ASM
Ambulatory Specialty Model
The Ambulatory Specialty Model (ASM) aims to improve prevention and upstream management of chronic disease, which would lead to reductions in avoidable hospitalizations and unnecessary procedures. Participation in ASM will be mandatory for specialists who commonly treat people with Original Medicare for heart failure or low back pain in an outpatient setting across selected regions.
Innovation
ASM focuses on outpatient specialty care of chronic conditions rather than hospital-based models, exempting participants from MIPS and rewarding specialists for upstream disease management and primary care coordination.
The Problem
Delayed detection of chronic conditions, financial incentives that encourage unnecessary procedures, and the lack of care coordination among specialists and primary care providers all contribute to poor health outcomes for people who are at risk for or living with chronic disease. These include delayed diagnosis and poor disease management.
The Solution
ASM will promote preventive care and more effective upstream chronic disease management by rewarding specialists for improving patient health outcomes and coordination with primary care providers.
Expected Outcomes
ASM will reduce avoidable hospitalizations and unnecessary procedures, improve patient experience and outcomes, and lower costs to Original Medicare.
Strategy
ASM will help to Make America Healthy Again by promoting preventive care through interventions like screening, increasing transparency by making provider performance assessments more widely available, and protecting American taxpayers by holding specialists accountable for the cost of care.
Model Goals
- Improve prevention and upstream management of chronic disease
- Reduce avoidable hospitalizations and unnecessary procedures
- Improve patient experience and outcomes
- Lower costs to Original Medicare
Patient Eligibility
People with Original Medicare treated for heart failure or low back pain in an outpatient setting.
- Enrolled in Original Medicare
- Treated for heart failure or low back pain in an outpatient setting
Provider Eligibility
Individual physicians billing under the Medicare Physician Fee Schedule in selected mandatory geographic areas who treat heart failure or low back pain.
- Bill claims under the Medicare Physician Fee Schedule
- Have a selected specialty type related to an ASM targeted chronic condition (cardiology, anesthesiology, interventional pain management, neurosurgery, orthopedic surgery, pain management, or physical medicine and rehabilitation)
- Are attributed to 20 or more episodes from the episode-based cost measure (EBCM) related to their specialty type and ASM targeted chronic condition
- Practice in one of the selected mandatory geographic areas
Care Categories
Chronic Disease Management
CMS Benchmarks & Thresholds
eligibility
financial
operational
quality
Operational Friction
Identified risk vectors and execution hurdles based on model structure.
Specialists must identify eligible Heart Failure (HF) and Low Back Pain (LBP) patients at the point of scheduling to initiate upstream conservative management and capture baseline functional assessments.
Specialists are held accountable for Risk-Standardized Acute Unplanned Cardiovascular-Related Admissions (Q492) and excess utilization, requiring real-time visibility into care occurring outside their ambulatory clinic.
The cost trajectory for LBP and HF episodes locks in quickly once a procedural intervention (e.g., spinal injection, surgery) or acute admission occurs, making upstream conservative management critical.
Specialists must rely on Primary Care Providers (PCPs) to co-manage comorbidities like hypertension, BMI, and depression to succeed in the model's holistic quality metrics.
Is this model right for your organization?
Answer three quick questions about your facility and get matched to the VBC models that fit your profile with verified benchmark context.
Start Your Analysis