CMS payment models
Six models decide who carries
the risk in 2027.
ASM, TEAM, CJR-X, ACCESS, LEAD and CARA get used interchangeably and they are not interchangeable. Three are mandatory and three are not. They start in different years, and only some of them reach musculoskeletal care at all. Every figure below links to the CMS page it came from.
Mandatory. Episode-based. The surgical lane.
No opt-out. These decide what a joint replacement, a fusion, or a low-back-pain episode is worth, and to whom.
Ambulatory Specialty Model
Clock
Jan 1 2027 – Dec 31 2031 (five performance years)
Reach
Two cohorts. Heart failure: cardiology. Low back pain: anesthesiology, pain management, interventional pain management, neurosurgery, orthopedic surgery, PM&R. Eligibility is historical attribution of at least 20 heart-failure or low-back-pain episodes a year, in roughly one quarter of CBSAs and metropolitan divisions.
The part people miss
Scored per clinician on four categories built on the MIPS Value Pathways framework — quality, cost, improvement activities, and interoperability. Part B adjustment runs −9% to +9% in the first two years and widens to −12% to +12% by the last. CMS currently lists the participant count as N/A; the mandatory geographies are published as a spreadsheet, not a list of names.
The CMS model page →Transforming Episode Accountability Model
Clock
Running now
Reach
Five surgical episodes on a 30-day window.
The part people miss
It reaches knee, hip, ankle and spinal fusion — and it does not reach shoulder, foot or hand. Anyone selling a whole-body musculoskeletal story into TEAM is selling past the model boundary.
The CMS model page →Comprehensive Care for Joint Replacement, expanded
Clock
Finalized in the FY2027 IPPS rule; most IPPS hospitals from January 2028
Reach
Ninety-day joint replacement episodes.
The part people miss
The episode window includes physical therapy, which is what makes post-acute adherence a hospital financial exposure rather than a clinical preference. It is the longest episode of the three mandatory models.
The CMS model page →Voluntary. Population-based. The chronic-care lane.
You opt in. These pay for care between visits, for prevention, and for the technology-enabled work fee-for-service never covered.
Advancing Chronic Care with Effective Scalable Solutions
Clock
Live since July 5 2026, ten-year model
Reach
Conditions covering more than two thirds of Medicare — hypertension, diabetes, depression, and chronic musculoskeletal pain, which is a named track.
The part people miss
It pays for technology-enabled care Medicare has never reimbursed, and it requires the participant to name a physician Clinical Director. That requirement is the reason this model rewards an accountable human rather than an accurate model.
The CMS model page →Long-term Enhanced ACO Design
Clock
Jan 1 2027 – Dec 31 2036
Reach
The ACO REACH successor, aimed deliberately at smaller, independent and rural practices and at organizations new to accountable care.
The part people miss
Ten performance years is the longest period CMS has ever tested, and the design point is a window without rebasing, alongside a 1.5% administrative add-on payment. The bet is that ACOs will invest differently when the benchmark stops moving under them.
The CMS model page →CMS-Administered Risk Arrangement
Clock
An element inside LEAD, so it moves on LEAD’s clock
Reach
Episode bundles negotiated between a LEAD ACO and its specialist partners.
The part people miss
CMS supplies the bundle design and the payment infrastructure, so the ACO and the specialist negotiate a target price and share episode savings rather than building the machinery themselves. CMS has said it will feature an episode-based falls-prevention program — a federal payment mechanism pointed at prevention in the home.
The CMS fact sheet (PDF) →What actually follows from the table.
Three consequences that survive contact with a finance committee.
A locked model is a need, not a grievance
ASM is mandatory with no opt-out. A practice inside an ASM geography cannot lobby its way clear; it can only arrive prepared. That converts the conversation from “you are being paid less” into “you are about to carry two-sided risk on low-back-pain episodes and be scored on interoperability you do not currently produce.” The four scoring categories are infrastructure questions, and they have a deadline.
What a specialist actually has to produce →The episode boundary is the sales boundary
TEAM reaches knee, hip, ankle and spinal fusion. It does not reach shoulder, foot or hand. CJR-X is joints only, on ninety days, with therapy inside the window. Any claim that a musculoskeletal product is “aligned with the mandatory models” is only true for the joints those models name, and a hospital finance team knows exactly where that line falls.
The health-system read →Two of these models pay for a named human
ACCESS requires a physician Clinical Director. CARA pays for an episode someone has to own. Neither model reimburses a more accurate model; both reimburse an accountable one. That is the same structure the attestation record exists to produce, and it is why the payment rail and the governance rail are the same rail.
Why the signature is the unit →Honest edges
What this page does not know.
- CARA payment amounts are largely unpublished. The program is sized against avertable cost rather than posted as a fee schedule, so any revenue figure built on it today is a model, not a rate.
- CMS lists the ASM participant count as N/A. Headcount figures circulating in trade coverage are secondary reporting, not a CMS number, and are not repeated here.
- ASM is finalized, but updates to it were proposed in the CY2027 Physician Fee Schedule. Comments on those proposed updates close at 11:59 PM ET on September 14, 2026. The model is not open for relitigation; the proposed updates are.
- Being in a model is not the same as being in a geography. ASM selects by CBSA and metropolitan division, and CMS publishes those areas as a spreadsheet — check it before assuming exposure either way.
- This page is a reference, not advice. Every figure links to the CMS page it came from so it can be checked rather than trusted.
Two of these models pay for an accountable human.
ACCESS names a physician Clinical Director. CARA pays for an episode someone owns. Neither reimburses a more accurate model. Bring one synthetic output to the sandbox and watch the record that a named clinician signs.