AHA, Others Address Issues with Ambulatory Specialty Model

October 27, 2026

Abe Sutton, JD
Deputy Administrator and Director
Center for Medicare and Medicaid Innovation
Centers for Medicare & Medicaid Services
200 Independence Avenue, S.W.
Washington, DC 20201

RE: Ambulatory Specialty Model (ASM)

Dear Deputy Administrator Sutton:

The undersigned organizations appreciate the webinars, office hours, and recently proposed technical refinements to the mandatory Ambulatory Specialty Model (ASM) by the Center for Medicare and Medicaid Innovation (CMMI) that address stakeholder feedback. Specifically, we appreciate the proposal to allow the exclusion of certain non-relevant cardiac subspecialties from the model and several revisions to Promoting Interoperability requirements to reduce reporting burden.

However, significant operational and technical issues remain that should be addressed to enable participants to focus on delivering high-quality care to Medicare beneficiaries. Delays in participant identification, online portal access, operational guidance, and technical support have materially constrained participants’ ability to prepare. Given the model’s significant financial risk and its imminent January 1, 2027 start date, if these issues are not resolved, participants’ focus and resources will be diverted to resolving avoidable operational and technical challenges and could undermine both participant performance and the validity of the model’s early results.

We therefore offer the following recommendations to address these operational concerns and ensure participant readiness by day one of the model:

• Delay the initial launch of ASM until all operational and technical infrastructure is available, tested, and ready for model launch, and hold participants harmless from downside risk in the first year if the launch is not delayed
• Maintain ongoing communications and support, including timely data, operational guidance, technical support, and a single, consolidated help desk
• Share prospective performance thresholds for cost and quality performance categories in advance of the model’s start date and allow practice-level reporting of quality measures to align with other CMS models and programs and minimize participant burden

ASM participants have experienced a number of challenges in preparing for the ASM. These delays and setbacks include, but are not limited to, delayed receipt of the final participant list; delayed access to ASM portal; challenges with logging into, accessing, or delegating authority within the portal; and receiving timely help and guidance from ASM SMEs. For example, the final ASM participant list was published on September 15, 2026, approximately two months later than indicated in the calendar year (CY) 2026 Physician Fee Schedule (PFS) final rule. Additionally, the final participant list for 2027 may further change if the CY 2027 PFS proposed rule is finalized, as it would allow clinicians to change their primary specialty to a cardiac subspecialty that is excluded from the model. The net effect of these actions is that 2027 ASM participants have three-months’ notice prior to model launch to prepare for implementation. Perhaps if pre-implementation information resources, like the ASM online portal, were readily available, three months would be an inconvenience rather than a detriment. Unfortunately, participants continue to encounter delays. The undersigned strongly urge CMMI to delay ASM’s launch until all operational and technical infrastructure is available, tested, and ready for the model to start. If CMMI maintains the January 1, 2027 start date, participants should not be subject to downside financial risk for the initial performance period while operational infrastructure stabilizes.

While ASM webinars and office hours have been helpful to a degree, these events do not address all participant and stakeholder questions. Participants and key stakeholders, such as administrative staff supporting ASM activities, are not receiving timely responses when submitting questions to the help desks. Moreover, the existence of multiple help desks makes it more confusing for participants to resolve their queries. Therefore, CMMI needs to provide timely, actionable data, operational guidance and technical support prior to and during ASM’s performance period.At a minimum, this should include: a single, consolidated help desk with published response-time targets; a searchable FAQ updated after each office hours session; and resolution of outstanding portal access and delegation issues. Operational infrastructure such as help desk triaging, testing the online portal’s usability, and opening a test submission window for quality measure data should be conducted in advance of going live. Failure to do so could confound CMMI’s evaluation by making it difficult to distinguish the effects of the payment model from the effects of implementation challenges.

Finally, participants deserve to have as much information upfront as possible when a significant portion of their Medicare Part B payment is at risk. CMS should share prospective cost and quality performance thresholds prior to the start of each performance year. Such information would allow participants to understand their current performance level and take quality improvement or corrective actions to improve their overall performance. CMMI could use historical cost and quality data to project the prospective thresholds, with the caveat that final performance thresholds can and will vary with actual performance results. Additionally, CMMI should permit practice-level reporting of quality and cost data. There is little reason for individual reporting under ASM, which adds unnecessary burden on specialists, who generally rely on practice-level infrastructure to collect, validate, and submit quality data for other CMS models and programs. Requiring individual-level submission could therefore measure clinicians’ familiarity with a new reporting process rather than accurately reflecting the quality of care patients receive. CMS recognized this in the CY 2027 PFS proposed rule by proposing to allow small practices to submit quality data as a group on behalf of all ASM participants in the practice. ASM participants in larger and multispecialty practices rely on the same centralized infrastructure. Implementing new internal quality reporting policies requires setting up and testing well ahead of the performance year and model participants must have sufficient lead time to enact said changes, further underscoring the need to delay the model’s launch date.

Addressing these implementation issues before the performance period begins will strengthen participant readiness, protect the integrity of the model’s evaluation, and help ensure that the model’s results reflect the care participants deliver to Medicare beneficiaries living with chronic conditions. Accordingly, we urge you to delay the model’s launch until these issues are resolved. We appreciate your consideration and welcome the opportunity to continue to work with CMMI to work through these and other model challenges.

Sincerely,

American Hospital Association
American Medical Association
AMGA
Health Care Transformation Task Force
Medical Group Management Association
National Association of ACOs
Premier Inc