When CMS finalized the Ambulatory Specialty Model in its 2026 physician fee schedule, it created a mandatory program that will tie Medicare Part B payments for certain specialists to how they manage heart failure and low back pain. Now that CMS has released its final participant list, Mike Verdon, MD, has a more basic concern than the model’s design: Few of the surgeons on that list seem to know it exists.
Dr. Verdon, a neurosurgeon in Dayton Ohio, first raised the alarm during a panel at Becker’s spine conference in June. He said he put the question to the room directly.
“I went to the meeting in June and I asked the question, ‘Who knows about ASM?’ It was like freaking crickets,” Dr. Verdon told Becker’s.
He has since posted about the model on LinkedIn. Colleagues he has spoken with who are on the list either had not heard of the program or assumed it would never take hold, he said.
“My answer is once the federal government starts moving in one direction, it does not change,” he said.
The model runs through Dec. 31, 2031, and its low back pain cohort includes anesthesiology, pain management, interventional pain management, neurosurgery, orthopedic surgery, and physical medicine and rehabilitation physicians in selected geographic areas who have historically treated at least 20 relevant Medicare episodes or patients in a year. Clinicians who qualify stay in the model for the full five years.
CMS scores participants on quality, cost, improvement activities and interoperability, then applies positive, neutral or negative adjustments to future Part B payments.
Dr. Verdon reads the model as a deliberate push.
“Are they trying to force value-based [care] into Medicare? And the answer is yes. That’s what this is about,” he said.
Of particular interest to surgeons with respect to the model is attribution. A patient can be assigned to a surgeon even if the surgeon was not the first clinician to see that patient for back pain, Dr. Verdon said. After a triggering event, the episode follows the clinician responsible for the largest share of the spending.
“If you’re the one who generated 30% of the claim dollars, it’s going to be attributed to you,” he said. “Who’s the most expensive claimant? The surgeon. That’s why they need to care.”
What frustrates Dr. Verdon most is that much of the downside can be avoided. CMS wants proof of quality, and one of the simplest forms of that proof is the Oswestry Disability Index, a questionnaire that measures how much back pain limits a patient’s daily function. Documenting the score before treatment and again afterward lets a surgeon show, in numbers, how much a patient improved.
“Some of the swings can be like a $2 million swing in either direction, just by simply documenting an ODI before you get started,” he said. “It’s really not hard. It’s a 10-minute questionnaire.”
Many surgeons still do not collect it, because no one has required them to.
“I have friends of mine who do not document ODI,” Dr. Verdon said.
The bigger risk, in his view, is not any single surgeon’s pay cut. It is what surgeons do in response. In some markets, physicians can afford to stop seeing Medicare patients altogether. Dr. Verdon said that choice looks very different depending on where a surgeon practices and how far they are from retirement.
“I live in Dayton, Ohio, right? I don’t have a lot of choice. Either way, I choose to take care of the people who live in my community,” he said.
He described younger partners with 10 or 15 years left in their careers as disheartened by the trajectory of physician pay, noting that his own payment for a one-level lumbar laminectomy has fallen from about $1,500 to $950. When he urges colleagues on the list to engage with the model, he said, some tell him they are not concerned yet.
“You have the right to not care, but the real issue here is people are going to walk away from Medicare,” he said. “But the largest portion of the market will be Medicare for these patients, and they won’t have access to care. And we will have successfully created a two-tier healthcare system by this alone.”
Because the model grades the entire episode rather than the procedure, Dr. Verdon expects it to put pressure on how patients reach a surgeon in the first place. He does not believe it should steer patients away from surgery they need; those with an anatomic problem that has failed conservative treatment still belong in the operating room. The problem, he said, is a legacy referral system in which back pain often goes straight from a primary care visit to a neurosurgery referral with nothing done in between, and in some markets moves straight from imaging to fusion.
“Not everybody needs to see a surgeon for every little ache and pain that they have; that’s the way the legacy model was built,” he said.
CMS’ final participant list, released in September, names more than 5,550 clinicians across both lower back pain and heart failure specialties. Dr. Verdon put the potential savings from better routing in simple terms.
“If I only get paid 150 bucks to say no to a patient, there’s 8,000 of me in the country,” he said. “I’ll say no to one Medicare patient a day. You do the math.”
For orthopedic and spine practice leaders, the first step is straightforward: Check the CMS list, identify which physicians are on it and estimate each one’s upside and downside exposure. Some individual exposures Dr. Verdon has reviewed come to roughly $50,000, but the math compounds quickly across a group.
“If you have multiple physicians in a group, you might want to develop a strategy about what we’re going to do,” he said. “It’s here. Just accept it.”
That strategy should center on intake, he said: routing patients to the right level of care based on symptom severity, whether that is the surgeon, a physician assistant or pain management, and building a way to track each episode of care inside existing workflows so the practice can produce a report on demand. Service line leaders have a role as well, he added, because physical therapy, radiology and other departments will need to work together on a single episode rather than treating each piece as someone else’s cost.
The stakes also extend beyond Medicare, Dr. Verdon said.
“This isn’t about Medicare. This is about Anthem, UnitedHealthcare, because they’re definitely watching and waiting,” he said. “And they’re going to say, ‘Great, we now have you guys all in value-based contracts.'”
He is quick to add that the model is not all downside. Physicians who outperform their peers can earn a payment increase, and when he told a mentor on the list what the model meant, the mentor’s reaction surprised him.
“He goes, ‘Wait a minute, there’s an opportunity here,'” Dr. Verdon said.
To surgeons still betting the model will quietly go away, he points to another federal mandate the industry once dismissed.
“No one believed that they could mandate us using electronic medical records,” he said. “Judy Faulkner was right, and everybody else was wrong.”
Dr. Verdon, who said in June that he is not on the participant list himself, said he has been surprised to find himself one of the few physicians speaking up.
“I can’t be the only person who thinks this is important,” he said. “To me, if we don’t have a solution, it’s our problem. And that’s how we’ve gotten here, by the way.”
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