The ASM Reality Check: What Clinicians and Practice Managers Need to Know About the Ambulatory Specialty Model

​CMS just moved the goalposts for specialists, and the ASM Model is the new playing field. Amanda Lord with Patient360 and Reyann Davis with Value Health Innovations & APM Connect, discussed ASM and what this mandatory shift means for your practice. The recording, Q&A, and slides can be accessed by APM Connect members.

CMS is changing how certain cardiologists, orthopedic surgeons, neurosurgeons, pain management specialists, anesthesiologists and physical medicine and rehabilitation physicians treating Medicare patients with heart failure and low back pain are paid, and it comes with downside risk.

To incentivize better management of heart failure and low back pain, the Centers for Medicare & Medicaid Services (CMS) finalized the Ambulatory Specialty Model (ASM) in the Calendar Year 2026 Physician Fee Schedule. ASM launches January 1, 2027, and runs through December 31, 2031. A physician’s performance in ASM will determine positive or negative Part B payment adjustments in 2029 through 2033.

This is not a voluntary alternative payment model; it is mandatory for 6,637 physicians in selected geographic areas. There are only six months left to understand what is required and what it means for your day-to-day practice.

What Is ASM?

The Ambulatory Specialty Model is a mandatory CMS Innovation Center payment model designed to hold certain specialist physicians accountable for the quality and cost of care they deliver to Medicare beneficiaries with heart failure and low back pain. CMS organized the model into two cohorts with separate measure sets, episode-based cost accountability, and performance scoring.

The overarching goals are clear: incentivize preventive and upstream management, reduce avoidable hospitalizations, improve patient-reported outcomes, and lower unnecessary costs for Medicare. In addition to paying specialists for the volume of services rendered, ASM ties a portion of the physician’s Medicare Part B reimbursement to performance across quality, cost, improvement activities, and data interoperability.

Who Is Affected?

Eligibility is determined at the individual physician level, rather than at the practice or health system level. To be subject to ASM, a physician must meet the following criteria: Qualifying specialty:

• Heart Failure Cohort: Cardiology

• Low Back Pain Cohort: Anesthesiology, Interventional Pain Management, Neurosurgery, Orthopedic Surgery, Pain Management, or Physical Medicine and Rehabilitation

• Bills under the Medicare Physician Fee Schedule

• Meets the Episode Based Cost Measure (EBCM) volume threshold of at least 20 attributed episodes for the applicable condition

• Practices in one of the mandatory Core-Based Statistical Areas (CBSAs) selected by CMS

CMS has published a preliminary participant list at data.cms.gov, and the finalized list of mandatory CBSAs will be released later in 2026. If your organization has physicians on the preliminary list, now is the time to prepare.

CMS did not finalize ASM as a payment model for Advanced Practice Providers (APPs), only physicians. CMS does not currently assign specialty codes to non-physician practitioners, so they cannot be identified as specialty providers.

The MIPS Trade-Off

ASM participants are exempt from MIPS reporting. However, that exemption does not mean less accountability; it means a more targeted set of requirements. ASM uses its own data submission framework:

• Quality: Reported at the individual clinician level (small practices with fewer than 15 clinicians may report at the TIN level)

• Cost: Evaluated at the individual clinician level via the applicable EBCM

• Improvement Activities (IAs): Submitted at the TIN level, with two required IAs for all participants

• Promoting Interoperability (PI): Submitted at the TIN level, requiring Certified EHR Technology (CEHRT)

The two required Improvement Activities are: IA-1, which requires connecting to primary care and ensuring completion of Health-Related Social Needs (HRSN) screenings for ASM beneficiaries; and IA-2, which requires executing a Collaborative Care Arrangement (CCA) with at least one primary care practice for shared ASM beneficiaries.

A common concern raised by practice administrators is whether TIN-level IA submission means the entire organization must redesign workflows. It does not. While submission is filed at the TIN level to reduce administrative burden, the actual clinical workflows apply specifically to the ASM participant and their attributed beneficiaries.

A practice with two cardiologists in a 2,500-provider TIN is not required to transform workflows for the entire organization; the attestation covers what those two specialists are doing for their ASM patients.

Quality Measures: Broader Than You Might Expect

One of the more consequential details in the ASM is that its quality measures are measured across all payers, not just Medicare. CMS confirmed in the Final Rule that the eCQMs and CQMs in both cohorts apply across a clinician's entire patient population, not just Medicare beneficiaries. Any patient who meets the denominator criteria for a given measure will be included, regardless of payer.

CMS designed it this way intentionally. All-payer measurement provides more stable denominators, reflects actual day-to-day clinical practice, and streamlines reporting workflows. In practice, this means clinicians must ensure their EHR documentation captures required measure data for all qualifying patients, not only those covered by Medicare.

There is also a nuance in the Low Back Pain cohort worth knowing: one measure — the functional status change measure — is a traditional CQM rather than an eCQM. CMS deliberately kept it as a CQM to allow flexibility in the validated survey instrument used. Whether your practice uses the FOTO tool or the Oswestry Disability Index, both are acceptable. CMS stated directly in the Final Rule that this flexibility was intentional, noting that Patient-Reported Outcome Measures are difficult to standardize into a single eCQM because practices use different validated tools.

How Payments Are Adjusted

ASM uses a two-sided risk model. Payment adjustments are applied to future Medicare Part B claims rather than a lump-sum settlement.

The risk level starts at 9% in the first performance year and rises to 12% by the final year of the model. CMS states that 85% of the total ASM incentive pool will be redistributed as payment adjustments to participants, while 15% is retained in the Medicare Trust Fund.

Here is an illustrative example from the Final Rule: if the total incentive pool for a cohort is $1 billion in Medicare Part B payments, the amount available for redistribution among participants is 9% x 85% x $1 billion = $76.5 million. Each clinician's individual score determines a payment multiplier that is then applied to every Part B claim during the applicable payment year.

Performance from 2027 will determine the payment multiplier applied beginning in 2029. CMS will provide performance reports, but with a meaningful lag. Practices that want to track performance in closer to real time will need to either replicate the EBCM specifications internally using incoming claims data or engage an analytics vendor to do so.

Operational Steps to Take Now

The model launches in 2027, but preparation is urgent. Here is where to start:

• Check the preliminary participant list at data.cms.gov to identify which physicians in your organization are currently listed

• Review the EBCM specifications for Heart Failure and Low Back Pain available via the QPP website's 2026 MIPS cost information forms

• Confirm CEHRT compliance for all participating physicians, as it is required for Promoting Interoperability and eCQM reporting

• Identify documentation gaps in your EHR for the required quality measures and train clinicians on where and how to capture the relevant data for all qualifying patients, not just Medicare beneficiaries

• Begin conversations with primary care partners now about Collaborative Care Arrangements and HRSN screening workflows, since both are required for IA attestation

• Build or source analytics capabilities to monitor EBCM performance in something approaching real time, rather than relying solely on lagged CMS performance reports

  
  

The Bottom Line

The Ambulatory Specialty Model is a genuine structural shift in how CMS holds specialist physicians accountable for value in Medicare. For clinicians in affected specialties and geographies, there is no opt-out. Given the tone from CMS, specialists not affected by this five-year pilot should anticipate the model being expanded to other geographies in future years.

The model structure will be familiar to clinicians with MIPS experience, ut the stakes are higher, the accountability is condition-specific, and benchmarking is peer-relative within each specialty cohort. Clinicians who understand the model well and build the infrastructure now will be better positioned both to avoid negative adjustments and to compete for positive ones.

If your organization has physicians on the preliminary participant list, start preparing now. Review eligibility, assess your EHR and CEHRT readiness, audit your quality measure documentation, build your primary care relationships, and make sure your team understands what is coming.

Sources & References

• CY 2026 Physician Fee Schedule Final Rule, Federal Register, Vol. 90, November 5, 2025 (42 CFR Part 512, Subpart G)

• ASM Webinar — "The ASM Reality Check: A Conversation on Specialty Value-Based Care," presented by Amanda Lord & Reyann Davis, APM Connect (May 20, 2026)

• ASM Q&A Follow-Up Document, ASM Reality Check Webinar (May 2026)

• CMS Innovation Center — Ambulatory Specialty Model: cms.gov/priorities/innovation/innovation-models/asm