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Heads up! CMS’s Proposed 2026 PFS Rule introduces a new payment model for tackling specialty care and costs in traditional Medicare. Clearly not a snap decision, Ambulatory Specialty Model (ASM) has been cooked until well-seasoned and served up in 210 pages of the proposed Rule. Unlike a typical Notice from the CMS Innovation Center that initiates many Value-Based Care payment models, this detailed presentation signifies its importance.
Specialty care accounts for 40 to 60 percent of total health care costs, with a broad range of services included, such as consultations, imaging, tests, procedures, admissions, and various therapies. Until recently, costs were broken out into categories without attributing those costs to a single physician who managed the patient’s condition and ordered or referred these other services. That attribution of patient to physician is now proposed in ASM. Starting with heart failure and low back pain, this new model calculates costs and quality performance for specialists treating patients with those conditions and pays them based on a formula which favors better quality and cost performance.
ASM is a significant new path for how to pay specialists for management of chronic conditions such as the two initiating the program. It goes further than any other value-based payment model in performance requirements, scope, physician-level responsibility for cost and outcomes, and engagement of physicians in Value-Based Care accountability. It’s worth a deeper dive to examine the impact. Here are five things you need to understand about ASM…