CMS has been making an attempt to scale value-based care for many years with combined outcomes — however the company’s newly introduced ACCESS mannequin might signify a extra significant step towards aligning cost with outcomes and prices.
Over the previous 20 years, CMS’ regular development of cost and care supply reforms embrace pay-for-performance, bundled funds, accountable care organizations and different cost fashions. Whereas a lot of these efforts layered incentives on high of suppliers’ fee-for-service fashions, ACCESS is a extra specific try and rewire conventional Medicare itself round affected person outcomes, whole price of care and suppleness in how care is delivered.
ACCESS stands for Advancing Continual Care with Efficient, Scalable Options. It can permit suppliers to make use of digital instruments, nontraditional companies and care groups that aren’t usually reimbursed underneath fee-for-service. Collaborating suppliers will tackle accountability for high quality and the overall price of care, with the chance to share in financial savings in the event that they enhance outcomes and reduce spending.
The mannequin, which is slated to start on July 1, is designed to advertise prevention, steady engagement and technology-enabled care somewhat than episodic visits.
Consultants assume it’s CMS’ clearest try but to maneuver conventional Medicare fee-for-service towards an outcomes mannequin, in addition to a key effort to assist broaden care past the 4 partitions of a hospital or clinic. Nevertheless, they supply a caveat: the success of ACCESS will rely on sustained participation, clear metrics and the flexibility to combine knowledge and digital instruments throughout fragmented care settings.
How does the mannequin work?
CMS stated its ACCESS program will initially give attention to situations affecting greater than two-thirds of individuals on Medicare, together with melancholy, diabetes, hypertension and continual musculoskeletal ache.
Below this system, CMS will consider collaborating suppliers based mostly on whether or not their sufferers’ situations meaningfully enhance over time and whether or not these enhancements translate into decrease use of pricey companies. That features monitoring modifications in medical metrics tied to every situation, in addition to downstream results like fewer hospitalizations, fewer emergency division visits and decrease general Medicare spending for sufferers seeing an ACCESS-enrolled supplier.
Suppliers that meet or exceed these high quality and price benchmarks can earn shared financial savings, however people who fall brief might face diminished funds.
Slightly than paying solely for particular person visits or procedures, CMS ties reimbursement to efficiency on these outcomes — incentivizing care that’s extra preventive and coordinated.
The mannequin additionally encourages the usage of know-how like distant monitoring, digital behavioral well being applications and digital care administration groups. All of those are identified to assist enhance affected person outcomes however aren’t usually reimbursed underneath fee-for-service.
For that reason, firms offering tech-enabled care are bullish on ACCESS. One chief — Ankoor Shah, vice chairman of medical excellence at digital care supplier Included Well being — stated the mannequin is the primary critical transfer inside conventional Medicare fee-for-service towards flexibility, outcome-based cost and protection for companies that traditionally weren’t paid for.
He identified that ACCESS is completely different from prior CMS initiatives meant to advertise value-based care. One purpose is that it’s focuses on Medicare Half B fee-for-service somewhat than capitation.
Half B has traditionally operated underneath a fee-for-service mannequin that reimburses suppliers for every outpatient go to, with little consideration for long-term affected person outcomes. In contrast to capitation fashions, which give suppliers a set funds per affected person, ACCESS retains Half B’s fee-for-service construction however ties funds to measurable outcomes. This implies suppliers are nonetheless reimbursed for every service, however they’ll earn extra shared financial savings — or incur penalties — based mostly on how effectively sufferers’ situations are managed over time.
This method permits suppliers to make use of know-how and care coordination companies in ways in which have by no means been financially supported underneath conventional Half B, Shah declared.
Linked units may help get monetary savings
Shah additionally highlighted the brand new mannequin’s emphasis on what occurs exterior medical settings, as ACCESS acknowledges that wearables, digital applications, specialty care fashions and ongoing affected person engagement all play an necessary position in outcomes.
For instance, this new protection might permit a Medicare affected person with coronary heart failure to obtain a mixture of distant monitoring and in-person care somewhat than relying solely on workplace visits.
A supplier collaborating in ACCESS would possibly use related units — comparable to good scales and blood strain displays to trace weight and blood strain at residence — paired with nurse-led check-ins, throughout which medical workers could make treatment changes and referrals to vitamin or cardiac rehab applications.
These kinds of interventions assist stop continual situations from worsening to the purpose of hospitalization, Shah remarked.
CMS’ purpose is to generate financial savings from the eventual discount in pointless hospital stays, emergency visits and problems, although the magnitude of these financial savings has but to be decided.
Nevertheless, outcomes from the Medicare Shared Financial savings Program, CMS’ largest and longest-running different cost mannequin, counsel there may be important potential to deliver prices down. CMS reported $2.1 billion and $2.5 billion in web financial savings from this system in 2023 and 2024, respectively.
Researchers have additionally been proving related units’ capability to decrease prices over the previous decade. One latest examine, printed final 12 months within the Journal of Cardiac Failurediscovered that distant affected person monitoring for coronary heart failure sufferers was related to a 52% discount in month-to-month healthcare prices, primarily by decreasing hospital stays and hostile occasions like coronary heart assaults.
And simply final month, digital care supplier Cadence printed a peer-reviewed examine on its collaboration with Mayo Clinic, and it confirmed that the startup’s distant monitoring applications resulted in a 27% drop in hospital admissions.
Elevating the bar on accountability
Fewer inpatient visits and shorter hospital stays are outcomes that immediately decrease spending on pricey acute care, famous Cadence CEO Christopher Altchek. CMS is in search of methods to economize, which is why ACCESS suits right into a broader coverage shift, he acknowledged.
He pointed to a few parallel developments — greater 2026 reimbursement for distant affected person monitoring and superior major care administration in CMS’ Doctor Payment Schedule, in addition to HHS’ $50 billion rural well being transformation fund prioritizing continual illness administration.
In Altchek’s view, ACCESS will assist increase the bar on accountability. Two implications stood out for him, the primary being that CMS will publish annual standardized efficiency outcomes, which is able to shortly separate high-quality contributors from weaker ones.
The second is that medical outcomes will probably be measured by enchancment over time. For instance, CMS will probably be being attentive to whether or not sufferers’ blood strain or A1c is decrease on the finish of this system than it was initially. Altchek stated this can be a extra exact and significant method than present CMS Star Rankings.
“The way in which Stars metrics are calculated shouldn’t be detailed sufficient. A Stars metric is like what share of your hypertension inhabitants is underneath management — it doesn’t provide you with any credit score for the motion inside the inhabitants or how efficient you’re. It’s a really crude metric. It is a rather more exact metric, and that’s actually useful to have — standardized on the stage of CMS,” he defined.
Altchek stated ACCESS might reset how payers and suppliers consider continual illness administration by creating an “apples-to-apples” commonplace for outcomes and price financial savings.
ACCESS bets on digital care — however provided that the information flows
Along with elevating the bar for accountability, ACCESS additionally units greater requirements for digital well being suppliers, stated Lark Well being CEO Julia Hu. Lark gives a digital platform for continual illness administration and prevention.
Hu stated she welcomes being held to stricter, outcomes-based requirements and believes ACCESS might drive underperforming digital well being and AI distributors out whereas rewarding these that may show their worth.
She thinks that knowledge integration would be the greatest problem to adoption.
“How can we mesh the standard (major care supplier) channels with these applied sciences to create a seamless expertise for the affected person whereas working by way of the medical workflow in order that suppliers can level to the right companies? I feel that will probably be a problem that we should always all work on,” Hu remarked.
There’s time, although. She identified that CMS has laid out a 10-year timeline for this challenge. This length is important, she stated, as a result of it offers suppliers time to mature and work by way of operational and integration challenges.
One other healthcare startup CEO — Jason Prestinario, CEO of information platform Particle Well being — stated that the mannequin’s success will hinge on the flexibility to seamlessly share affected person knowledge throughout varied suppliers and care settings.
He argued the mannequin can not work with out seamless knowledge move throughout all these touchpoints. Whereas there was progress in nationwide knowledge trade, gaps stay — particularly round particular person entry and chronic info blocking by EHR distributors, Prestinario famous.
“There’s going to be a number of completely different sources of knowledge, and methods and instruments and know-how that suppliers are going to make use of to holistically deal with the affected person — so we have to make it possible for EHRs can’t block that entry in ways in which we nonetheless see at this time. I feel we’re making a number of strides and a number of enhancements, however there’s nonetheless work to be performed, for positive,” he declared.
Prestinario referred to as for stronger enforcement on the “provide aspect” of information. He argued that CMS has targeted closely on stimulating demand for higher knowledge use by way of its initiatives aimed toward bettering private knowledge entry and higher clinician workflows — however that it has not performed sufficient to make sure the provision of information is definitely obtainable.
He stated value-based care fashions like ACCESS will solely work if regulators extra aggressively implement information-blocking guidelines and require EHR distributors and suppliers to make affected person knowledge readily accessible when sufferers obtain care throughout completely different settings.
Prestinario added that he expects the mannequin to profit value-based and digitally native suppliers first. He thinks suppliers which can be already targeted on outcomes — significantly in CMS’ goal areas like cardiac illness, diabetes, behavioral well being and musculoskeletal — will profit most. He’s much less sure how business payers and Medicare Benefit will in the end adapt, on condition that they’ve completely different incentive constructions and usually lack standardized necessities round knowledge sharing and outcomes measurement.
In the end, ACCESS might give Medicare the instruments to pay for outcomes as a substitute of quantity — however its success will rely on how CMS follows by way of on measurement, enforcement and knowledge sharing.
Picture: Charday Penn, Getty Photos
