CMS Policy · Value-Based Care · Heart Failure

DrKumo Editorial Team
6 min read
ASM
Heart Failure
RPM

The Ambulatory Specialty Model (ASM) introduced by the Centers for Medicare & Medicaid Services (CMS) through the Center for Medicare and Medicaid Innovation represents a targeted CMS specialty payment model affecting selected outpatient specialists beginning January 1, 2027.

According to CMS, the Ambulatory Specialty Model for heart failure is a mandatory model in selected geographic regions for specialists who commonly treat Original Medicare beneficiaries with heart failure or low back pain in outpatient settings.

The model will run for five performance years, from 2027 through 2031. Unlike traditional fee-for-service reimbursement, ASM represents a Medicare specialty payment reform that links specialty payment adjustments to measurable quality performance and total cost of care outcomes across an attributed patient population.

2027Year ASM begins for selected specialists
5 yrsPerformance years, running through 2031
~25%Core-based statistical areas (CBSAs) initially included

Why Only Selected Outpatient Specialists Are Included

ASM is not a nationwide program. CMS selects specific geographic regions and identifies participating specialists using historical Medicare claims data.

As stated in the CMS model summary:

Participation in ASM will be mandatory for specialists who commonly treat people with Original Medicare for heart failure or low back pain in an outpatient setting across selected regions.

CMS Ambulatory Specialty Model Overview

Physicians are identified based on claims-driven attribution, not voluntary enrollment. This means cardiologists and other specialists practicing in designated regions may be included automatically if they meet CMS attribution criteria.

What the Ambulatory Specialty Model Requires

The ASM does not mandate specific technology platforms or require Remote Patient Monitoring devices. Participation will be mandatory for specialists who commonly treat people with original Medicare for heart failure or low back pain in outpatient settings across selected geographic regions.

Under ASM:

  • Specialists will be accountable for patient outcomes and total cost of care.
  • The model will use a two-sided risk arrangement, meaning participants may receive positive, neutral, or negative payment adjustments based on performance, reinforcing the shift toward value-based care for cardiologists.
  • Payment adjustments will apply to future Medicare Part B claims for covered services.

Performance Assessment Categories

CMS states that participant performance will be evaluated across four categories, leveraging the Merit-based Incentive Payment System (MIPS) Value Pathways (MVP) framework:

  1. Quality. For example, controlling blood pressure in patients with heart failure or improving functional status for patients with low back pain.
  2. Cost. Particularly reductions in avoidable and unnecessary care.
  3. Improvement Activities. Including clinical care processes, patient engagement, and screening for health-related social needs.
  4. Improving Interoperability. Encouraging adoption of certified electronic health record technology (CEHRT) to support electronic communication and data sharing.

CMS further states that ASM “aims to improve prevention and upstream management of chronic disease, which would lead to reductions in avoidable hospitalizations and unnecessary procedures.”

Geographic and Specialty Scope

Initially, ASM will include specialists in approximately one-quarter of core-based statistical areas (CBSAs) and metropolitan divisions. For heart failure, ASM heart failure specialists will be physicians specializing in general cardiology who have historically treated at least 20 qualifying episodes per year under CMS’s episode-based cost methodology.

Statutory Authority

ASM operates under Section 1115A of the Social Security Act, which authorizes CMS to test payment and service delivery models intended to reduce program expenditures while preserving or enhancing quality of care.

Why Episodic Care Limits Performance in a Continuous Care Model

Heart failure instability often develops between scheduled visits, while payment models like the ASM assess performance across time. Heart failure exacerbation does not always occur suddenly at the moment of a clinic visit.

An observational study published in Circulation evaluated daily weight patterns among patients enrolled in a home monitoring program and found that weight gain began to diverge from controls approximately 30 days before hospitalization, with more pronounced increases during the week prior to admission. Increases of more than 2 pounds within 7 days were associated with significantly higher odds of heart failure hospitalization. These findings suggest that in some patients, measurable changes such as progressive weight gain may precede clinical decompensation, highlighting the potential value of structured monitoring when paired with timely clinical evaluation.

At the same time, evidence demonstrates that not all telemonitoring approaches improve outcomes. A large randomized controlled trial published in The New England Journal of Medicine found that a telephone-based telemonitoring system did not reduce readmissions or mortality compared with usual care among patients recently hospitalized for heart failure. These findings underscore that episodic care alone may miss evolving risk, and that monitoring programs are most effective when embedded within coordinated clinical workflows that support timely decision-making.

Key insight

Weight gain patterns can start to diverge as much as 30 days before a heart failure hospitalization, but a separate large trial found telephone-based telemonitoring alone didn’t reduce readmissions or mortality. The data only helps when it feeds into a structured, responsive clinical workflow, not when it exists on its own.

Where Remote Patient Monitoring Aligns with the Model

CMS does not state that RPM is required for ASM participation. However, remote patient monitoring for heart failure supports several operational priorities embedded in the model’s structure:

  • Consistent physiologic documentation
  • Greater visibility into blood pressure and weight trends
  • Earlier outpatient intervention
  • Structured escalation workflows

CMS separately recognizes RPM under CPT codes 99453, 99454, and 99457 in the Medicare Physician Fee Schedule. These billing pathways establish RPM as a recognized care delivery framework when clinically appropriate. In the context of ASM’s emphasis on prevention and upstream management, RPM aligns operationally with longitudinal oversight goals, without being mandated.

Total Cost of Care and Hospitalization Prevention

Hospitalizations represent a substantial share of heart failure-related Medicare expenditures. The Medicare Payment Advisory Commission (MedPAC) has consistently reported inpatient utilization as a primary driver of Medicare spending growth. Under ASM, avoidable admissions influence both quality metrics and total cost of care benchmarks.

Monitoring physiologic indicators such as:

  • Blood pressure
  • Weight
  • Oxygen saturation
  • Symptom changes

can support timely outpatient response when clinically indicated. The model evaluates outcomes. It does not dictate the devices practices use to achieve them.

How DrKumo Supports Heart Failure Practices Preparing for ASM

DrKumo provides secure, HIPAA-compliant Remote Patient Monitoring solutions designed to support structured chronic disease management. Through connected physiologic devices and encrypted data transmission, DrKumo supports capture of blood pressure, weight, oxygen saturation, and symptom data. These capabilities support longitudinal oversight and documentation continuity across the care continuum.

For heart failure practices operating in regions affected by the ASM, DrKumo supports:

Defined Monitoring Workflows

Structured processes for capturing and reviewing physiologic data on a consistent schedule.

Clinically Aligned Escalation

Escalation protocols aligned with clinical oversight when readings warrant attention.

Specialist Coordination

Coordination between specialists and primary care providers across the care team.

Secure Data Management

Data handling consistent with HIPAA requirements throughout the data lifecycle.

Takeaways

The Ambulatory Specialty Model is a geographically targeted, mandatory specialty payment model beginning in 2027. Participation is claims-based and region-specific.

CMS does not require RPM. However, the model emphasizes prevention, upstream chronic disease management, and hospitalization reduction. RPM aligns with these structural priorities by supporting consistent documentation and earlier outpatient intervention when clinically appropriate.

Practices in designated regions should evaluate their longitudinal monitoring infrastructure well before the first performance year.

Frequently Asked Questions

The Ambulatory Specialty Model (ASM) is a mandatory value-based payment model from the Centers for Medicare & Medicaid Services through the Center for Medicare and Medicaid Innovation that holds selected outpatient cardiologists accountable for quality and total cost of care for Medicare patients with heart failure. Starting in 2027, payment adjustments are tied to performance rather than volume alone.

Yes. Cardiologists in CMS-selected geographic regions who meet claims-based episode thresholds are automatically included. Participation is not voluntary and is determined by historical Medicare data.

ASM shifts reimbursement toward performance-based adjustments under a two-sided risk structure. Future Medicare Part B payments may increase or decrease based on quality scores, cost benchmarks, and care coordination performance.

Specialists must strengthen chronic disease management through proactive follow-up, documented care coordination, and early intervention when symptoms worsen. Preventing avoidable admissions directly supports both quality performance and total cost of care targets.

Remote Patient Monitoring (RPM) is not required by CMS, but it supports longitudinal oversight by tracking weight, blood pressure, oxygen saturation, and symptom trends between visits. When integrated into clinical workflows, RPM can help practices identify risk earlier and manage heart failure more consistently under value-based payment models.

References

Disclaimer: This article is intended for informational purposes only and does not constitute medical advice. Always consult with a licensed healthcare provider for guidance on diagnosis, treatment, or medical decisions.

References to the U.S. Department of Veterans Affairs (VA), the Food and Drug Administration (FDA), and the Centers for Medicare & Medicaid Services (CMS) do not constitute or imply an endorsement by the VA, the FDA, CMS, or the U.S. Government.