Impact of the CMS Ambulatory Specialty Model on Anesthesiology
Scheduled to launch on January 1, 2027, the Centers for Medicare & Medicaid Services (CMS) Ambulatory Specialty Model (ASM) represents a five-year mandatory alternative payment model targeting high-cost, high-volume chronic conditions in outpatient settings.1 Within this framework, anesthesiologists and pain management physicians who historically treat at least 20 low back pain episodes annually in selected geographic areas will be mandatorily enrolled.2,3 While conceptually aligned with broader value-based care initiatives, the inclusion of anesthesiology in the CMS Ambulatory Specialty Model has generated substantial concern, particularly from the American Society of Anesthesiologists (ASA).4
A central concern is the model’s reporting structure, as the ASM requires a fundamental shift in how practitioners submit their performance data. Although ASM builds on the Merit-based Incentive Payment System (MIPS), a CMS program that adjusts physician payments based on performance across quality, cost, improvement activities, and interoperability metrics, and replaces traditional MIPS participation for enrolled clinicians, it departs in a critical way by mandating individual-level reporting.1,3 This is a major shift for anesthesiology, where group-based reporting, in which the entire practice reports as one unit, has been the norm. The ASA argues that this creates a dual-reporting burden, forcing practices to simultaneously maintain ASM reporting for some clinicians and MIPS reporting for others within the same group, significantly increasing administrative complexity and cost.4
More fundamentally, ASA argues that the performance metrics used by the Ambulatory Specialty Model are poorly aligned with anesthesiology practice. ASM scores clinicians based on quality and cost, each contributing 50% of the final score.1,2 However, the proposed quality measures for the low back pain cohort include measures that are not routinely collected or reported by anesthesiologists, including screening for depression and conducting a functional status assessment.3,4 Many ambulatory anesthesia practices, which work in procedural settings, may lack the full clinic-style electronic infrastructure that usually supports seamless reporting of electronic clinical quality measures.
Additionally, CMS evaluates clinicians based on the total cost of a “low back pain episode,” including imaging, procedures, hospitalizations, and other downstream care. However, these costs are attributed to individual clinicians based on billing patterns, even if they were not the primary drivers of care. Notably, anesthesiology was not among the primary specialties involved in developing the low back pain cost measure, raising concerns that clinicians will be evaluated based on spending patterns they do not meaningfully control.4
These structural issues impact clinicians financially. The ASM introduces two-sided risk, with payment adjustments ranging from -9% to +9% initially in 2027, and expanding up to a -12% penalty by the model’s final year in 2031.1,2 Crucially, these adjustments apply to an individual physician’s total Medicare Part B revenue, not just services related to low back pain.1,4 As a result, anesthesiologists may face substantial financial penalties even if low back pain represents only a small portion of their clinical activity. The ASA further notes that the model includes punitive elements tied to improvement activities and interoperability requirements, such as care coordination tasks that fall outside the typical, episodic scope of anesthesiology practice, which is largely procedural and perioperative with limited longitudinal patient engagement.2,4
While the Ambulatory Specialty Model is intended to advance value-based care, its current design appears misaligned with the realities of anesthesiology for most practitioners. The potential negative impacts of the model may exacerbate existing difficulties with fair payment and burnout that the specialty faces.
References
1. Jeffcoat H, Murphy K, Sage J. New ambulatory specialty model takes effect in 2027. Bull Am Coll Surg. January 7, 2026. Accessed April 3, 2026. https://www.facs.org/for-medical-professionals/news-publications/news-and-articles/bulletin/2026/january-2026-volume-111-issue-1/new-ambulatory-specialty-model-takes-effect-in-2027
2. Oseran AS, Wadhera RK. The ambulatory specialty model—imitation or innovation? JAMA. 2025;334(24):2161-2162. doi:10.1001/jama.2025.20630
3. Centers for Medicare & Medicaid Services. Ambulatory specialty model (ASM) frequently asked questions. Last modified March 4, 2026. Accessed April 3, 2026. https://www.cms.gov/priorities/innovation/asm-ambulatory-specialty-model-frequently-asked-questions
4. American Society of Anesthesiologists. Re: 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 (CMS-1832-P). Submitted September 12, 2025. Accessed April 3, 2026. Available via: https://www.asahq.org/advocacy-and-asapac/fda-and-washington-alerts/washington-alerts/2025/09/asa-opposes-flawed-and-adverse-payment-proposals-from-cms-for-2026