‘Like MIPS on Steroids’: What Practices Can Expect From Ambulatory Specialty Model

The CMS Innovation Center’s Ambulatory Specialty Model (ASM), which represents a new approach to engaging specialists in value-based care, will begin in 2027 for selected specialists who treat people with Original Medicare for heart failure or low back pain in an outpatient setting across selected geographic regions. Healthcare Innovation recently spoke with former NAACOS executive David Pittman, M.P.H., founder of Pittman Policy Strategies, about the significance of this new model and why specialists in those fields should begin preparing now. 

Initially a journalist, Pittman held a policy and communications role at NAACOS for seven years. His new consulting firm offers a blend of policy, communications strategy, and advocacy expertise. He wrote a concise explanation of the implications of the ASM model on his website, so I reached out to him to dive into this topic. 

Pittman noted that many specialists are going to be chosen to participate in ASM and it would be best for them to start thinking about it now and start getting the infrastructure in place to make it happen if they need to. It's only for cardiologists and specialists who deal with low back pain, including anesthesiology, and it will only be mandatory for roughly a quarter of them.

The model aims to improve prevention and upstream management of chronic disease, which should lead to reductions in avoidable hospitalizations and unnecessary procedures. Pittman noted that ambulatory-based specialists traditionally haven’t had to deal with some of these issues. “What makes this model unique is now they're having to think about some of these things,” he said.

ASM will use a two-sided risk arrangement. Based on performance relative to their peers, a participant will receive a positive payment adjustment, a neutral payment adjustment, or a negative payment adjustment on their future Medicare Part B claims for covered services. One of the CMS Innovation Center’s current principles is to increase competition, and this may work to create competition among specialists in the same field, Pittman noted. 

CMS will release preliminary participant lists early next year, and then the final participant list in July 2026, with plans to start in 2027. “It's been described as MIPS on steroids,” Pittman said. In many ways, it's like MIPS, but it does add things that are not in MIPS. There are things like patient-reported outcomes that the specialists have to report. Patient-reported outcomes are relatively new in the quality measurement space, Pittman noted. “We don't have that in ACO models today. People are still learning how to optimize it. I think we need a little bit more specificity from CMS on what it looks like, and how to track it, and how to collect those patient functional status scores to tell how much of a lift it will be. It will take some effort to successfully report those.”

The model also calls for setting up collaborative care arrangements with primary care practices. “CMS should be applauded for trying to create more of these relationships between specialists and primary care, because having that relationship is necessary, and this is another area that will take effort by practices to establish these agreements,” he said. 

Pittman added that if a practice hasn’t been doing electronic clinical quality measures, that takes time to set up as well.

He noted that CMS has previously tried to engage specialists in value-based care through hospital-based payments, like bundled payments and now through the TEAM model which starts in January. But outside of oncology and the kidney space, there hasn't been a concerted effort to involve specialists in ambulatory settings in alternative payment models.

ACOs also have had difficulty engaging ambulatory specialists. “In my opinion, some physician specialties make a lot of money in the outpatient setting, unlike primary care, which generally is underpaid for their value to the health system,” Pittman said. “So to ask them to participate in ACOs means that they might make less money. When you squeeze the balloon in the health system, maybe they're the ones being squeezed. When I worked at NAACOS, what we heard from our ACO members was that people had difficulty going to specialists because they saw it as making less money with the possibility of maybe sharing in shared savings later. It just wasn't a value proposition for them financially. So they would say they were happy with the status quo.”

The success of the model will depend on whether it saves Medicare money and improves quality. "It is in the law that that's CMMI’s standard,” Pittman said. “They have to improve quality or lower Medicare spending or both. That will dictate, what they do going forward, and whether they involve other specialists and other conditions."