Stakeholders in the Medicare value-based care world have without a doubt heard of the Merit-based Incentive Payment System (MIPS), MIPS Value Pathways (MVPs), and alternative payment models (APMs). While all these initiatives are related (MVPs are a pathway for reporting MIPS, and participation in MIPS and APMs are options under the Quality Payment Program), the Centers for Medicare & Medicaid Services (CMS) recently answered the question, what happens when you combine different pieces of all three? The Ambulatory Specialty Model (ASM), proposed by CMS in the calendar year (CY) 2026 Physician Fee Schedule (PFS) proposed rule, would accomplish this feat by incorporating elements of MIPS and MVPs into a new APM.
To help me examine the significance of this accomplishment (including describing the newly proposed model), I’m bringing in my colleague Simeon Niles.
Context for ASM
Before discussing what this new model would test and how it would be structured, let’s put it into context. In many ways, the model perfectly aligns with where CMS wants to take the MIPS program and APMs more generally. CMS has stated for multiple years that it wants to phase out the traditional MIPS reporting pathway and fully transition to MVPs. MVPs represent a streamlined reporting option for MIPS-participating clinicians, enabling them to choose from a narrow set of measures based on a specialty, episode, or condition. The goal of MVPs is to create a more meaningful experience for clinicians by assessing them on measures that are more pertinent to their clinical practice. Although stakeholders have pointed out some concerns about MVPs (explored in this Regs & Eggs blog post), CMS continues to believe that MVPs should be the only option for MIPS in the future and plans to make this currently voluntary option mandatory as soon as 2029.
While transitioning to MVPs is the goal for MIPS, one could argue that the ultimate value-based care goal for clinicians is to move from MIPS (and therefore MVPs) to APMs. Under the Quality Payment Program established by the Medicare Access and CHIP Reauthorization Act, clinicians that have a certain proportion of their patients or payments tied to advanced APMs (i.e., APMs that include substantial downside financial risk) are exempt from MIPS and have been eligible for incentive payments in the past. Although the incentive payments have been phased out, starting in CY 2026 these clinicians will be eligible for a higher conversion factor under the Medicare PFS. Thus, there will continue to be additional financial incentives for clinicians participating in advanced APMs. However, while there are higher incentives for participating in advanced APMs versus MIPS, few specialists currently have opportunities to participate in APMs or advanced APMs, so often MIPS is their only option. The CMS Innovation Center is responsible for testing APMs, including advanced APMs, and under the Trump administration it has clearly indicated that it wants to produce APMs that guarantee cost savings and push providers to take on greater downside financial risk in traditional Medicare fee-for-service programs. The administration has also expressed a desire to get more specialists to participate in advanced APMs.
Structure of ASM
The proposed ASM is built on the MIPS chassis, as it essentially turns a set of MVPs into a new APM. As proposed, the ASM is a five-year model that would require physicians in select geographic regions to report modified versions of MVPs for lower back pain and heart failure with altered performance and scoring rules from MIPS. The model would begin in 2027 and end in 2031. Like MIPS, bonuses and penalties would be applied two years after the performance period, so the last set of financial adjustments would occur in 2033.
The ASM would maintain the four MIPS performance categories (quality, cost, improvement activities, and promoting interoperability) but apply them to a mandatory peer-based context. Unlike MIPS, measure selection would not be optional; clinicians would be required to report on pre-specified measures tailored to their specialty and condition. Moreover, comparisons in performance would be made within peer groups (e.g., cardiologists treating heart failure), not across all MIPS clinicians.
Individual clinicians would be identified and evaluated at the tax identification number (TIN) and national provider identifier (NPI) level based on whether they perform services related to the treatment of the relevant diagnoses within randomly selected geographies (either a core-based statistical area or metropolitan division). Specialties likely to be included are cardiology, orthopedic surgery, neurology, physical medicine and rehabilitation, and pain management. Most of these specialties currently participate in MIPS and are not involved in an APM.
Each clinician would receive a composite final score (0 – 100) weighted on quality (50%) and cost (50%), with clinician performance compared only to peers treating the same condition. Improvement activities and promoting interoperability scores would contribute only if underperformance occurs (e.g., lack of reporting). CMS would make positive, neutral, or negative adjustments to clinicians’ Medicare Part B payments based on performance relative to peer group and to ensure budget neutrality, like MIPS. CMS also proposes to increase the amount of Part B payments at risk under the model from 9% beginning in the 2027 performance year/2029 payment year to 12% by the 2031 performance year/2033 payment year. ASM would retain a portion of savings by building in a discount factor to the performance target (proposed as 15% of the applicable risk level). In other words, while MIPS (and therefore MVPs) is a budget neutral program (all penalties are used to pay bonuses), this APM is designed to guarantee savings for the Medicare program.
Model considerations
Like all proposals in the CY 2026 PFS proposed rule, stakeholders have until September 12, 2025 to provide input on the model. Clinicians and other stakeholders that would be directly impacted by the model likely will provide comments on the design, payment methodology, required measures, and other aspects of the model. Other stakeholders could provide higher-level comments on CMS’s general approach. The fact that CMS is designing a model based on only a couple of MVPs, when there are more than 20 total MVPs (and more are being added every year), may indicate that this is just the start, and that CMS could apply this same model concept to other MVPs going forward. Thus, most of the physician world is paying attention here.
Some particularly notable considerations include:
- Different performance thresholds. CMS is making a concerted effort to create more stability in MIPS. The MIPS performance threshold (the score threshold that must be reached in order for clinicians to obtain a bonus and avoid a penalty) has been kept at 75 points the last few years, and CMS proposes to maintain this threshold through the 2028 performance period. In MIPS, the vast majority of clinicians (80% or more) have been able to avoid a penalty and a payment adjustment year after year. In contrast to this stable performance threshold, which applies to all clinicians nationally, the ASM performance threshold would be based on a smaller cohort of clinicians and on the relative distribution of scores within the relevant peer group. As a result, it is possible that clinicians who performed well under MIPS could find it more difficult to achieve a bonus and avoid a penalty under ASM.
- Required versus optional measures. CMS would require clinicians to report on select measures that are currently included in the Advancing Care for Heart Disease MVP (for heart failure) and the Rehabilitative Support for Musculoskeletal Care MVP (for lower back pain). MVPs include a more limited set of measures than traditional MIPS, but clinicians still have some choice. For example, in the quality performance category in traditional MIPS, clinicians can choose from nearly 200 measures (they have to report on at least six measures, and CMS takes the highest of the six scores), while an MVP usually has between 10 and 20 measures (clinicians have to report on at least four measures, and CMS takes the highest of the four scores). While an MVP has a much more limited measure set, clinicians still have some choice of quality measures within the MVP. The ASM, in contrast, would require clinicians to report all the quality measures within the applicable measure set; clinicians could not pick and choose which ones to report. Table 39 of the PFS proposed rule lays out the five required measures for heart failure and for lower back pain.
Given the range of healthcare services that physicians can provide, even within the same specialty or subspecialty, some physicians argue that not all quality measures that are said to apply to a particular specialty, episode, or condition are in fact applicable to their individual practice. By not providing any choice in quality measures in the ASM, CMS seems to be making the case that there are some universal measures for particular conditions (lower back pain and heart failure) that all clinicians must be accountable for meeting.
- Mandatory MVPs: As stated earlier, CMS plans to fully transition traditional MIPS to MVPs, and ASM doubles down on CMS’s belief that MVPs will drive more meaningful quality improvement and cost reductions. While the policy direction is clear, what remains to be seen is if MVPs will achieve that goal.
Thus far, participation in MVPs has been limited. MVPs became a reporting option in 2023 and that, coincidentally, is the latest year for which we have performance data. During the 2023 performance period, 41,765 clinicians (7.7% of all clinicians in MIPS) registered for MVPS, and almost half submitted MVP data (20,484). Clinicians who reported MVP data also had the option of reporting through traditional MIPS, and CMS took the highest score. Almost all (98%) clinicians who reported through an MVP also reported through traditional MIPS. Only 16% of clinicians received a final MIPS score based on their MVP participation (6,790). Thus, 84% of clinicians who reported through an MVP wound up receiving a score based on their reporting through traditional MIPS. The mean and median overall scores for clinicians who reported an MVP were 61.93 and 73.09 points, respectively, regardless of whether their MVP data was their final score. When MVP reporting counted as a clinician’s final score (and determined their MIPS payment adjustment), mean and median scores increased to 82.87 and 87.86 points, respectively. Clinicians who reported both an MVP and traditional MIPS generally had a higher mean overall score from their traditional MIPS reporting.
Only 12 MVPs were available in the 2023 performance period, including the Advancing Care for Heart Disease MVP (the Rehabilitative Support for Musculoskeletal Care MVP did not become an option until 2024). With respect to the Advancing Care for Heart Disease MVP, 731 clinicians registered for the MVP and 534 reported MVP data, but only 49 clinicians received a final score from the MVP.
Participation in MVPs could be higher in 2024 than it was in 2023, but it may still be relatively low given that MVPs are a voluntary option. Nonetheless, more clinicians could be inclined to attempt to voluntarily report MVPs in coming years to prepare for potential mandatory reporting and the possible expansion of ASM to additional conditions.
As the comments come rolling in, it remains to be seen what changes to the model, if any, CMS might adopt. Because the ASM start date is not until January 1, 2027, there could be additional opportunities down the line to provide input. CMS’s decisions regarding this model could signal how CMS plans to get more specialists, who up until now have had limited opportunities to participate in APMs, to transition to APMs going forward.
Until next week, this is Jeffrey (and Simeon) saying, enjoy reading regs with your eggs.
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