In its 2026 Physician Fee Schedule, the Center for Medicare & Medicaid Innovation finalized a mandatory payment model, effective Jan. 1, 2027, that will tie Medicare payments to clinician performance on quality, cost and care coordination metrics in specialties including cardiology.
The goal of the Ambulatory Specialty Model is to reduce avoidable hospitalizations and unnecessary procedures, aiming to hold cardiologists financially accountable for how they manage chronic conditions such as heart failure.
However, the policy has sparked concern from some cardiologists, especially those who were randomized for mandatory participation in the model. Some feel that the model does not properly account for cardiology’s “team-based” nature, while others note that patient health can be affected by circumstances outside of a cardiologist’s control.
Three cardiologists recently joined Becker’s to discuss their thoughts on the ASM and how they foresee it impacting their practice in the near future.
Editor’s note: These responses have been lightly edited for clarity and length:
Question: What are your thoughts on the new CMS model rollout? If you are a participant in the ASM model, how are you preparing your practice to meet these new requirements?
Ilan Kedan, MD. Cardiologist and Professor of Cardiology at Smidt Heart Institute, Cedars-Sinai Hospital (Los Angeles): This approach is a repeated theme from CMS to shifting risk and responsibility to physicians and specialists for the global care of chronic disease management.
The assumption built into the thought process is that there is currently adequate access to both specialists and primary care. As reported previously in Becker’s, the wait times for access to cardiology specifically are approaching a month or more. From clinical practice, I can share that the real-world access to Medicare cardiologists may be even longer than that.
There are assumptions that care-coordination and communication between specialists have been identified as deficient and are a target or opportunity for improvement. Again, the real-world experience for specialists caring for Medicare patients is that very often patients do not have reliable and consistent care and access to a primary care physician, let alone a primary care team. This inevitably results in the shifting of non-specialty care and primary care to specialists. By increasing the volume of work and number of care-coordination and co-occurring administrative tasks to specialists, the amount of time and resources to manage the care of these patients can only increase. The cost of that management and additional infrastructure to support that care for Medicare reward payments is likely to come at the expense of specialists’ income. The result can be predicted to further increase the scarcity of specialist access.
Additionally, by increasing regulatory control of care and care-coordination and tying it to Medicare payments, independent specialists are less likely to be able to participate in the care of these more complex Medicare patients. Sadly, this may also serve to push specialists out of Medicare participation and further limit access to care for Medicare patients.
Heart failure patients are often complex and many have multiple comorbidities with long medication lists to manage co-incident chronic diseases. Often, these comorbidities can lead to adverse outcomes that may be attributed to deficient care of their ASM-included diagnosis.
Thomas Maddox, MD. Professor in the Cardiovascular Division and Director of Clinical Innovation at WashU Medicine (St. Louis): I understand CMMI’s goal of addressing variation and high costs in heart failure care, but the Ambulatory Specialty Model needs refinement before penalties begin. Heart failure care is inherently team-based and affected by factors well beyond any individual cardiologist’s direct control, so accountability should be aligned at the practice or group level and focused on improving guideline-directed care rather than primarily reducing total cost. I am also concerned about retroactive patient attribution, regional and practice-setting differences, and the fact that payment adjustments apply broadly to Medicare Part B payments rather than heart-failure-related care alone. A testing and transition period, with continued input from cardiologists and practices, would make the model fairer, more clinically meaningful, and more likely to improve outcomes for patients with heart failure.
Varsha Tanguturi, MD. Cardiologist at Mass General Brigham Heart & Vascular Institute (Boston): ASM reflects CMMI’s commitment to expanding mandatory value-based care models to specialists. Bringing specialists into value-based care is exciting, and MGB clinicians across all practice areas are committed to delivering high-quality, high-value, evidence-based care. While MGB-employed physicians were not randomized to participate in the model, we continue to innovate and improve outcomes for patients with heart failure and other cardiovascular conditions through value-based population health programming.
Shawn Ragbir, MD. Cardiologist with Methodist Physician Practices (San Antonio, Texas): The ASM heart failure payment model, in its best version and execution, standardizes care models for heart failure patients and reduces unnecessary cost and testing, reducing system cost via reduction in unplanned inpatient and outpatient encounters while preserving or enhancing survival, lowering morbidity, and improving quality of life.
There are multiple flaws in the current version, but the “care depersonalization” is the most obvious. It assumes that all patients with heart failure are treated the same, have the same opportunities for survival, improved quality of life, and morbidity reduction, as well as have the same understanding of their disease process and same social support. This is simply not true.
Our practice serves a large portion of southwest and lower central Texas and consequently pulls patients from MUAs that do not have the same opportunities for consistent same-provider interaction as their suburban counterparts. Because of rising costs of living, insurance difficulties, lack of transportation, etc., first responders and the ER are sometimes their “[primary care physicians].” This scenario unfairly attributes the suboptimal care to the cardiologist of record on the ASM in frequent ER visits and readmissions. These patients are frequently not as keen on adhering to simple salt and fluid restrictions or A1C / LDL goals, in spite of the best efforts of the PCP and community hospital. In my outreach panel, health education is a daily challenge that not uncommonly results in medication non-adherence. Patients cite rising costs of living as the most common reason for resorting to inexpensive but highly processed foods for basic sustenance or not paying for necessary medications or office visits. These directly impact metrics in spite of the best efforts of the cardiologist.
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