ASA Urges CMS to Refine CJR-X and ASC Episode Models in FY 2027 IPPS Proposal

The American Society of Anesthesiologists (ASA) submitted formal comments to the Centers for Medicare & Medicaid Services (CMS) in response to the FY 2027 Hospital Inpatient Prospective Payment System (IPPS) proposed rule, urging refinements to episode-based payment models to better reflect clinical realities, multidisciplinary care, and responsible stewardship of Medicare resources.

Drawing on anesthesiologists’ expertise in perioperative medicine, care coordination, and value-based payment models including the Comprehensive Care for Joint Replacement (CJR) model and the Transforming Episode Accountability Model (TEAM), ASA identified key structural gaps in the proposed CJR-X model.

Most notably, ASA emphasized that anesthesiologists often operate in a position of de facto accountability for episode outcomes, influencing cost, quality, throughput, and care pathways, yet lack consistent access to data, governance participation, and gainsharing opportunities tied to those outcomes. This misalignment limits meaningful engagement in care redesign and reduces the effectiveness of value-based models intended to promote coordinated, high-quality care.

Key Recommendations for CJR-X

To strengthen specialist engagement, improve care coordination, and enhance model performance, ASA urged CMS to:

• Track and report specialist contributions
  Include anesthesiology, pain medicine, and critical care in performance measurement and financial accountability frameworks to reflect their impact on outcomes and resource utilization.
• Establish clear expectations for gainsharing participation
  Build on CMS’s proposal requiring written financial agreements by defining minimum standards for including non-surgeon specialists, with transparent methodologies and equitable distribution of shared savings.
• Ensure meaningful representation in governance
  Require hospital governing bodies to include anesthesiologists and other non-surgeon specialists, recognizing their leadership role in perioperative care coordination and care pathway design.
• Align incentives across the full care team
  Reduce reliance on variable, institution-specific arrangements and promote consistent, shared accountability across clinicians contributing to episode performance.
• Strengthen and modernize risk adjustment
  Ensure models account for clinical complexity and other risk factors, including uncontrolled comorbidities, frailty, behavioral health conditions, and barriers to recovery such as housing instability, transportation limitations, and limited access to follow-up care.
• Align performance measurement with care quality
  Support more accurate evaluation of outcomes and equitable participation by ensuring quality metrics appropriately reflect patient populations and care complexity.

In addition, ASA recommended that CMS reconsider mandatory participation in CJR-X and instead adopt voluntary or phased participation approaches, citing financial pressures on practices and hospitals and the need for flexibility to support readiness for value-based care.

Concerns with Expanding Episode Models to Ambulatory Surgical Centers (ASCs)

ASA also raised significant concerns regarding the potential expansion of episode-based payment models to Ambulatory Surgical Centers (ASCs) through the TEAM model.

ASA emphasized that ASCs differ substantially from hospital-based settings in patient acuity, infrastructure, staffing, and ability to manage complications. Without tailored model design, applying hospital-based episode frameworks to ASCs could introduce patient safety risks, operational challenges, and unintended financial consequences.

Particular concern was raised for higher-risk patients, including those with frailty, uncontrolled chronic conditions, behavioral health needs, or social barriers that affect recovery and follow-up care. ASA cautioned that inadequately designed financial incentives could influence site-of-care decisions in ways that do not align with clinical appropriateness.

ASA further underscored that anesthesiologists in hospital and safety-net settings often treat more complex patient populations. Without appropriate safeguards, models may inadvertently penalize providers caring for higher-acuity patients or create disincentives to serve these populations.

Key Recommendations for TEAM Expansion to ASCs

To ensure safe and effective participation, ASA urged CMS to:

• Adopt robust, ASC-specific risk adjustment methodologies
  Incorporate clinical and non-clinical risk factors such as comorbidities, frailty, procedural complexity, behavioral health conditions, and barriers to recovery and follow-up care.
• Establish shared accountability models
  Reflect the multidisciplinary nature of perioperative care by including ASCs, surgeons, anesthesiologists, hospitals, and other participants in financial accountability and care redesign efforts.
• Provide phased participation and operational support
  Implement voluntary or staged participation timelines and offer upfront investment support for care coordination infrastructure, particularly in resource-limited ASC settings.
• Develop tailored quality measurement frameworks
  Ensure measures are feasible, appropriately risk-adjusted, and specific to the ASC environment—avoiding direct comparisons to hospital outpatient departments without accounting for differences in patient complexity and capabilities.
• Preserve physician-led site-of-care decision-making
  Safeguard clinical judgment to ensure patients receive care in the most appropriate setting based on medical need, not financial incentives.

Ensuring Access, Safety, and High-Quality Care

ASA cautioned that without targeted refinements, episode-based payment models risk misaligning incentives, limiting multidisciplinary collaboration, and restricting access to care for higher-risk Medicare beneficiaries.

Effective model design must recognize the shared nature of perioperative care, the diversity of care settings, and the complexity of patient populations. Aligning accountability, incentives, and measurement frameworks across the full care team is essential to achieving CMS’s goals of improving outcomes while maintaining access and patient safety.

Read ASA’s full comment letter for detailed recommendations and analysis of the FY 2027 IPPS proposed rule.