Main Library

The 2026 CMS PFS Final Rule: The 5 Ways CMS Aims to Control Total Cost of Care

David HalpertRoji Health IntelligenceBest Practices & Strategies for Success,Care Management & Coordination,TEAM,Risk Management & Stratification,Social Determinants Of Health (SDOH),Medicare, MA, MSSP, & Medicare ACOs,Interoperability,Quality Metrics, Quality Reporting, Clinical Quality Measures (CQMs),Primary Care,Payers, Plans, & Claims,Health Equity,CMS, CMMI, Government, Policy & Regulations,Specialty Care,Accountable Care Organizations (ACOs),Physician-Led ACOs,Contracts, contract management,Physician Fee Schedule,Merit-based Incentive Payment System (MIPS)

The CMS PFS Final Rule is out . . . early? If you’re wondering how, in the midst of the Shutdown, a 2,375-page Rule could be released, the answer is simple: most of the proposals from this summer were finalized as is.

There are always exceptions, but the big takeaway is that this Rule solidifies CMS’s proposals to control the Total Cost of Care. Through a variety of finalized proposals, we’ve identified five themes that illustrate how they intend to accomplish this, and what it means for you.

1. Bit by Bit, Everyone Will be Shunted into Two-Sided Risk

The key tenet in CMS’s push to save money through accountable care relationships is that providers must be at financial risk. A program that will pay providers a bonus but not recoup high costs will not reduce CMS expenditures. Through a new and mandatory program, the Ambulatory Specialty Model (ASM), and a change to the Medicare Shared Savings (MSSP) ACO model, the theme of two-sided risk will have an extremely broad impact across organizations and providers.

The Ambulatory Surgical Model (ASM) was finalized as a mandatory model for providers treating patients with heart failure or low back pain. The program is set to begin in 2027 and run for seven years (including post-reporting payment years).

Full Article

Visit the Roji Health Intelligence Exhibit Booth

 

Free Webinar Access

Please fill out the form below to access recording.