Mandatory Medicare Specialty Pilot Reveals Texas Participants
By Phil West

More than 1,100 Texas physicians have been initially chosen to participate in a mandatory Medicare program for patients with heart failure and low back pain, with a launch date of Jan. 1, 2027.

The Ambulatory Specialty Model (ASM), which will run for five years, will require selected physicians to adopt measures from the Merit-Based Incentive Payment System’s (MIPS’) Value Pathways (MVPs) – a new reporting structure introduced in 2023 that has seen limited adoption to date. This is the first model out of the Centers for Medicare and Medicaid Innovation to adopt MVPs to track quality, cost, improvement activities, and interoperability in determining payment, per the Centers for Medicare and Medicaid Services (CMS).  

The Texas Medical Association has been critical of MIPS and MVPs performance measures in the past, noting that they sometimes penalize physicians for factors beyond control, “with no evidence that [MIPS] supports care improvements,” and that, despite the steps CMS has taken to improve MIPS reporting by rolling out MVPs, “TMA skeptically views [MVPs] as the same old MIPS, just rebranded and wrapped in a shiny new package.”

Physicians can now review the initial database of participants, representing about a quarter of federally designated regions where ASM will be piloted, in the following specialties:

• Cardiology,
• Anesthesiology,
• Pain management,
• Interventional pain management,
• Neurosurgery,
• Orthopedic surgery, and
• Physical medicine and rehabilitation.

“The model will only include physicians who have historically treated at least 20 heart failure or low back episodes per year as identified by the episode-based cost measure methodology,” CMS specified on its site.

In this first payment year, 2029, payment will be subject to as much as a 9% increase or decrease in ASM’s initial year, as MIPS is, depending on how the physician scores on the program’s performance measures. That 9% variance is slated to rise to 12% before the pilot ends. Per CMS’ info sheet, performance years will run from 2027 to 2031, with corresponding payment years running from 2029 to 2033.

In a September 2025 letter addressing the proposed 2026 Medicare Physician Fee schedule, TMA expressed concern about the program, designed by the Center for Medicare and Medicaid Innovation.

While TMA appreciates “CMS efforts to develop a specialist-focused value-based payment model centered on the ambulatory care setting, where individual physicians – rather than health care facilities or physician aggregators – can take the lead,” it also critiques utilizing the MVP framework for payment, urging the federal agency to “to adopt a more measured glide path to risk by lowering payment adjustment rates.”

ASM will measure physicians at the individual (NPI) level, rather than the group (TIN) level, on quality and cost performance, with each weighted at 50%. The care improvement and promoting interoperability categories will be measured at the group level. However, CMS notes ASM participants in small practices are allowed to report quality data at the TIN level.

ASM intends to “focus on interventions that are low cost with high patient benefits,” per the model’s webpage. CMS says it is targeting heart failure and low back pain because they are among the costliest conditions for Medicare patients. with annual spending ranging up to $13 billion and $8 billion, respectively.

Although ASM is limited to these conditions, the model’s rollout may signal broader changes in Medicare payment, with CMS placing greater emphasis on condition-based models across other specialties.

TMA will continue to monitor developments ahead of the launch date, including more details about payment and performance measures, and how attribution will be determined – particularly for patients who see several different physicians within the same physician group. 

Find a FAQ page and more resources on CMS’ ASM page.