Concerns Mount Ahead of CMMI’s Specialty Model Launch

The model was developed by the Center for Medicare & Medicaid Innovation (CMMI) and is slated to begin Jan. 1, 2027. It will test whether performance-based payment adjustments can improve quality and reduce spending for traditional Medicare beneficiaries receiving treatment for heart failure and low back pain in outpatient settings. Participating specialists will be evaluated on quality, cost, improvement activities and interoperability with their performance affecting future Medicare Part B payments.

The model’s first performance year begins in 2027, with payment adjustments taking effect in 2029. In an Oct. 27 letter to federal officials, the coalition asked CMS to postpone implementation until the model’s operational and technical infrastructure is fully functional as explained in Healthcare Innovation. Seven entities are included:

1. The American Hospital Association
2. American Medical Association
3. AMGA
4. Health Care Transformation Task Force
5. Medical Group Management Association
6. National Association of ACOs
7. Premier Inc.

The groups said delayed participant identification, limited access to the ASM online portal, inadequate guidance and slow technical support have left practices with only a few months to prepare for a model that carries significant financial risk. They also noted that the final participant list was released Sept. 15, roughly two months later than anticipated, leaving affected specialists just three months to prepare for implementation. Provider organizations argued that ongoing portal problems, difficulties delegating staff authority and inconsistent responses to operational questions have further complicated readiness efforts.

Health Exec reported if CMS proceeds with the planned launch, the coalition is seeking protection from downside financial risk during the first performance year and greater transparency around cost and quality benchmarks so practices can understand how their performance will be measured. They also want CMS to establish a single help desk and provide practice-level reporting to reduce administrative burdens.

Even if CMS proceeds with the scheduled launch, the groups are asking the agency to waive downside financial risk during the first performance period while technical infrastructure stabilizes. They also want CMS to provide greater clarity on performance thresholds and reporting requirements before the model takes effect. While most stakeholders support the broader goal of moving specialty care toward value-based reimbursement, some critics contend the problems run deeper than implementation.

Harold D. Miller, president and CEO of the Center for Healthcare Quality and Payment Reform, has called for CMS to abandon the model altogether. Miller shared his opinion with Inside Health Policy arguing the program’s design could penalize physicians even when they deliver high-quality care because participants are measured against one another rather than against a fixed performance standard. Thus, many physicians could see payment reductions despite delivering high-quality care. According to Miller, payment cuts could reach 9% for some participating physicians, creating incentives to limit the number of Medicare patients with heart failure or low back pain they treat. He warned the consequences could be especially significant in rural communities, where specialist shortages already challenge access to care. Miller contended that reduced physician participation could make it harder for rural hospitals to recruit specialists, potentially forcing service reductions or even threatening the viability of some facilities. Miller said,

CMS intentionally designed ASM so that it cuts payments to the majority of these physicians even if they are delivering high-quality care. The payment cuts could be as high as 9%. The only way these specialists can avoid the payment cuts is to stop providing services to Medicare beneficiaries with heart failure or low back pain. This could reduce access to care for tens of thousands of Medicare beneficiaries.

The debate underscores the tension at the center of Medicare’s value-based care agenda. Supporters see the ASM as an important test of whether specialty physicians can be more directly engaged in cost and quality improvement efforts. Opponents counter that launching a mandatory model before providers have the tools and support needed to participate could compromise both the program’s effectiveness and patient care. As the Jan. 1 launch date approaches, providers are warning that unless CMS addresses both operational concerns and broader questions about the model’s design, the experiment could have unintended consequences for the very patients it is intended to help.