The first mandatory model aimed at individual specialists starts in 2027. It scores cardiologists and back pain clinicians on outcomes they share with primary care.
Every model so far in this course pays for a procedure or an episode. The Ambulatory Specialty Model does something different: it holds individual specialists accountable for how well they manage a chronic condition over time, and it does so mandatorily.
What ASM is
ASM “aims to improve upstream management of chronic disease to reduce avoidable hospitalizations and unnecessary procedures in Original Medicare. It tests whether performance-based payment adjustments for select specialists who care for beneficiaries with heart failure or low back pain will encourage stronger care coordination and chronic disease management.”
ASM is a mandatory model with five performance years that run from January 1, 2027, through December 31, 2031. As of mid-2026 its stage is Announced, with a preliminary participant list published and further changes proposed in the CY2027 Physician Fee Schedule rulemaking.
Participation is determined by specialty, geography, and volume: specialists who frequently treat low back pain or heart failure, practice within selected core-based statistical areas or metropolitan divisions, and have historically treated at least 20 Original Medicare patients with either condition over a twelve-month period.
The two conditions
Heart failure and low back pain look unrelated and were chosen for the same reason. Both are conditions where:
- A specialist is often the primary manager rather than a consultant.
- Downstream costs are dominated by events that better upstream management could prevent, namely hospitalizations for heart failure and procedures for back pain.
- Practice variation is wide and not obviously explained by patient need.
CMS states the problem as fragmentation: “People with chronic conditions often see multiple, unconnected clinicians, which can lead to fragmented care, delayed diagnoses and treatment, unnecessary procedures and hospitalization, and poor health outcomes.” The solution is framed as “rewarding ASM participants that are heart failure and low back pain specialists for improving patient health outcomes and coordinating with primary care providers.”
Built on MIPS Value Pathways
ASM “leverages the CMS Merit-based Incentive Payment System (MIPS) Value Pathways (MVP) framework,” so that “ASM’s performance measures and activities are tailored to the provider type and condition being treated.”
That choice is significant. The Medicare course covered MedPAC’s objection to MIPS, that scoring individual clinicians misstates how outcomes are produced. MVPs were the response: condition-specific measure sets that at least ask a cardiologist about cardiology. ASM takes that framework and attaches real money and mandatory participation to it.
Worth remembering: ASM is the answer to the question this course exists to ask. For a decade the specialist’s role in value-based care was to be managed by somebody else, through referral steering by an ACO, through a hospital’s episode program, through a health plan’s network tier. ASM makes selected specialists directly accountable for the longitudinal outcomes of a population they treat, and requires them to coordinate with primary care rather than around it. Whether it works is unknown; it has not started. What is already true is that the specialist is no longer only an input to someone else’s accountability.
What to watch
Three questions will determine whether ASM is a template or a cautionary tale: whether condition-specific measures can be attributed fairly to one specialist, whether the payment adjustment is large enough to change behavior given what MIPS taught about weak incentives, and whether the coordination requirement with primary care produces genuine shared management or a documentation exercise.
Key takeaways
- ASM is mandatory for selected specialists, running January 1, 2027 through December 31, 2031.
- It covers heart failure and low back pain, selected on geography, specialty, and a minimum of 20 Medicare patients.
- It uses performance-based payment adjustments built on the MIPS Value Pathways framework.
- It is the first federal model to hold individual specialists accountable for longitudinal condition management.
Sources
Check your understanding
What makes the Ambulatory Specialty Model different from episode models like TEAM?
ASM targets upstream chronic disease management by heart failure and low back pain specialists, using performance-based payment adjustments built on the MIPS Value Pathways framework. It is about ongoing condition management rather than a procedure-triggered episode.