Medicare's Ambulatory Specialty Model (2027): What It Means for Cardiology, Spine and Pain Physician Pay

Most Medicare payment changes hit every physician at once: the conversion factor, a new code, a MIPS threshold. The Ambulatory Specialty Model is different. It applies to a few thousand named physicians in randomly chosen markets, it grades each of them against their peers on one condition, and it moves their Medicare pay up or down by as much as 12%. If you are a cardiologist or a spine or pain physician, this guide covers whether you are in it, what it can cost or pay you, and what to do before it starts.

For the conversion factor and the rest of next year's Medicare rule, see our 2027 Medicare physician fee schedule guide.

What the Ambulatory Specialty Model is

The ASM is a CMS Innovation Center payment model, finalized in the 2026 Medicare physician fee schedule rule on October 31, 2025. It holds individual specialists financially accountable for how well, and how expensively, their Medicare patients with two common chronic conditions are cared for: heart failure and low back pain.

It borrows MIPS's four categories (quality, cost, improvement activities and promoting interoperability) but scores them differently, compares you only with other physicians treating the same condition, and uses a larger, two-sided payment adjustment. For the years you are in it, it replaces MIPS. It runs for five performance years, 2027 through 2031.

Who is in it

A physician is in the model for a given year when all three of these are true:

1. Specialty. Cardiology for the heart failure cohort. Anesthesiology, pain management, interventional pain management, neurosurgery, orthopedic surgery or physical medicine and rehabilitation for the low back pain cohort. CMS uses the specialty code on most of your Medicare Part B claims, so a cardiologist who bills mainly as interventional cardiology or electrophysiology is generally not in the heart failure cohort.
2. Location. A service location in one of the 235 metropolitan areas and divisions CMS selected at random, roughly a quarter of the 935 nationwide. The draw was stratified by Medicare spending, episode volume and metro status, so it includes both expensive and inexpensive markets.
3. Volume. At least 20 attributed episodes of the condition, using Medicare's episode-based cost measures. Eligibility for 2027 is based on 2025 claims.

Inclusion is decided per physician, by NPI and billing TIN, not per practice, so two partners in the same group can be treated differently. CMS posted a preliminary list of 6,637 clinicians in February 2026 and the final 2027 list in September 2026: 5,556 physicians, with no one added who wasn't on the preliminary list.

To check: open the ASM Participants dataset on data.cms.gov and search by NPI or name. Each record shows the cohort and the performance years you must meet the model's requirements. Practice managers can search by organization name to see everyone in a group at once.

Timeline and risk levels

Each year's performance sets the payment adjustment two years later. The “risk level” is the largest cut or bonus possible that year.

The first two years carry the same ±9% as MIPS. After that, the stakes are higher than MIPS has ever been.

What it means in dollars

The adjustment applies to your Medicare Part B payments for your own services in the payment year. The table shows the most you could lose or gain at three levels of yearly Part B payments. Most participants will land well inside these limits, because CMS deliberately designed the scoring to damp results at the extremes.

The pool is tilted against participants. Bonuses are funded from the cuts within each cohort, and for 2027 CMS pays out only 85% of that pool as bonuses. The other 15% goes to the Medicare Trust Fund. So for every $100 taken from below-average physicians, above-average physicians share about $85. Doing better than your peers is not optional if you want to come out ahead.

How the score works

Each participant gets a final score from 0 to 100 for each performance year:

The two required improvement activities both tie the specialist to the patient's primary care:

• Connect patients to primary care and screen for social needs. Confirm each patient in the model has a primary care clinician (and help them find one if not), send visit information back, and make sure an annual health-related social needs screening is done, by you or the primary care practice.
• A collaborative care arrangement. Sign at least one written agreement with a primary care practice that shares your patients, setting expectations for communication and co-management.

Two rules carry the most financial weight. Failing to submit quality data triggers the maximum cut, according to analyses of the rule. And a physician who reports but can't be scored on quality or cost, because they have fewer than 20 episodes or 20 cases in the performance year, gets no final score and a neutral adjustment.

Cardiology vs. spine and pain

Heart failure cohort (2,215 cardiologists)

The quality measures, as finalized, are unplanned cardiovascular admissions for heart failure patients, beta-blocker therapy and ACE inhibitor, ARB or ARNI therapy for reduced ejection fraction, blood pressure control, and functional status assessment. On cost, hospital admissions and readmissions drive most of the variation, so the practices that score well on cost will mostly be the ones that keep heart failure patients out of the hospital: fast follow-up after discharge, medication titration and remote monitoring.

Low back pain cohort (3,341 physicians)

The quality measures, as finalized, are lumbar MRI use for low back pain, high-risk medications in older adults, depression screening and follow-up, BMI screening and follow-up, and functional status change for low back impairments. Cost covers the whole episode, so imaging, injections, surgery and opioid prescribing all count against you. For physicians whose income depends on procedure volume, this is the first Medicare program that directly rewards doing fewer of them for the same patient population.

Anesthesiology, orthopedics and neurosurgery groups should note that only physicians who meet the episode threshold are included, which usually means the pain and spine physicians in a group, not every anesthesiologist or surgeon. Our cardiology, anesthesiology, orthopedic surgery and neurosurgery salary guides cover what these specialties earn today.

Employed physicians vs. practice owners

The adjustment lands on the Medicare claims billed for your work, which means it lands on whoever owns those claims.

• Practice owners and partners feel it directly: a cut comes out of collections, and therefore out of distributions.
• Employed on pure wRVU pay: no direct effect, since wRVUs don't change with Medicare adjustments. Expect your employer to care a great deal about your score anyway, and to ask you to change workflows.
• Employed on collections, net revenue or a quality bonus: you may share the result. Read the compensation section of your contract for language about payer adjustments, MIPS or “value-based” payments, and ask how the employer will treat ASM. Our wRVU guide and contract negotiation guide explain what to look for.

If you are negotiating a new job in a selected market, it is reasonable to ask that ASM adjustments be excluded from any collections-based pay for the first years, while the model and its benchmarks are new.

Changes proposed for 2027

CMS proposed a set of ASM changes in the 2027 physician fee schedule proposed rule on July 14, 2026. The final rule is expected around November 1, so these may change. Among them:

• Rural adjustment: five extra points on the final score for rural participants, who would keep the small-practice and complex-patient adjustments.
• Patient-reported outcomes: five extra quality points for voluntarily submitting patient-reported outcome data such as PROMIS.
• Low back pain measures: a new claims-based lumbar spine imaging measure, and a functional outcome assessment process measure in place of the functional status change measure.
• Staying in: a clinician selected for any performance year would remain a participant for the rest of the model unless terminated under specific rules.
• Exceptions: a permanent exception for certain heart failure specialists who change their specialty designation, and a formal process for TIN changes and other qualifying circumstances.

We will update this guide when the final rule is published.

What to do before January 1

1. Check the list. Search data.cms.gov for every cardiologist and spine or pain physician in your group, by NPI.
2. Update your contact information with CMS using the ASM participant contact form, so model notices and reports reach you.
3. Plan the quality reporting. Choose how you will submit the five measures (EHR, registry or another method) and confirm you can reach the data-completeness requirement. Not reporting is the one sure way to take the maximum cut.
4. Sign a collaborative care arrangement with at least one primary care practice you share patients with, and set up the primary care and social-needs workflow. Each missing activity costs 10 points.
5. Confirm your EHR meets the interoperability requirements (certified EHR technology), worth up to 10 points.
6. Estimate your exposure. Multiply your yearly Part B payments by the risk level; that is your range for 2029. If you're employed, ask how your contract treats it.
7. Watch the final rule around November 1 for the 2027 changes above.