CMS’ Ambulatory Specialty Model could cause thousands of Medicare beneficiaries with low back pain and heart failure to lose access to specialty care, and could leave small rural communities without specialists, according to an Oct. 27 report from the Center for Healthcare Quality and Payment Reform.
The mandatory model is set to begin in January 2027, requiring more than 5,500 specialists to participate. This includes 2,200 cardiologists, 826 physiatrists, 760 orthopedic surgeons, 626 pain management physicians, 395 interventional pain management physicians, 487 anesthesiologists and 246 neurosurgeons, the report said.
Medicare Part B payments to physicians assigned to ASM will be increased or decreased from 2029 through 2033 based on their model performance scores from 2027 to 2031. Adjustments can reach up to 9% in 2029 and 2030, 10% in 2031, 11% in 2032 and 12% in 2033.
The report said payment increases under ASM are limited to 85% of total reductions, and are designed to create cuts for most specialists, even if they deliver high-quality care. The adjustments touch every service a physician offers to every Medicare patient, not only those for patients with heart failure or low back pain.
Physicians join the model once they are attributed 20 episodes of care under the MIPS Heart Failure Episode-Based Cost Measure or the Low Back Pain Episode-Based Cost Measure based on services they provided two years prior.
CMS said 43% of cardiologists assigned to the model treat only 20 to 29 Medicare beneficiaries with heart failure, with 35% of the specialists assigned to low back pain treating only 20 to 29 Medicare beneficiaries with low back pain. Physicians could avoid the ASM entirely by treating fewer of those patients, the report said. It also said the model could discourage one-time consultations or second opinions due to a single visit making a specialist accountable for a patient’s costs for up to one year.
The report said geography could increase the risk. The model covers 235 areas, with most of the country’s largest metros like New York City, Los Angeles, Chicago, Philadelphia and Boston excluded.
About one-third of the selected areas are completely rural, and in 19% of them only one cardiologist is assigned to ASM. In Rice Lake, Wis., and Dodge City, Kan., for example, losing a single specialist could force patients to travel an hour or more for care, the report said.
“The payment cuts under ASM will penalize specialists for providing services to heart failure and low back pain patients in these communities, and it could discourage specialists from practicing in these communities,” the report said. “As a result, the residents of these communities will be less likely to receive the services they need, and mortality and hospitalization rates will increase as a result. Rural hospitals could close if specialists are no longer willing to work in the community.”
CMS reaffirmed a plan to launch ASM in the proposed 2027 physician fee schedule. Public comments closed Sept. 14, with the final rule expected before the end of the year.
Becker’s 3rd Annual Fall Chief Pharmacy Officer Summit is the top tier event that the people leading the future of pharmacy convene. This 3-day event is built specifically for Chief Pharmacy Officers and senior pharmacy leaders. The sessions examine the workforce, financial and clinical priorities shaping pharmacy today. Becker’s is where candid discussions flourish and new ideas thrive. Becker's 3rd Annual Fall Chief Pharmacy Officer Summit
