Assessing CMS’ Ambulatory Specialty Model: Policy Recommendations to Reduce Administrative Burden for Anesthesiologists and Pain Medicine Physicians

June 2026

ASA Center for Anesthesiology and Perioperative Economics (CAPE)

Download Policy Brief: Assessing CMS' Ambulatory Specialty Model (PDF)

Executive Summary

The Centers for Medicare and Medicaid Services’ (CMS) Ambulatory Specialty Model (ASM) is a five‑year mandatory payment model starting in January 2027 that aims to hold specialists treating low back pain and heart failure responsible for cost and quality of care. Specialists are selected for participation based on a minimum volume threshold attributed to the respective episode-based cost measure, as well as geographic location. ASM is based on the Merit-Based Incentive Payment System (MIPS) framework and includes maximum payment adjustments of -9/+9% in the first year that increase to -12/+12 by the model’s final year.

Overview

The Centers for Medicare and Medicaid Services’ (CMS) Ambulatory Specialty Model (ASM) is an Innovation Center model that aims to hold specialists accountable for cost and quality of care while improving chronic disease management.¹ The mandatory model is set to run from January 2027 through December 2031 and includes select anesthesiologists and pain medicine physicians in its low back pain cohort.²
ASM uses the Merit-Based Incentive Payment System (MIPS) framework, with the Quality and Cost categories scored at 50% each and the Improvement Activities (IA) and Promoting Interoperability (PI) categories functioning only as penalties if requirements are not met. Participation in ASM’s low back pain cohort occurs at the individual physician level and is limited to select geographic areas, with CMS applying a volume minimum of 20 episodes a year attributed to the episode-based cost measure for low back pain.¹

Physician and practice financial risk is substantial for ASM, and the model’s structure indicates a high likelihood for expansion. Potential payment adjustments start at -9%/+9% and climb to -12/+12% in the model’s final year. These payment adjustments occur two years after each respective performance year and are applied to a participant’s total Medicare B revenue. Unlike MIPS, which provides clinicians with a known threshold to target for a neutral or positive adjustment, ASM will not publish benchmarks in advance.³ This leaves participants with limited ability to gauge their performance in advance or target areas for improvement.

Although ASM allows for positive payouts, CMS will withhold 15% of all incentive payments as savings to the Medicare program.³ While discounts and shared savings mechanisms are common across payment models, they are traditionally linked to care delivery transformation, allowing both participants and Medicare to share in savings gained through value-based care initiatives. However, the ASM withhold represents a direct cut to payments not tied to care transformation. This design also increases the likelihood that the model will qualify for expansion, as it almost guarantees Medicare savings, even in the absence of meaningful transformation in care delivery.

Analysis—Administrative Burden

ASM is set to result in significant administrative burden for anesthesiologists, pain medicine physicians, and physician practices. Yet CMS does not provide any financial support or incentives for participants confronting significant implementation costs. By CMS’ calculations, ASM will result in over $100 million in total administrative costs. A CAPE analysis found this figure to be an underestimation, since it does not account for many of the upfront costs associated with the model.

CMS’ Projected Administrative Costs

Source: Analysis by ASA CAPE based on projections from the CMS 2026 Physician Fee Schedule Final Rule.³ CAPE used CMS’ projected administrative costs per ASM participant per year to calculate total projected costs for all participants over the model period. Values were calculated using unrounded figures but are presented rounded to the nearest dollar.

CMS’ substantial ASM administrative burden projection of $102,122,192 is a significant underestimation.

• CMS’ projected administrative burden for ASM is substantial, but the real figure is likely much higher. CMS’ calculations mostly focus on the labor required to report measures. Because of this, CMS does not capture the full scope of new workflows, technology, and roles that might be needed to build the necessary infrastructure to be ASM compliant. Readiness assessments, new data collection systems, compliance with Improvement Activities, and additional practice hiring needs have the potential to significantly increase the administrative burden of ASM.
• For ASM participants who do not already participate in MIPS, upfront costs will be even higher. Based on CMS’ estimates, approximately 50% of ASM participants are not currently participating in MIPS.³ These ASM participants may not be familiar with the framework that ASM is built on and will need to invest a significant amount of time and money into developing the necessary new infrastructure to support compliance with ASM.

Upfront costs will likely also be higher than expected for ASM participants with experience in MIPS. CAPE found that the majority of ASM participants with MIPS experience used the group-reporting option instead of the individual reporting option that is required under ASM.⁴ ASM also includes mandatory quality measures, a significant deviation from MIPS, which allows for measure selection.¹ ASM’s individual-reporting requirement, mandatory quality measures, and lack of special statuses make it likely that new workflows, technology, and roles might be needed even for those who already participate in MIPS.

Anesthesia and Pain Medicine practices may require additional financial support to implement ASM.

• ASM holds physicians accountable at the individual level but does not provide any upfront payments or adequate time to support model implementation. ASM represents a troubling breakaway from other models by not allowing group reporting or supporting implementation. Most Innovation Center models function at the hospital, ACO, or practice level, and models like Making Care Primary provided upfront infrastructure payments to support participation.⁵

ASM’s high administrative costs may create barriers to meaningful participation among required participants and could increase consolidation across the healthcare landscape.

• Financial Barriers to Participation: For some participants, total costs of active engagement, including administrative costs, may exceed maximum losses under the model, making meaningful participation difficult to justify. Even though ASM operates at the individual level, medium-to-large practices are likely to handle reporting centrally at the practice level. For medium-to-large practices with a small number of physicians selected for ASM participation, the investment required to participate in the model may far exceed potential payment losses under the model.
• Consolidation: Because larger organizations may be better equipped to absorb ASM payment losses and support ASM infrastructure, ASM participants may be incentivized to join a larger practice or become directly employed by a health system to minimize risk associated with the model. Increased healthcare consolidation can hinder competition and patient choice, which is in contradiction to the Administration’s goals for the CMS Innovation Center.⁶

Analysis—Special Statuses

ASM does not honor special statuses, which departs from the established MIPS framework. A CAPE analysis concludes that over two-thirds of anesthesiologists in ASM would likely qualify for MIPS special statuses, undermining CMS’ argument that special statuses would not be applicable for selected ASM participants.³

• For anesthesiology and interventional pain management, over two-thirds of participants qualify for at least one special status that exempts them from reporting the PI category in MIPS, and over half of those in pain management qualify for an exemption.⁴
• CMS has never posted a clear estimate of the true cost of PI participation. Implementation and reporting costs must account for purchasing or maintaining Certified Electronic Health Record Technology/Electronic Health Record (CEHRT/EHR) systems, interface development, information technology (IT) vendor fees, workflow redesign, clinician training, registry connectivity, Trusted Exchange Framework and Common Agreement (TEFCA) participation costs, cybersecurity investments, consultant support, and internal compliance oversight. Requiring PI participation for those who never participated will incur significant per user expenses.
• Many anesthesiologists and pain physicians do not control the full EHR environment, portal configuration, health information exchange, or e-prescribing infrastructure. Special status PI exemptions reflect clinical workflows unique to anesthesiologists and pain medicine physicians.
• The proportion of anesthesiologists and pain medicine physicians in ASM who likely qualify for a special status exempting them from reporting PI in MIPS is significantly higher than that of other specialties in the ASM low back pain cohort.⁴ Therefore, not honoring special statuses puts anesthesiologists and pain medicine physicians at a clear disadvantage in ASM.

Qualification for PI Exemption Based on Special Status by Medical Specialty – Low Back Pain Cohort

Source: Analysis by ASA CAPE based on the 2024 Quality Payment Program (QPP) Public Use File (PUF).⁴

I. Includes all Tax Identification Numbers-National Provider Identifiers (TINs-NPIs) from the 2024 QPP PUF associated with ASM Participant NPIs.
II. Count of physicians who had at least one special status (i.e., small practice, hospital-based, non-patient facing, Ambulatory Surgery Center (ASC) based) that qualified them for automatic reweighing of the PI performance category in MIPS for 2024.

Looking Forward

CAPE’s evaluation of ASM indicates that the model will result in significant physician and practice burden while failing to engage anesthesiologists and pain medicine physicians in the meaningful care transformation that drives value in healthcare. Anesthesiologists and pain medicine physicians want to be incorporated into alternative payment models that decrease healthcare costs while improving care quality. CMS should actively and transparently engage with specialists as a partner to innovation and avoid unnecessarily burdensome requirements. Future specialist-specific model development would greatly benefit from early conversations between the CMS Innovation Center and specialty associations. Early conversations between the ASA and the CMS Innovation Center would promote buy-in while ensuring that models reflect clinical workflows and minimize physician burden.

References

1. Centers for Medicare & Medicaid Services. ASM (Ambulatory Specialty Model). April 23, 2026. Accessed June 1, 2026.
   ASM (Ambulatory Specialty Model) | CMS
2. Centers for Medicare & Medicaid Services. Ambulatory Specialty Model Participants. February 4, 2026. Accessed June 1, 2026.
   Ambulatory Specialty Model Participants Data | CMS Data
3. Centers for Medicare & Medicaid Services. Medicare and Medicaid Programs; CY 2026 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; and Medicare Prescription Drug Inflation Rebate Program. November 5, 2025. Accessed June 1, 2026
   Federal Register :: Medicare and Medicaid Programs; CY 2026 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; and Medicare Prescription Drug Inflation Rebate Program
4. Centers for Medicare & Medicaid Services. 2024 Quality Payment Program (QPP) Public Use File (PUF). May 19, 2026. Accessed June 1, 2026.
   Quality Payment Program Experience Data | CMS Data
5. Centers for Medicare & Medicaid Services. Making Care Primary (MCP) Model. Accessed June 1, 2026.
   Making Care Primary (MCP) Model | CMS
6. Centers for Medicare & Medicaid Services. CMS Innovation Center Strategy to Make America Healthy Again. May 15, 2025. Accessed June 1, 2026.
   CMS Innovation Center Strategy to Make America Healthy Again | CMS

Suggested Citation:
Center for Anesthesia Perioperative Economics. Assessing CMS’ Ambulatory Specialty Model: Policy Recommendations to Reduce Administrative Burden for Anesthesiologists and Pain Medicine Physicians. Schaumburg, IL: American Society of Anesthesiologists; June 2026.