The Texas Medical Association has raised concerns about financial risk and performance measures in a new five-year mandatory pilot program for certain physicians treating heart failure or low back pain. Still, the Centers for Medicare & Medicaid Services (CMS) is poised to move forward, publishing a final list of required physician participants that includes 960 Texas physicians.
The agency also opened registration for an ASM participants’ office hour on Wednesday, Sept. 30, from noon to 1 pm CT, offering information about the ASM Participant Portal and onboarding resources, plus a live question-and-answer session with agency representatives.
The Ambulatory Specialty Model (ASM), slated to start on Jan. 1, 2027, requires selected physicians to adopt measures from the Merit-Based Incentive Payment System’s (MIPS’) Value Pathways (MVPs), a reporting structure introduced in 2023. CMS developed ASM, in part, to test whether holding select physician specialists accountable for the quality and cost of managing specific chronic conditions – heart failure and low back pain – can reduce Medicare spending while maintaining or improving care quality.
In its Sept. 14 comment letter on the proposed 2027 Medicare physician fee schedule, TMA asked CMS to delay the ASM program.
“Physicians need final participation information and adequate time and guidance to prepare before being subjected to significant financial risk,” TMA President Bradford W. Holland, MD, wrote. “TMA continues to oppose mandatory participation and urges CMS, at minimum, to provide an initial period of actionable performance feedback before physicians are subject to downside risk.”
Once launched, ASM will be an experimental Centers for Medicare and Medicaid Innovation model, adopting MVPs ahead of the planned 2029 CMS-wide transition from MIPS to MVPs. Similar to MIPS, ASM will determine a physician's performance score by tracking:
- Quality, such as controlling blood pressure in heart failure patients or improving functional status for low back pain patients;
- Cost, measured by reduction in care deemed unnecessary;
- Care-improvement activities, including increased patient engagement; and
- Improvement of interoperability, including implementing technology to communicate and share data electronically between patients and their primary care physicians.
The full list of physicians subject to the mandate can be downloaded from the CMS ASM participants’ webpage.
Based on the initial 2027 performance year, payment in 2029 is subject to up to a 9% increase or decrease, depending on how physicians score on performance measures, per CMS’ info sheet. CMS plans to raise the 9% plus-or-minus range to 12% before the pilot ends. Performance years run through 2031; corresponding payment years run through 2033.
In payment years, CMS will compare an ASM-participating physician's performance score with those of other ASM participants in the same cohort and specialty. For purposes of ASM, CMS uses Medicare Part B claims data – rather than a physician's self-reported specialty – to determine specialty type. As a result, the score needed to avoid a payment reduction will depend, in part, on the performance of other physicians in the same ASM cohort and specialty, which will not be known in advance. For a year in which a physician is required to participate, ASM reporting takes the place of MIPS reporting requirements.
CMS selected physicians based on their specialty, practice location, Medicare billing, and at least 20 qualifying episodes, as identified by the applicable episode-based cost measure methodology and attributed to a physician’s particular Taxpayer Identification Number/National Provider Identifier (TIN/NPI) combination during the applicable historical 12-month period. Importantly, an episode is a period of related care for one Medicare patient identified through Medicare claims, not a single visit or necessarily a distinct patient. So, 20 episodes does not mean 20 separate visits or even 20 different patients.
San Antonio orthopedic surgeon Adam Bruggeman, MD, who served on TMA’s Ad Hoc Committee on Alternative Payment Models, is among the 960 Texas physicians mandated to participate. He points out that for instance, even though ASM’s low back pain measures relate more to physical therapy and chiropractic care than orthopedic surgery, surgeons will be held to those standards.
“What we'd rather see is a mandatory model around something that we have knowledge about,” he said. “You start with an elective process, confirm that your measures are working, confirm that the process makes sense, and then you navigate over to a mandatory process.”
Rick Snyder, MD, a former TMA president who is currently president of a cardiology group and chief physician executive of another, says certain cardiologists at both practices have been enlisted into ASM, while others remain in MIPS. Because CMS moved some but not all of a practice’s physicians from MIPS to ASM, each practice now must report on separate sets of Medicare performance measures.
“This is one of the problems with this program. ... How do you manage that when you have these conflicting and different ways of approaching [performance]?” Dr. Snyder asked, noting that while his practice has a robust value-based care division that should be able to handle ASM requirements, smaller practices likely lack those resources.
Based on a quick tally of the final participant list, the 960 Texas physicians listed make up 17% of the more than 5,500 participants nationwide. That includes 346 Texas cardiologists, 143 (41%) of whom are in practices of 15 or fewer physicians. Of the 614 Texas physicians caring for low back pain patients across six specialties, 342 (56%) are from practices with 15 or fewer physicians.
Anesthesiologists, pain management specialists, and physical medicine and rehabilitation specialists make up the majority of that group, with interventional pain management, orthopedic surgery, and neurosurgery also represented.
If you provide care for Medicare patients with low back pain or heart failure and are unsure whether you are a required ASM participant, check the CMS ASM participants list for your NPI and each TIN/NPI combination.
Learn more about TMA’s views on the proposed Medicare physician fee schedule through its federal advocacy page.
Phil West
Associate Editor
(512) 370-1394
phil.west[at]texmed[dot]org
Phil West is a writer and editor whose publications include the Los Angeles Times, Seattle Times, Austin American-Statesman, and San Antonio Express-News. He earned a BA in journalism from the University of Washington and an MFA from the University of Texas at Austin’s James A. Michener Center for Writers. He lives in Austin with his wife, children, and a trio of free-spirited dogs.