CMS has been attempting to scale value-based care for many years with blended outcomes — however the company’s newly introduced ACCESS mannequin might characterize a extra significant step towards aligning fee with outcomes and prices.
Over the previous 20 years, CMS’ regular development of fee and care supply reforms embrace pay-for-performance, bundled funds, accountable care organizations and various fee fashions. Whereas a lot of these efforts layered incentives on prime of suppliers’ fee-for-service fashions, ACCESS is a extra express try to rewire conventional Medicare itself round affected person outcomes, whole value of care and suppleness in how care is delivered.
ACCESS stands for Advancing Persistent Care with Efficient, Scalable Options. It should enable suppliers to make use of digital instruments, nontraditional companies and care groups that aren’t sometimes reimbursed beneath fee-for-service. Taking part suppliers will tackle duty for high quality and the full value 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 fairly than episodic visits.
Consultants suppose 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 develop care past the 4 partitions of a hospital or clinic. Nonetheless, they supply a caveat: the success of ACCESS will rely on sustained participation, clear metrics and the flexibility to combine information and digital instruments throughout fragmented care settings.
How does the mannequin work?
CMS mentioned its ACCESS program will initially give attention to circumstances affecting greater than two-thirds of individuals on Medicare, together with melancholy, diabetes, hypertension and persistent musculoskeletal ache.
Beneath this system, CMS will consider taking part suppliers primarily based on whether or not their sufferers’ circumstances 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 total 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 those who fall quick might face decreased funds.
Moderately 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 recognized to assist enhance affected person outcomes however aren’t sometimes reimbursed beneath fee-for-service.
For that reason, corporations offering tech-enabled care are bullish on ACCESS. One chief — Ankoor Shah, vp of medical excellence at digital care supplier Included Well being — mentioned the mannequin is the primary severe transfer inside conventional Medicare fee-for-service towards flexibility, outcome-based fee 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 fairly than capitation.
Half B has traditionally operated beneath a fee-for-service mannequin that reimburses suppliers for every outpatient go to, with little consideration for long-term affected person outcomes. Not like 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 will earn extra shared financial savings — or incur penalties — primarily based on how effectively sufferers’ circumstances are managed over time.
This strategy permits suppliers to make use of know-how and care coordination companies in ways in which have by no means been financially supported beneath conventional Half B, Shah declared.
Linked units will help lower your expenses
Shah additionally highlighted the brand new mannequin’s emphasis on what occurs outdoors medical settings, as ACCESS acknowledges that wearables, digital applications, specialty care fashions and ongoing affected person engagement all play an essential function in outcomes.
For instance, this new protection might enable a Medicare affected person with coronary heart failure to obtain a mix of distant monitoring and in-person care fairly than relying solely on workplace visits.
A supplier taking part in ACCESS would possibly use linked units — reminiscent of sensible scales and blood strain displays to trace weight and blood strain at residence — paired with nurse-led check-ins, throughout which medical employees could make remedy changes and referrals to diet or cardiac rehab applications.
Most of these interventions assist stop persistent circumstances from worsening to the purpose of hospitalization, Shah remarked.
CMS’ aim is to generate financial savings from the eventual discount in pointless hospital stays, emergency visits and issues, although the magnitude of these financial savings has but to be decided.
Nonetheless, outcomes from the Medicare Shared Financial savings Program, CMS’ largest and longest-running various fee mannequin, recommend there’s vital potential to convey 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 linked units’ skill to decrease prices over the previous decade. One current examine, printed final 12 months within the Journal of Cardiac Failure, discovered 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 opposed 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 straight decrease spending on pricey acute care, famous Cadence CEO Christopher Altchek. CMS is on the lookout for 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 main care administration in CMS’ Doctor Payment Schedule, in addition to HHS’ $50 billion rural well being transformation fund prioritizing persistent 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 members from weaker ones.
The second is that medical outcomes might be measured by enchancment over time. For instance, CMS might be taking note of whether or not sufferers’ blood strain or A1c is decrease on the finish of this system than it was at the start. Altchek mentioned it is a extra exact and significant strategy than present CMS Star Scores.
“The best way Stars metrics are calculated is just not detailed sufficient. A Stars metric is like what proportion of your hypertension inhabitants is beneath management — it doesn’t offer you any credit score for the motion inside the inhabitants or how efficient you might be. It’s a really crude metric. It is a way more exact metric, and that’s actually useful to have — standardized on the stage of CMS,” he defined.
Altchek mentioned ACCESS might reset how payers and suppliers consider persistent 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, mentioned Lark Well being CEO Julia Hu. Lark presents a digital platform for persistent illness administration and prevention.
Hu mentioned 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 information integration would be the largest problem to adoption.
“How will we mesh the normal [primary care provider] channels with these applied sciences to create a seamless expertise for the affected person whereas working by the medical workflow in order that suppliers can level to the proper companies? I feel that might be a problem that we should always all work on,” Hu remarked.
There may be time, although. She identified that CMS has laid out a 10-year timeline for this undertaking. This length is important, she mentioned, as a result of it provides suppliers time to mature and work by operational and integration challenges.
One other healthcare startup CEO — Jason Prestinario, CEO of knowledge platform Particle Well being — mentioned that the mannequin’s success will hinge on the flexibility to seamlessly share affected person information throughout varied suppliers and care settings.
He argued the mannequin can not work with out seamless information move throughout all these touchpoints. Whereas there was progress in nationwide information change, gaps stay — particularly round particular person entry and protracted data blocking by EHR distributors, Prestinario famous.
“There’s going to be loads 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 be sure that EHRs can’t block that entry in ways in which we nonetheless see immediately. I feel we’re making loads of strides and loads of enhancements, however there’s nonetheless work to be accomplished, for certain,” he declared.
Prestinario known as for stronger enforcement on the “provide facet” of knowledge. He argued that CMS has targeted closely on stimulating demand for higher information use by its initiatives aimed toward bettering private information entry and higher clinician workflows — however that it has not accomplished sufficient to make sure the provision of knowledge is definitely out there.
He mentioned 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 information 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 might be already targeted on outcomes — notably 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, provided that they’ve completely different incentive constructions and sometimes lack standardized necessities round information sharing and outcomes measurement.
Finally, ACCESS might give Medicare the instruments to pay for outcomes as an alternative of quantity — however its success will rely on how CMS follows by on measurement, enforcement and information sharing.
Photograph: Charday Penn, Getty Photos
