals, preferences, and intent.

That belief matters more than the individual measure specifications.

CMS is no longer asking:

Did you document preferences?

It is moving toward:

Did care decisions over time align with what mattered to the person?

That is a fundamentally different accountability model.

Why ACP Is Being Elevated Now

The timing is not accidental.

CMS is facing a convergence of pressures:

• Rising utilization driven by aging populations

• Increasing chronic complexity

• Workforce constraints that make reactive care unsustainable

• Value-based models that require predictability, not episodic intervention

Under these conditions, intent-blind care becomes expensive care.

When goals of care are unknown or known but inaccessible, organizations default to utilization patterns that are misaligned with patient priorities and system economics. Avoidable hospitalizations rise. Late-stage escalation increases. Care teams make decisions without context.

From CMS’s perspective, this is no longer acceptable.

Advance care planning is being elevated not because it is new, but because it enables a different operating assumption: care should be anticipatory, not reactive.

The Misread: Treating ACP as a Documentation Problem

Many organizations still approach ACP as a discrete task:

• A form to complete

• A conversation to document

• A checkbox to satisfy

That framing worked when ACP was peripheral.

It does not work when ACP becomes infrastructure.

Infrastructure implies:

• Persistence across time

• Portability across settings

• Visibility at the point of decision

• Governance and accountability

A scanned PDF buried in one EHR instance does not meet that standard.

Neither does a one-time conversation that cannot be surfaced during transitions, referrals, or utilization decisions.

CMS is not signaling interest in better forms. It is signaling interest in operational readiness.

Advance Care Planning as an Operational Input

What CMS is really testing is whether care organizations can treat preferences and goals as operational data, not narrative artifacts.

If ACP is meant to inform care, then:

• It must be accessible before utilization decisions are made

• It must follow individuals across care settings

• It must be interpretable by different care teams

• It must be durable over time, not episodic

This reframes ACP from a clinical courtesy into a system capability.

In this model, ACP functions less like documentation and more like contextual intelligence.

That shift aligns directly with the broader CMS roadmap.

Alignment With ACCESS, LEAD, and MAHA ELEVATE

Seen in isolation, ACP appears to be a narrow quality domain. Seen in context, it is foundational.

ACCESS

ACCESS assumes longitudinal accountability for populations with complex needs. That accountability breaks down when care teams do not know what outcomes matter most to the individual. ACP provides the grounding context for chronic care prioritization, escalation thresholds, and intervention timing.

LEAD

Long-horizon accountability only works when care decisions compound in the right direction. Without persistent visibility into goals and preferences, ten-year accountability models default to utilization management rather than care alignment.

MAHA ELEVATE

Whole-person care cannot be operationalized without clarity on what “whole” means to the individual. Lifestyle, functional goals, and well-being measures require an intent framework to be meaningful.

In all three models, advance care planning infrastructure becomes a prerequisite, not an enhancement.

The Shift From Measurement to Alignment

One of the most important signals in the 2025 MUC list is not ACP alone, but what it is being paired with.

Dialysis life-goals discussions. Well-being indicators. Person-reported outcomes.

Taken together, CMS is moving away from measuring whether conversations occurred and toward evaluating whether care trajectories actually aligned with stated priorities.

This is a subtle but profound shift.

It shifts accountability from: "Did you ask?"

To: Did care reflect what was asked? That is a much higher bar.

The Operational Consequences Most Organizations Are Not Ready For

This shift exposes several readiness gaps.

Fragmented Data

Preferences documented in one system do not reliably surface in another. Transitions of care remain blind spots.

Workflow Misalignment

Care teams often lack ACP context when decisions are made, especially during nights, weekends, or cross-coverage.

Governance Gaps

Organizations rarely define ownership for maintaining, updating, and operationalizing ACP over time.

Measurement Risk

As ACP moves from consideration to enforcement, organizations that cannot demonstrate alignment risk performance penalties, even if documentation exists.

These are not theoretical concerns. They are execution failures waiting to surface.

CMS Advance Care Planning Infrastructure as a Readiness Test

CMS has not announced enforcement timelines yet. That is intentional.

Historically, CMS introduces measures in the MUC list not to surprise organizations, but to observe who prepares early.

Organizations that treat this as a documentation exercise will scramble later. Organizations that treat it as an infrastructure signal will quietly build advantage.

This pattern has repeated across interoperability, risk adjustment, and quality reporting.

ACP is following the same trajectory.

What Executives and Boards Should Be Asking Now

The right questions are no longer:

• Do we have an ACP form?

• Are we compliant today?

They are:

• Can goals and preferences be accessed across settings?

• Do care teams see intent before making decisions?

• Does ACP survive transitions and time?

• Is alignment measurable, not just documented?

These are operating model questions, not clinical niceties.

Why This Matters Beyond ACP

Advance care planning is the most visible early signal, but it is not the endpoint.

CMS is constructing a system that assumes:

• Intent informs utilization

• Preferences shape pathways

• Accountability is longitudinal

• Coordination is infrastructure

ACP reveals where organizations stand on that continuum. Those who ignore it will misread the broader roadmap.

Key Takeaways

CMS is elevating advance care planning as infrastructure, not documentation.

The 2025 MUC list signals a shift from measuring conversations to measuring alignment over time.

ACP is being positioned as an operational input across ACCESS, LEAD, and MAHA-aligned models.

Organizations that treat ACP as compliance will struggle as enforcement approaches.

Organizations that operationalize intent will reduce avoidable utilization and improve value-based performance.

Conclusion

The 2025 CMS Measures Under Consideration list is not a quiet appendix. It is a directional signal.

Advance care planning is being elevated because CMS believes care organizations should already be able to align decisions with preferences over time and across settings.

That belief will soon be enforced.

The question for leaders is not whether ACP matters.

It is whether their organization is prepared to operate as if it already does.