The Ambulatory Specialty Model is mandatory, and January 1 is closer than it looks
The headlineTwenty weeks from now, the first mandatory Medicare model aimed at individual specialists goes live. The Ambulatory Specialty Model runs five performance years, January 1, 2027 through December 31, 2031, and it does not take applications: CMS selects participants, identified at the TIN/NPI level, from two cohorts. The heart failure cohort is cardiology. The low back pain cohort spans anesthesiology, pain management, interventional pain management, neurosurgery, orthopedic surgery, and physical medicine and rehabilitation. A specialist is in if they have historically been attributed at least 20 heart failure or low back pain episodes a year under the episode-based cost measure methodology and practice in a mandatory geographic area, roughly one quarter of core-based statistical areas and metropolitan divisions per CMS. The mechanics are MIPS MVP architecture with the volume turned up. Per Milliman's actuarial read of the final design: quality and cost each carry 50 percent of the composite, improvement activities score as a zero-to-minus-20-percent adjustment, promoting interoperability as zero-to-minus-10, with up to 10 points back for complex patients and another 10 for small practices of 15 or fewer clinicians. Performance becomes a payment adjustment on future Part B claims, plus-or-minus 9 percent in the first two performance years rising to plus-or-minus 12 by the final year, on a two-year lag: 2027 performance lands on 2029 payment. The model is budget neutral with a haircut, per the same analysis: 85 percent of downside dollars are redistributed to upside performers and 15 percent go to the Trust Fund. ASM participants get a MIPS waiver and safe harbor during active performance periods. And CMS has already published the participant dataset and the mandatory-geography file, which means the question "are my specialists in this" is checkable today.
The CY2027 proposed rule would rewire the model before it starts. On participation: exceptions for TIN changes, with 60 days' notice before a performance year or 30 during one; a permanent specialty-redesignation exception for heart-failure cardiologists who move into procedural cardiac subspecialties; authority for CMS to terminate participants; and payment adjustments that follow a clinician to a new TIN. On quality: a new claims-based measure targeting MRI overuse in the low back pain cohort, the Functional Status Change outcome measure swapped for a Functional Outcome Assessment process measure, claims-based measures scored at the individual TIN/NPI, and a voluntary five-point incentive for submitting patient-reported outcome data. On promoting interoperability: electronic prior authorization optional in 2027 and mandatory in 2028 for medical services and drugs, the Security Risk Analysis and ONC Direct Review attestations dropped, a measure-suppression policy, and public-health reporting exclusions. On scoring: a five-point rural adjustment and an expanded collaborative-care pathway. Comments close September 14, on the same docket as the MSSP benchmark and quality proposals we covered in Issue #5, which makes the next four weeks the only window to shape both at once.
Three moves before January. First, inventory. Pull every cardiologist and every clinician in the six low-back-pain specialties across your participant TINs, at the TIN/NPI level, and check them against CMS's participant dataset and mandatory-geography file; the 20-episode threshold means your busiest specialists are the most likely to be in. Second, connect the risk. Your heart failure and low back pain care pathways now carry two-sided specialist risk alongside your MSSP risk: the same admission avoided and the same MRI not ordered now move two sets of dollars, and a specialist carrying ASM downside has a new reason to take your care-coordination call. Third, rewire reporting operations. An ASM participant gets a MIPS waiver during active performance periods, which changes who is on your MIPS reporting list in 2027, and the two-year lag means the cash consequence of 2027 performance arrives in 2029; budget accordingly. If the MRI measure or the TIN-change mechanics would hit your groups, the September 14 docket is where that goes.
The Pulse Platform will support ASM for the 2027 performance year: registry quality reporting for both cohorts, ASM episode and attribution data feeds, and cost-and-quality performance analytics, so a participating specialist, and the ACO that shares their patients, can see where they stand against the peer comparison before CMS runs the math. If your specialists appear in the participant dataset, we would start that conversation this fall, not in January.
ACCESS scales past 250 participants, and the first wave starts this week
The headlineCMS refreshed the ACCESS Model's pages on August 12, and the roster grew again: the accepted-applicant list now shows more than 250 organizations, up from the 150-plus we relayed in Issue #5. The infrastructure around the model is filling in too. Medicare.gov now carries a beneficiary-facing ACCESS page at Medicare.gov/ACCESS, a provider webpage is live, and, the detail with the longest shadow, CMS lists health plans pledging an "ACCESS-aligned payment option," the clearest signal yet that the model is being built as a chassis for multi-payer alignment rather than a Medicare-only experiment. The rolling starts are now upon us: organizations accepted in the first wave begin August 17, a second wave starts October 1, and applicants who came in after May 15 start January 1, 2027.
The benchmark mechanics we flagged in Issue #2 are unchanged and worth restating now that the roster is real: ACCESS spending stays out of MSSP benchmarks through 2027 and folds in beginning in 2028. That gives you a season and a half of grace while the model's utilization patterns, including whatever the consumer-health entrants on the roster generate billing Medicare for chronic-condition co-management, accumulate in your regions without touching your numbers, followed by a 2028 in which they do. The roster is public; the overlap analysis is yours to run.
Map the 250 against your service area now. Know which participants operate in your counties, because their beneficiary engagement is attribution competition heading into an Open Enrollment season that starts October 15. Then put a 2028 marker in your benchmark planning: when ACCESS spending folds into regional expenditures, the direction of the effect depends on whether ACCESS participants in your region spend above or below your ACO, a question your claims can start answering as soon as their patterns show up. And if a health plan you contract with is on the aligned-payment list, ask what "ACCESS-aligned" means in your next negotiation; multi-payer alignment is leverage for whoever understands it first.
County-level overlap is a claims question with a standing answer: which ACCESS participants touch your attributed beneficiaries, at what volume, in which service lines. We are adding the August roster to the market view we build from claims for the ACOs on our platform, so the 2028 benchmark question starts accumulating data now, not in 2028.
The LEAD silence: twelve days past the deadline, still no cohort
The headlineAs we publish, it has been twelve days since August 5, the deadline for accepted first-cohort LEAD applicants to submit their participant TINs, and CMS has made no public announcement of the cohort. The model page has not been updated since July 20. The silence is not necessarily a signal: the TIN deadline ran applicant-side, not CMS-side, and nothing in the model's guidance commits CMS to publishing a roster on any particular date. But the contrast with ACCESS, which got a roster page, a Medicare.gov presence, and a press cycle, is hard to miss, and every ACO that applied is doing its September planning without knowing who else is in.
The operational clock does not care about the press cycle, and the next two dates land within a week of each other. September 8 at 12:00 noon ET is the deadline to drop a LEAD TIN, the last exit for a participant that will not sign, and the same noon cutoff as the MSSP RFI-2 close. September 15 opens the Implementation Period: no aligned beneficiaries, no payments, no risk through December 31, the model's only rehearsal window. The financial-guarantee deadline of December 31 has not moved either, and as we said in Issue #5, letters of credit move at bank speed. If the cohort announcement breaks between now and our next issue, and it remains the story most likely to, the roster's geography is the thing to read first.
If you are in the cohort, run September 8 exactly as you ran August 5: reconcile the TIN list against your MSSP participant list one more time, because the RFI-2 overlap machinery closes the same day and a contested TIN unresolved at noon becomes a disposition problem in October. If you are waiting on the announcement to plan, stop waiting; the Implementation Period starts September 15 whether or not CMS has published a roster, and the workplan we itemized in Issue #5, network operations, beneficiary outreach, aligned-cohort reporting, has lost two weeks of runway since. If you are not in LEAD at all, September 8 still deserves a calendar entry: it is the same noon deadline where your own RFI-2 deletes and overlap disputes land.
Our position from Issue #5 stands, with less runway: aligned-cohort reporting is where Implementation Periods get underestimated. If you cannot filter quality data to a CMS-supplied beneficiary list across every participant practice today, that fix belongs in the September workplan, and we would rather pressure-test it with you in August than debug it in January.
Your Q2 reports are landing, and the assignment lists are the ones to watch
The headlineThe Q2 data cycle is arriving on schedule, in pieces. The quarterly expenditure/utilization reports were delivered August 6, and the quarterly exclusion files followed August 10. The Q2 assignment list reports had not been delivered as we went to press; on CMS's standard cadence of five to six weeks after quarter close they are due any day, and CMS announces the drop through ACO-MS and the ACO Spotlight. It is the assignment lists that carry this quarter's news value: the mid-year read on attribution movement, and the last quarterly picture you get before the RFI-2 delete-and-overlap window closes September 8.
Two reasons this quarter's files deserve more than the usual glance. First, the EXPU reports are your running read on PY2026 spend at the moment the PY2025 reconciliation, delayed to November as covered in Issue #5, has stretched the gap between performance and settlement to nearly two years; the quarterly files are the only current signal you have. Second, the assignment movement in Q2 is the population on which your fall decisions get made: the beneficiaries behind your CAHPS sample, the denominator your quality season inherits, and the roster context for any TIN you are still deciding to keep or drop by September 8. Pull the exclusion files against the assignment lists when they land; the beneficiaries who dropped out tell you as much as the ones who arrived.
Treat the assignment drop, whenever it lands this week or next, as the trigger for a specific sequence: reconcile attribution movement against Q1, flag the practices driving losses, and get anything that changes your RFI-2 calculus in front of your roster decision before the September 8 noon cutoff. And if your Q2 EXPU trend is running hot against benchmark, November's delayed reconciliation means you will live with the uncertainty longer than usual, which argues for acting on the quarterly signal now rather than waiting for CMS to settle the math.
Your Q2 EXPU and exclusion files are already loaded in the Pulse Data Hub, and the assignment lists load the day CMS delivers them. If you want the attribution-movement view reconciled against Q1 before you touch your RFI-2 roster, ask; that report runs in minutes, not weeks.
CJR-X has a name, and the comment window enters its final month
The headlineFour weeks remain on the CY2027 comment clock, and the docket has company on the hospital side. NAACOS's August side-by-side materials work through the proposed nationalization of the joint-replacement bundle under the shorthand CMS itself now uses: CJR-X, the Comprehensive Care for Joint Replacement Expanded model, a mandatory, nationwide, episode-based payment model for lower-extremity joint replacement proposed to begin October 1, 2027. The design holds most IPPS hospitals accountable for spending and quality across the inpatient stay or outpatient procedure and the 90 days after discharge. For an MSSP ACO the mechanics that matter are the overlap mechanics: your attributed beneficiaries will have joint replacements at CJR-X hospitals, both entities will carry accountability for the same episode dollars, and the precedence rules CMS writes for that overlap will decide how much of the episode savings your reconciliation ever sees.
The comment letters are where all of this converges, and the big one is still pending: NAACOS's letter on the CY2027 package has not published, though its August materials telegraph the priorities. Our own read of what deserves ink, four weeks out, in descending order of money: the ENHANCED regional-adjustment trim and the retroactive ACPT guardrail from Issue #5's lead; the PY2025 reconciliation delay, which the association's July statement left conspicuously unaddressed; the ASM participation and quality mechanics from this issue's lead, if your specialists sit in a mandatory CBSA; and the Medicare eCQM scoring details, where flat benchmarks will reward or punish depending on where your rates sit. Comments close 11:59 p.m. ET on September 14 at regulations.gov. Episode-model overlap belongs in the letter too, because CJR-X's October 2027 start would make the first full year of overlap the first year of the new MSSP benchmark math.
Write the comment, even a short one. Prioritize the provisions with your money in them, attach track-level analysis where you have it, CMS explicitly invited it, and name the overlap problem if your market has likely CJR-X hospitals. Then put an internal marker on October 1, 2027: if CJR-X finalizes on schedule, your joint-replacement episodes stop being just an MSSP cost line and start being someone else's bundle, and the contracting conversations with your orthopedic groups and hospital partners are easier eighteen months early than six.
Episode overlap is visible in claims before it is visible in policy. We can flag which of your attributed beneficiaries had lower-extremity joint replacements at which hospitals over the trailing three years, the fastest way to size what CJR-X would touch in your ACO. It is a one-report question, worth asking before you write the comment rather than after.
What we're tracking next
- REACH's public wind-down continues. CMS hosts its REACH Q2 webinar August 18. The model's final performance year is closing out in public view, with the December 31 sunset fixed; sunset-transition guidance is the thing to listen for.
- The RAPID device pathway is open for comment. The notice CMS published August 7 takes comments through October 13. If the pathway starts moving device spending through attributed populations' claims, it becomes an ACO benchmark story, and we will cover it when it does.
- The HIPAA Privacy Rule final is running out of August. The final amendments were targeted for this month and had not published as we went to press. The pattern the Security Rule overhaul set holds: the targets slip, the vendor-breach wave that motivated them does not.
- Post-acute finals take effect October 1. The FY2027 post-acute payment final rules are on the books with an October 1 effective date; if your care-transition economics lean on SNF or home-health rates, the new numbers arrive in six weeks.
- The GLP-1 Bridge is still a data-free zone. Six weeks in, CMS has published no utilization or enrollment numbers. The prior-authorization mechanics we filed in Issue #5 stand; the story resumes when the first numbers land.