First Look: CMMI Proposes Ambulatory Specialty Model For HF
The Centers for Medicare and Medicaid Services (CMS) has released the 2026 Medicare Physician Fee Schedule (PFS) proposed rule, which includes the CMS Innovation Center's (CMMI's) proposal for a mandatory five-year Ambulatory Specialty Model (ASM). The model would hold specialists in selected metropolitan areas financially accountable for managing chronic conditions, specifically heart failure (HF) and low back pain, targeting those who historically treated at least 20 Original Medicare patients with these conditions.
Using the Merit-based Incentive Payment System (MIPS) Value Pathways (MVPs) framework, ASM is intended to examine adjusting specialists' payment based on their performance on selected quality measures, cost, care coordination, and meaningful use of certified electronic health record (EHR) technology with the goal of improving quality of care and reducing cost during longitudinal chronic care management.
The model would use a two-sided risk arrangement where participants are subject to financial gains or losses. Based on performance relative to their peers, a participant would receive a higher rate (positive payment adjustment), the standard rate (neutral payment adjustment), or a lower rate (negative payment adjustment) on their future Medicare Part B claims for covered services.
An initial overview of the proposed ASM for HF management is below. CMS will accept public comments on the 2026 Medicare PFS proposed rule until Sept. 12, 2025. The ACC is developing comments on this model in addition to other proposals.
| More Details on Proposed Ambulatory Specialty Model | |
| Goal of the ASM | The model aims to test whether adjusting payment for specialists based on their performance on targeted measures of quality, cost, care coordination, and meaningful use of certified EHR technology results in enhanced quality of care and reduced costs through more effective upstream chronic condition management. |
| Time Period | ASM is scheduled to begin Jan. 1, 2027, and end Dec. 31, 2031 (performance period 2027-2031 and payment period 2029-2033).
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| Eligible Participants | Clinicians who meet the following ASM participant eligibility criteria would be required to participate in ASM:
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| Clinician Specialty Identification | Consistent with the Quality Payment Program specialty type based on the specialty code indicated on the plurality of a clinician's Medicare Part B claims. Currently, clinicians with specialty codes other than cardiology are not included as ASM participants. As proposed, nonphysician practitioners are not eligible for ASM due to the lack of specialty designation. |
| Mandatory Geographic Areas | 25% of the core-based statistical areas (CBSAs) or metropolitan divisions within the U.S. will be selected for mandatory participation. |
| Performance Assessment | CMS will assess the performance of ASM participants in four ASM performance categories: (1) quality, (2) cost, (3) improvement activities, and (4) promoting interoperability conditions. |
| Quality Measures |
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| Cost Measure | HF Episode Based Cost Measure, including the following costs, as used in MIPS and the Advancing Care for Heart Disease MVP:
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| Improvement activities |
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| Promoting Interoperability Conditions |
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| Final Score Methodology | CMS is proposing to only add weights to the quality and cost ASM performance categories (50% each) for the final score. The improvement activities and promoting interoperability performance categories would not have added weights to broaden the distribution of final scores. The maximum improvement activities performance category scoring adjustment would be negative 20 points. The maximum promoting interoperability performance category scoring adjustment would be negative 10 points. |
| ASM Payment Approach | Based on performance scoring, participants will be assigned a payment adjustment factor from –9% to +9%, a portion of the Medicare Part B payments paid to ASM participants for covered professional services during an ASM performance year, which would result in net positive, neutral, or negative payment adjustments during an ASM payment year. CMS is proposing that risk levels increase in performance year 3-5 by 1% per year. |
| Waivers of Medicare Program Requirements |
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| Beneficiary Incentives | ASM participants would be allowed to provide in-kind patient engagement incentives provided the ASM participant is solely responsible for the cost of the incentive and advance clinical goals. CMS envisions the inclusion of remote monitoring devices, scales, etc. Incentive may not exceed $1,000 in retail value. |
Keywords: Centers for Medicare and Medicaid Services, U.S., Electronic Health Records, ACC Advocacy, Fee Schedules, Quality Indicators, Health Care, Chronic Disease, Physicians
