When Mike Verdon, MD, a neurosurgeon in Dayton, Ohio, first heard about the Ambulatory Specialty Model, his reaction was alarm — not for himself, but for the colleagues he looked up on the CMS participant list.
“I looked, I’m not on it,” Dr. Verdon said June 12 during a panel discussion at Becker’s 23rd Annual Spine, Orthopedic and Pain Management-Driven ASC + The Future of Spine Conference in Chicago. “I know a lot of people that are and they don’t know.”
The ASM, finalized by CMS on Oct. 31, 2025, is a mandatory alternative payment model that applies to select specialists treating Medicare patients with low back pain or heart failure in outpatient settings. For the low back pain cohort, eligible specialties include anesthesiology, pain management, interventional pain management, neurosurgery, orthopedic surgery and physical medicine and rehabilitation. The model launches Jan. 1, 2027, and runs through 2031.
CMS projects about 8,600 physicians across selected geographic areas — roughly one-quarter of core-based statistical areas and metropolitan divisions nationwide — will be required to participate, collectively managing an estimated $2.8 billion in episode spending annually. Participation is mandatory, with no opt-out or hardship exemption pathway.
What makes the model unusual is how CMS communicates — or doesn’t — with the physicians it’s watching. Physicians who fall short on cost, quality and prior authorization measures don’t receive a warning. Their Medicare Part B rates are simply cut for two years. Physicians who meet or exceed benchmarks can receive a payment increase of up to 12%, depending on the performance year.
“If you don’t meet certain measures — cost quality, unnecessary spend and basically prior authorization protocols — they don’t tell you that there is anything wrong,” Dr. Verdon said. “They’re just going to cut your rates for two years.”
CMS released a preliminary participant list in February 2026 based on 2024 claims data. A final list based on 2025 data is expected in July 2026. Physicians can search the CMS website to determine whether they or someone they know is included.
The model scores participants individually across four categories: quality, cost, care improvement activities and interoperability. CMS calculates the cost and quality measures using claims data, meaning physicians are not required to submit additional data for those categories. But two improvement activities — connecting to primary care and establishing collaborative care arrangements — are required of every participant.
For Dr. Verdon, the awareness gap is itself a policy problem, and closing it is among the most concrete advocacy actions spine surgeons and neurosurgeons can take right now.
“So physicians were sailing blind without a rudder with no sail into this 10% pay cut,” he said. “Social media is one of those things. We need to put that out there or talk about it, but that’s why we’re here.”
The model is not the only CMS initiative reshaping the low back pain payment landscape. The NOPAIN Act — which addresses access to non-opioid pain treatment — and new AI-supported prior authorization protocols under the WISeR model are adding pressure on the same specialties simultaneously. Together, they represent a significant structural shift in how outpatient specialty care for chronic conditions is measured and reimbursed.
Dr. Verdon’s prescription for the physicians caught in the model’s crosshairs was process-oriented rather than political.
“I feel like a better advocacy to me was to create definitive processes for the patients to come in and just set that up because it’ll be there when I’m gone,” he said. “And I think that’s the only way I can work around prior auth and all these things to make a difference.”
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
