Can Payment Reform Transform Heart Failure Care?
Published by APM Connect on 11/9/2026
Sarah Chuzi, MD, MSc; Karen Joynt Maddox, MD, MPH; Tara Lagu, MD, MPH.
JAMA Viewpoint, published online November 2, 2026.
Heart failure (HF) is one of the most evidence-rich areas of cardiovascular medicine, yet a persistent gap separates proven therapies from the care patients actually receive. In this JAMA Viewpoint, the authors argue that closing that gap requires more than changing clinician behavior. It requires infrastructure such as multidisciplinary teams, standardized pathways, and longitudinal care coordination, which fee-for-service payment has historically failed to support.
The authors examine the CMS Innovation Center’s Ambulatory Specialty Model (ASM) as a test of whether payment reform can drive that investment. Beginning in 2027, eligible cardiologists in selected mandatory geographic areas will join a five-year model that holds them accountable for the quality and cost of care for Medicare beneficiaries with HF. Unlike earlier models aimed at hospitals, health systems, or primary care–led organizations, the ASM places accountability directly on specialists. Performance is assessed across quality, cost, improvement activities, and interoperability. Participants are ranked against one another, and the authors report payment adjustments of up to ±9% in the first two years, rising to 12% by 2031.
The authors identify several areas where the model’s incentives could improve care:
Earlier cardiology involvement through systematic referral pathways and EHR-based patient identification
Better use of guideline-directed medical therapy, supported by titration clinics led by pharmacists or advanced practice clinicians, and by remote monitoring
Higher uptake of cardiac rehabilitation and structured post-discharge programs
Stronger integration of palliative care for patients with advanced HF
They also raise concerns about the model’s design:
Its limited geographic footprint may discourage system-wide redesign.
Social risk adjustment is narrow, which could disadvantage clinicians serving complex populations and encourage patient selection.
Reporting demands are heavy, and returns don’t arrive until reconciliation, which is especially hard for small practices.
Attribution is unclear when patients see several cardiologists.
The authors conclude that the ASM’s success will depend on whether its incentives are strong enough to motivate real care redesign. Otherwise, it may change payment without changing care.
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