SUMMARY
Executive Summary
CMS’s ACCESS model is more than a digital health demonstration; it is a serious attempt to create a new Medicare payment architecture for technology-supported chronic care. Rather than paying for visits, devices, remote-monitoring events, app interactions, or care-management minutes, ACCESS uses Outcome-Aligned Payments tied to measurable clinical improvement or control. This design directly addresses a long-standing Medicare problem: fee-for-service payment pulls digital innovation toward billable activity rather than better health.
ACCESS begins in 2026 as a 10-year CMMI model in Original Medicare, with tracks for cardiometabolic disease, musculoskeletal pain, and behavioral health. Its most important features include baseline-relative outcome targets, a fee-for-service exclusion for ACCESS participants, physician oversight, FDA/HIPAA compliance, co-management payments for referring clinicians, public outcome reporting, and randomized evaluation. The model also links payment policy to FDA’s TEMPO pilot, making ACCESS a potential regulatory sandbox for digital health and AI-enabled care.
The accepted-applicant list provides early market validation. CMS attracted a broad set of digital-first, hybrid, behavioral health, MSK, cardiometabolic, nutrition, remote-monitoring, and provider-affiliated organizations. The list does not prove execution, but it shows that ACCESS has already created a credible pathway for nontraditional chronic-care organizations to enter Original Medicare.
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MAIN ARTICLE
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Below is a policy-watcher memo draft. I’ve grounded it in the CMS ACCESS webpages/technical FAQ and the JAMA Perspective by Jacob Shiff and CMMI Director Abe Sutton. Key source points include: ACCESS is a 10-year Original Medicare CMMI model beginning July 5, 2026; it uses Outcome-Aligned Payments for technology-supported chronic care; it covers four initial tracks; it includes random assignment of a small control group; it creates a PCP/referring clinician co-management payment; and it is explicitly positioned as an alternative to, not an add-on to, FFS billing.
CMS ACCESS Model: A Policy Assessment for Top-Tier CMS Watchers
Executive take
CMS’s ACCESS model is more important than it first appears. On the surface, it is a voluntary CMMI demonstration for technology-supported chronic care in Original Medicare. But the more strategic reading is that ACCESS is an attempt to solve a long-standing Medicare payment-design problem: how to pay for digital, AI-enabled, remote, asynchronous, and software-mediated care without simply creating another fee-for-service volume engine.
ACCESS is not merely a digital health model. It is a new CMS payment architecture. It creates recurring, condition-track payments tied to measurable outcomes rather than to enumerated activities, time increments, devices, or visits. In doing so, it tries to avoid the trap that has plagued remote patient monitoring, chronic care management, telehealth, and digital therapeutics: the more CMS tries to define and price each service unit, the more it invites utilization growth, coding gamesmanship, and fragmented care.
The Shiff/Sutton JAMA article is significant because it reads less like a descriptive article and more like a policy manifesto from inside CMMI. It argues that fee-for-service is pulling digital innovation toward billing optimization rather than clinical transformation. It also argues that shared-savings and total-cost-of-care models, while directionally better, have not created a clean contracting path for technology-enabled chronic care organizations. ACCESS is offered as the third way: pay fixed amounts for measurable clinical improvement, let the care model vary, and let technology compete on outcomes rather than code capture.
What ACCESS is trying to fix
CMS identifies a familiar but real problem: Original Medicare has no clean payment pathway for many modern technology-supported chronic care services. Fee-for-service pays for defined activities. That works tolerably well for office visits, procedures, and tests, but poorly for continuous digital support, asynchronous coaching, remote monitoring, algorithmic triage, app-mediated behavioral support, and hybrid care models that do not map neatly to CPT units.
The JAMA paper sharpens the critique. It says that many of the fastest-growing health technology uses are not necessarily the highest-value uses. Technology adoption is often directed toward documentation, billing optimization, and shifting clinician time toward reimbursable services. That is not an accident; it is an artifact of the payment system. In a fee-for-service environment, technology that helps generate more billable units may be monetized faster than technology that quietly prevents worsening blood pressure, improves depression scores, reduces pain interference, or keeps prediabetes from progressing.
CMS is therefore trying to create a payment model that changes the target of innovation. Under ACCESS, the vendor or care organization is not rewarded for how many remote pings, app sessions, telehealth contacts, monitoring events, or care-management minutes it produces. It is rewarded for achieving defined clinical improvement or control. That is the central philosophical move.
The basic structure
ACCESS is a 10-year CMMI model in Original Medicare, beginning July 5, 2026, with rolling admissions. It initially covers four broad clinical tracks:
Early cardio-kidney-metabolic conditions, including hypertension, dyslipidemia, obesity or overweight with central obesity, and prediabetes.
Cardio-kidney-metabolic conditions, including diabetes, stage 3a/3b chronic kidney disease, and atherosclerotic cardiovascular disease.
Musculoskeletal conditions, specifically chronic musculoskeletal pain.
Behavioral health conditions, specifically depression and anxiety.
These tracks are deliberately broad. CMS is not paying for a single app, device, or narrow digital therapeutic. It is paying organizations to manage a cluster of related conditions with similar care intensity and overlapping interventions. This is important because it pushes ACCESS away from the “one technology, one billing code” model and toward something closer to an accountable care product line.
Participating organizations must be Medicare Part B-enrolled providers or suppliers, must designate a physician clinical or medical director, and must comply with applicable licensure, HIPAA, and FDA requirements, or be within FDA enforcement discretion. Care may be in-person, virtual, asynchronous, or technology-enabled. The model contemplates clinician consultations, lifestyle and behavioral support, patient education, care coordination, medication management, diagnostic interpretation, and FDA-authorized or enforcement-discretion digital devices and software.
Patients voluntarily enroll, either directly or by referral. Medicare Advantage patients are not in the model, although MA plans may voluntarily create similar arrangements. A small share of beneficiaries attempting to enroll may be randomized into a control group, which is crucial for evaluation and eventual expansion authority.
The central payment innovation: Outcome-Aligned Payments
The central mechanism is the Outcome-Aligned Payment, or OAP. Participating organizations receive recurring payments for managing a qualifying condition track. Full payment depends on achieving measurable outcomes, such as improvement or control relative to baseline. The CMS materials use examples like reducing blood pressure by a clinically meaningful amount or reaching guideline-informed targets.
This is subtle but important. ACCESS does not simply pay for outcomes in the abstract. It pays for outcomes relative to starting point and track-specific measures. That design attempts to reduce two opposite risks: rewarding easy patients who are already controlled, and punishing organizations that enroll more difficult patients. At least one measure must be uncontrolled to qualify for full initial payment, which is meant to prevent enrollment of already-controlled patients simply to harvest payments.
The model also uses an organization-level attainment threshold. In the first model year, for example, an organization can earn full payment if at least 50 percent of aligned beneficiaries whose care period ends during the assessment period meet all required outcome targets. If performance falls below the threshold, payment is reduced proportionally, with a cap on the reduction. This creates a portfolio logic: the organization is accountable for a population, but it is not financially destroyed because some patients fail to improve.
This is not full capitation, and it is not total-cost-of-care risk. It is closer to condition-specific, outcome-contingent payment. CMS is trying to capture the upside of value-based care without forcing every digital chronic care company to become an ACO or insurer.
Why this is strategically different from prior digital health payment policy
ACCESS is a departure from prior Medicare approaches in four ways.
First, it is not built around CPT code proliferation. CMS is not trying to create a billing code for every digital care activity. That matters because activity codes often produce activity inflation.
Second, it is not a device add-on payment. The model is not paying because a device is novel, expensive, or FDA-cleared. Devices and software are tools inside a care model, not the unit of payment.
Third, it is not simply telehealth expansion. ACCESS is broader than live virtual visits. It can include asynchronous care, coaching, remote monitoring, patient education, diagnostic interpretation, and technology-supported longitudinal management.
Fourth, it is not dependent on bespoke ACO-vendor contracting. The JAMA article emphasizes that risk-bearing entities have had difficulty contracting with technology-enabled chronic care organizations because savings are condition-specific, attribution is difficult, and contracting can create transaction costs and vendor lock-in. ACCESS creates a standardized Medicare claims-based pathway that ACOs and other risk-bearing entities can use indirectly.
That last point is highly significant. ACCESS may become a kind of payment “rail” for digital chronic care. ACOs can refer patients to ACCESS organizations without having to negotiate every parameter of condition-specific savings attribution. CMS can then count ACCESS expenditures in ACO reconciliation over time, while the ACCESS organization bills Medicare directly.
The co-management payment: small dollars, large policy signal
ACCESS includes a new co-management payment for primary care and referring clinicians who review ACCESS updates and document coordination activities. The payment is modest, approximately $30 per service, with an additional initial setup modifier of roughly $10 and limits of about once every four months per beneficiary per track, up to about $100 per year.
The dollar amount is not the main story. The main story is that CMS recognizes the primary care doctor’s coordination labor as a necessary bridge between external technology-enabled care organizations and traditional care. This is an attempt to prevent ACCESS from becoming a parallel digital health universe detached from the patient’s ordinary clinician.
CMS is also trying to solve a behavioral problem. Primary care physicians may be skeptical of digital health vendors that enroll their patients, alter care pathways, or generate data streams without meaningful integration. The co-management payment says: CMS wants the PCP or referring clinician in the loop, wants documented review, and is willing to pay a small but explicit amount for that work.
This may be one of the most practical pieces of the model. If it works, it could become a template for future models that bring external technology-enabled specialty or chronic care organizations into relationship with traditional clinicians.
The FFS exclusion: the guardrail that makes the model real
ACCESS is explicitly an alternative to FFS billing for the ACCESS participant for that beneficiary during the care period. It is not an add-on. The participant and its affiliates may not bill ordinary Medicare FFS claims for other services furnished to the same ACCESS-aligned beneficiary during an active ACCESS care period, except through ACCESS-specific codes.
This is one of the most important anti-gaming provisions. Without it, ACCESS could become another layer on top of existing FFS claims. CMS is trying to prevent a scenario where the organization receives an outcome-aligned payment while also billing remote monitoring, care management, evaluation services, or other claims for the same patient under ordinary FFS.
The rule is beneficiary-specific and participant-specific. A participating organization can use ACCESS for Patient A and traditional FFS for Patient B. But it cannot use ACCESS and ordinary FFS simultaneously for Patient A during the active care period. That design preserves flexibility while drawing a reasonably clear anti-duplication line.
For policy watchers, this is classic CMMI architecture: create a new payment pathway, then build a billing exclusion around it so it does not simply accrete on top of legacy FFS.
FDA and TEMPO: ACCESS as a regulatory sandbox
The FDA angle is unusually important. ACCESS requires participants to comply with applicable FDA requirements, or to operate within FDA enforcement discretion. CMS also points to FDA’s TEMPO pilot, which allows certain digital health device manufacturers to seek FDA enforcement discretion in connection with ACCESS while real-world performance data are collected.
This is potentially a major policy bridge. ACCESS is not only a payment model; it may become a controlled environment for digital health regulatory experimentation. The model allows CMS and FDA to connect three things that are often separate: payment, real-world clinical use, and evidence generation.
For AI diagnostics, connected devices, and clinical software, this could be especially important. The JAMA paper explicitly argues that ACCESS may help address a market failure in early detection. Detection alone often lacks a business model if finding a condition does not trigger a reimbursable care pathway. Under ACCESS, identifying early chronic kidney disease, prediabetes, uncontrolled hypertension, or other early markers could become economically valuable because there is now a care-management payment path tied to improving those conditions.
That is a very big idea. It means ACCESS could indirectly stimulate AI diagnostics and screening tools not by paying for the diagnostic itself, but by creating a downstream economic pathway for organizations that can find and manage patients earlier.
The model’s savings theory
ACCESS has two savings theories.
The first is clinical-control savings. If organizations improve blood pressure, weight, HbA1c, lipids, pain, function, depression, or anxiety, downstream spending may fall. This is the prevention logic: improve leading indicators, reduce later acute and high-cost utilization.
The second is substitution savings. Some beneficiaries may choose ACCESS-supported care instead of more expensive traditional services. For example, a technology-enabled MSK program may substitute for repeated specialty visits or some physical therapy use; behavioral health technology-supported care may create lower-cost access where in-person care is scarce.
The JAMA paper is careful to acknowledge a counterpoint: ACCESS may engage people who would otherwise not seek care, increasing near-term spending. CMS’s answer is that many such patients eventually appear in high-cost settings anyway, and earlier structured care may generate net savings. This is exactly why randomized evaluation matters. ACCESS is not merely a payment option; it is an experiment designed to test whether proactive technology-supported care saves money or simply expands utilization.
The risk framework
CMS and Shiff/Sutton are unusually explicit about risks. The main risks are selective enrollment, lemon-dropping, overtreatment, fragmentation, spending outside the payment, and limited price competition.
Selective enrollment is addressed through baseline-relative outcomes, requiring at least one uncontrolled measure for full initial payment, and publishing risk-adjusted outcomes.
Lemon-dropping is addressed by limiting participant-initiated disenrollment to narrow circumstances.
Overtreatment is addressed through monitoring of claims and clinical submissions for inappropriate intensity. This is especially relevant in cardiometabolic tracks, where aggressive medication intensification could improve measures but create safety or polypharmacy concerns.
Fragmentation is addressed by requiring integrated management of all conditions within a track, electronic care updates, HIE or trusted-network integration, and co-management payments for traditional clinicians.
Spending outside the payment is addressed through a substitute-spend adjustment for duplicative services from other Medicare providers, such as certain physical therapy evaluations when an ACCESS MSK organization is already managing the relevant condition.
Limited price competition is acknowledged but not fully solved. CMS uses fixed payment rates and public outcome reporting, meaning competition is primarily on quality and outcomes, not price. CMS considered price competition but concluded that allowing organizations to forgo beneficiary cost-sharing was more important for access and affordability.
This risk section is worth reading as the real policy design logic. It shows that CMS understands the predictable failure modes of outcome-based payment. The question is not whether the model has risks; it does. The question is whether the guardrails are strong enough without making participation unattractive.
What is most innovative
The most innovative feature is not “digital health.” It is the abstraction layer. CMS is trying to define a payment unit that is neither a visit, nor a device, nor a software license, nor a care-management minute. The unit is a condition-track episode of technology-supported care, paid according to outcome attainment.
This may be the most scalable part of the model. If CMS can define condition tracks, baseline measures, outcome thresholds, reporting APIs, and payment logic, the specific technologies can evolve without constant code creation. That is exactly what CMS needs in AI-enabled care, where software changes faster than CPT and HCPCS processes can comfortably absorb.
The second major innovation is the combination of standardized claims-based payment and randomized evaluation. ACCESS is not just a negotiated contracting model. It creates billing rails, reporting infrastructure, risk-adjusted public outcomes, and control-group evaluation. That combination gives it a chance, if successful, to become a model that can be expanded, made permanent, or replicated by MA, Medicaid managed care, and commercial payers.
The third innovation is the FDA/CMS interface. TEMPO could become a precedent for using CMMI models as controlled environments for digital health evidence generation and regulatory learning.
Why CMS top-tier watchers should care
For CMS policy observers, ACCESS should be watched for several reasons.
First, it is an early major sign of how the current CMS/CMMI leadership wants to handle AI and technology-enabled care. Rather than paying separately for every algorithm or app, ACCESS channels payment through outcomes.
Second, it may create a new category of Medicare-participating care organizations. These may be digital health companies, hybrid care companies, specialty chronic care vendors, provider-affiliated virtual care groups, or ACO-adjacent service organizations. But because they must enroll in Medicare Part B, designate physician oversight, and accept compliance obligations, CMS is pulling them into the regulated provider/supplier world rather than treating them as mere vendors.
Third, it may become a template for condition-specific chronic care payment outside full ACO risk. Many organizations are not prepared to take total-cost-of-care risk, but may be prepared to take outcome risk for a defined condition domain. ACCESS could become the middle layer between FFS and full capitation.
Fourth, the model may shape private-sector contracting. CMS says it will provide reference agreements, source code, adjustment logic, and technical documentation to support payer alignment. Even if ACCESS itself remains limited, its definitions and payment logic may become a reference architecture.
Fifth, it gives digital health and AI companies a new strategic question: not “what code pays for our product?” but “what outcomes can our product help a Medicare-enrolled care organization achieve under a track?”
Likely winners
The most advantaged organizations will be those that already combine clinical operations, software, patient engagement, remote monitoring, and outcome measurement. ACCESS does not look like a good fit for a pure software company with no clinical infrastructure unless it partners with or becomes a Medicare-enrolled provider/supplier. Nor is it ideal for a traditional provider group with little digital infrastructure.
Likely winners include hybrid virtual chronic care companies, cardiometabolic management organizations, MSK digital care platforms with clinical staffing, behavioral health platforms with validated measurement infrastructure, and provider organizations that can wrap technology around existing chronic care programs.
The model may also help companies with devices or AI diagnostics if those tools generate enrollable patients or help achieve outcomes. But the device or diagnostic is not the revenue center by itself. It is part of an outcome-production system.
Likely pain points
The first pain point will be operational complexity. Participants must manage enrollment, baseline data collection, recurring outcome measures, HIPAA, FDA issues, APIs, care updates, HIE or trusted-network connectivity, and Medicare compliance. Many digital health companies that are comfortable selling to employers or commercial plans may find Medicare provider/supplier obligations more burdensome than expected.
The second pain point will be patient attribution and engagement. Voluntary enrollment is attractive politically and operationally, but it may create churn, selection, and engagement challenges. The patients most likely to enroll and use technology may not be the patients most in need.
The third pain point will be risk adjustment and public reporting. Public risk-adjusted outcomes can create competition, but they can also create reputational risk and disputes over whether adjustment fairly accounts for social risk, clinical complexity, behavioral barriers, and local access constraints.
The fourth pain point will be the economics of fixed payments. CMS says payment rates are expected to be below spending for comparable traditional care and reflect lower marginal costs of technology-enabled services. That may be true for scaled digital operators, but thin for organizations with high-touch clinical models or complex patients.
The fifth pain point will be overlap with ordinary care. The FFS exclusion prevents duplication by the ACCESS participant, but beneficiaries remain free to see other providers. The substitute-spend adjustment will be crucial, and possibly contentious, because it determines when CMS views outside services as duplicative rather than complementary.
Political and administrative durability
ACCESS has an interesting political profile. It is voluntary, outcome-based, chronic disease-focused, and framed around prevention, patient choice, rural access, and technology modernization. Those features give it cross-administration durability. It is not obviously “left” or “right.” It is not a coverage expansion in the conventional sense, nor a pure austerity model. It fits a Republican-friendly rhetoric of innovation, competition, private-sector technology, and lower costs, while also fitting a Democratic-friendly rhetoric of access, chronic care, behavioral health, and prevention.
The involvement of Abe Sutton as co-author of the JAMA Perspective is important. It signals that ACCESS is not a stray technical model buried in CMMI; it is part of leadership’s broader payment philosophy. The model’s design also aligns with recent CMS rhetoric that CMMI should produce models that are more operationally scalable, more fiscally disciplined, and more directly tied to measurable results.
The caveat is that a 10-year model beginning in 2026 will live across multiple administrations. Its survival will depend on early participation, stakeholder support, operational feasibility, and the absence of visible abuse or runaway spending. The randomized control design may help, but it also means that definitive results will take time.
Bottom line
ACCESS is best understood as CMS’s attempt to build a new Medicare payment rail for technology-enabled chronic care. It is not simply another digital health experiment. It is a test of whether Medicare can pay for AI-enabled, software-mediated, remote, and asynchronous care through measurable outcomes rather than through activity-based billing codes.
The model’s strongest feature is its conceptual clarity: pay for improvement or control, not for clicks, minutes, devices, or visits. Its second strongest feature is its guardrail architecture: FFS exclusion, physician oversight, FDA/HIPAA compliance, co-management requirements, public outcome reporting, and randomized evaluation. Its biggest vulnerability is whether real-world participants can make the economics and operations work without selecting easier patients, over-intensifying care, fragmenting care, or shifting costs outside the model.
For CMS watchers, the key takeaway is that ACCESS may be a prototype for the next generation of Medicare payment policy. If it works, it could become a scalable model for chronic disease, AI-enabled diagnostics, digital therapeutics, connected devices, and hybrid virtual care. If it fails, the failure will likely teach CMS that outcome-based payment is not enough unless the model also solves engagement, risk adjustment, clinical integration, and total-cost accountability.
Either way, ACCESS is one of the more intellectually coherent CMMI models in recent years. It deserves close attention.
The most “watch this space” detail, in my view, is that ACCESS makes early detection economically useful only when paired with accountable downstream care. That is a potentially powerful shift for AI diagnostics, but it also means many standalone diagnostic/software firms will need provider-like partners rather than simply a better code.
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Accepted Party List - Does It Tell You Much?
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The applicant list is useful less as a set of tea leaves than as a revealed-market test of who thinks ACCESS is commercially actionable. The biggest signal is that CMS attracted far more than a symbolic pilot cohort: CMS says more than 150 organizations have been accepted, and the PDF list I count at roughly 190 accepted entries, though some are affiliated entities or state-specific professional corporations rather than unique parent companies. CMS also cautions that inclusion is not endorsement and does not guarantee final participation, since Medicare enrollment, participation agreement execution, and final approval remain pending.
The most important pattern is that ACCESS has clearly landed with digital-first chronic care organizations, not just conventional health systems. The names include Headspace, Headway, Sondermind, Noom, Weight Watchers, Welldoc, Withings, WHOOP Physician Services, Verily, Foodsmart, Cadence, Story Health, Somatus, Aledade-related entities, Curai, HealthTap, DocGo, PocketRN, TailorCare, Bold, RightMove, Limber/Revel AI, and others. That is exactly the market CMS was trying to call into being: technology-supported, condition-focused care organizations that may not have had a clean Original Medicare business model before. CMS itself says most accepted organizations have not previously served Medicare beneficiaries, which is a striking admission and probably the single strongest “non-tea-leaf” signal in the document.
The second pattern is that cardiometabolic care dominates. From the listed tracks, I count approximately 144 eCKM entries and 136 CKM entries, compared with about 109 behavioral health and 76 MSK. The most common combinations are eCKM + CKM and all four tracks. That makes sense: hypertension, obesity, prediabetes, diabetes, CKD, and ASCVD are huge Medicare problems; they have measurable biomarkers; and digital coaching, remote monitoring, nutrition, medication management, and adherence tools map naturally onto them. This is where ACCESS looks most administratively plausible: the outcomes are measurable, the patient pool is enormous, and the intervention stack is already commercially mature.
The third pattern is that ACCESS is attracting multi-track “platform” entrants, not merely narrow specialty products. About 50 listed entities appear in all four tracks: eCKM, CKM, MSK, and BH. Some may be small or opportunistic applicants, but the pattern matters. It suggests that many organizations view ACCESS not as “a diabetes code” or “an MSK code,” but as a generalizable payment chassis for longitudinal virtual/hybrid chronic care. That aligns with the Shiff/Sutton thesis: CMS is trying to pay for outcome production across condition clusters, rather than for discrete app functions, telehealth minutes, or devices.
The fourth pattern is that behavioral health is heavily represented, but often as a standalone or paired category. Names like Headspace, Headway, Sondermind, Concert Health, Mindoula, Innerwell, Limbic Care, Sleep Reset, M3 Information, and others suggest real interest from digital and hybrid behavioral health firms. This is not surprising because depression and anxiety have validated scales, large access gaps, and strong virtual-care precedent. But it may also be operationally harder than cardiometabolic care: PHQ-9 and GAD-7 are measurable, but outcomes can be noisier, harder to risk-adjust, and more dependent on patient engagement.
The fifth pattern is that MSK is present but less dominant. There are focused MSK names — Bold, RightMove, TailorCare, Stern at Home Physical Therapy, Plethy, Redefine Healthcare, Livara, JOGO, Flagler — and also multi-track players with MSK included. MSK probably has an appealing substitution story: avoid unnecessary specialist visits, imaging, procedures, or prolonged PT through structured digital/hybrid care. But compared with eCKM/CKM, it may be harder to prove clean savings and avoid overlap with ordinary PT, imaging, orthopedics, and pain management.
A more subtle signal is that CMS is allowing a broad ecology of organizational forms: medical groups, professional corporations, community health centers, nephrology practices, behavioral health companies, virtual-first platforms, nutrition/weight-management brands, remote monitoring companies, AI-branded firms, and payer/provider-adjacent groups. This fits the ACCESS theory that the participant must become Medicare-enrolled and clinically accountable, but the actual care model can vary. In other words, CMS is not picking one “digital health” archetype. It is letting the market test which organizational forms can survive outcome-aligned payment.
What I would not overread: the list does not tell us which applicants are serious, adequately capitalized, operationally ready, or likely to enroll meaningful numbers of beneficiaries. It also does not tell us whether CMS screened deeply for business quality versus basic eligibility and model fit. Some names look substantial; others look like small professional corporations, newly organized entities, or local practices. Since CMS says participation is still contingent on further requirements, this is better viewed as an accepted-applicant funnel, not the final launch roster.
My bottom line: the list supports the idea that ACCESS is not a sleepy demonstration. It has created a visible call option for digital chronic care, especially cardiometabolic care, behavioral health, MSK, and remote/hybrid platforms. The most concrete takeaway is that CMS has succeeded, at least at the application stage, in attracting exactly the nontraditional Medicare-adjacent organizations it wanted. The open question is whether those organizations can cross the harder bridge from accepted applicant to Medicare-enrolled, clinically integrated, outcome-measured, financially viable participant.
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Financing of MDs and Vendors
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For CMS ACCESS, there are really two payment streams to keep separate:
1. Payments to ACCESS participants — the tech-enabled care organizations.
CMS pays a fixed annual Outcome-Aligned Payment per aligned beneficiary, paid monthly, with part withheld and reconciled against outcomes. For 2026–2027, published allowed amounts are roughly:
| ACCESS track | Initial year | Follow-on year |
|---|---|---|
| Early cardio-kidney-metabolic | $360/year | $180/year |
| Cardio-kidney-metabolic | $420/year | $210/year |
| Musculoskeletal | $180/year | — |
| Behavioral health | $180/year | $90/year |
These are allowed amounts, including Medicare’s 80% share plus beneficiary coinsurance. Monthly payment is one-twelfth of the annual amount; CMS withholds 50% of the Medicare share and reconciles it later based on outcomes. (ArentFox Schiff)
2. Payments to ordinary physicians / PCPs / referring clinicians.
ACCESS is not mainly a new physician fee schedule model. However, CMS says PCPs and referring clinicians can bill a new co-management payment when they review ACCESS patient updates and perform documented coordination activities, such as medication changes or problem-list updates. CMS frames this as helping ACCESS “complement traditional care,” not replace the patient’s regular physician. (cms.gov)
Key policy point: ACCESS payment is not an add-on to ordinary FFS for the same ACCESS participant and same aligned beneficiary. CMS says ACCESS is an alternative to FFS billing by the ACCESS organization for that beneficiary; only ACCESS-specific G-codes may be billed during the active care period. Other non-ACCESS providers remain free to bill Medicare normally. (cms.gov)
So the take-home is: the model pays digital/technology-supported chronic-care organizations modest PMPM-style amounts, with outcomes at risk; regular clinicians get a small coordination hook, not the main payment.
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ACCESS vs SAVING MONEY vs MISSING CARE
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The premise is that CMMI projects must save money. Attached is a 20260602 article in Health Affairs by Liao, a Medpac member, that ACCESS is complex and problematic. Discuss. Then move to my point: ACCESS is supposed to save money, but there are myriad ways that it will be better patient care to spend money. These are problematic patients. You may find they are non compliant with their $5000 medication, but the ACCESS tech company is NOT incented, quite the opposite, to point that out and fix it. Discuss this as a fundamental paradox of the "save money" statute creating CMMI and what would really be found with under-managed chronic disease patients.
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Yes — this is exactly the central tension in ACCESS.
Liao’s Health Affairs piece is useful because it refuses the easy version of the argument. He does not say “ACCESS is obviously good” or “ACCESS is obviously a giveaway to digital-health vendors.” He says the model sits inside a real Medicare failure — FFS is bad at continuous chronic care — but that ACCESS imports all the familiar distortions of value-based payment: selection, metric gaming, documentation optimization, and ambiguous relationships with regular clinicians.
The most important sentence in the Liao article is the question under the title: can ACCESS generate enough clinical improvement to justify the distortions that accompany large-scale payment reform? That is a sophisticated MedPAC-style framing. It accepts that distortions are inevitable. FFS distorts toward more services. Capitation distorts toward fewer services. Quality measurement distorts toward documentation and denominator management. ACCESS will almost certainly distort toward patients who are reachable, digitally engaged, measurable, and improvable. Liao’s point is not that these risks make ACCESS invalid, but that they must be weighed against the fragmented, underfinanced chronic-care status quo.
Where your point bites harder is the CMMI savings premise. ACCESS is not just a clinical-care experiment. Under the CMMI statute, models are supposed to reduce spending without reducing quality, or improve quality without increasing spending. That sounds tidy on paper. But in real chronic disease management, especially in under-managed Medicare patients, “better care” will often mean more immediate spending, not less.
For example: ACCESS may discover that a beneficiary with heart failure, diabetes, CKD, depression, or musculoskeletal disability is not receiving the right medication, is not taking it, cannot afford it, has not had appropriate specialist follow-up, needs labs, needs imaging, needs PT, needs behavioral health support, or needs closer monitoring. In many cases, the clinically correct answer is to activate care that Medicare was not previously paying for. That may be wonderful medicine, but it is not obviously a near-term savings strategy.
Your $5,000 medication example is especially sharp. Suppose the patient is prescribed a high-value, expensive drug but is nonadherent because of side effects, confusion, affordability, refill friction, or lack of follow-up. The ACCESS organization can improve care by identifying this and helping restart therapy. But from the Medicare-spending perspective, successful adherence may look like higher Part D spending, more labs, more office visits, more care coordination, and possibly more downstream specialist management. The better the ACCESS vendor is at uncovering under-treatment, the more it may increase legitimate spending.
That produces the paradox:
ACCESS is framed as a savings model, but the patients most likely to benefit may be precisely the patients in whom better care reveals suppressed demand, unmet need, underuse of indicated therapy, and avoidable clinical neglect.
That is not a bug at the margin. It is fundamental. Chronic disease under-management often “saves money” only because the system is passively failing the patient. A model that fixes the failure may spend more before it saves anything — and in some cases it may never save money in the measurement window, even if it improves health.
This creates a deep incentive problem for the ACCESS company. If its performance is judged partly on total cost or substitute spending, it has at least some reason to prefer interventions that improve measured quality without unleashing expensive care. Outreach, reminders, documentation, coaching, metric capture, and low-cost protocol nudges are attractive. But finding the patient who needs a $5,000 drug, a cardiology workup, better CKD therapy, GLP-1 adherence, biologic adjustment, home support, or repeated PT may be financially awkward. The patient gets better care; the model may look worse.
Liao gestures toward this when he distinguishes scalable, protocolized chronic care from the needs of highly complex multimorbid beneficiaries. ACCESS may work best for a middle band: sick enough to improve, not so sick or socially complex that improvement requires expensive, individualized, multi-system intervention. That is exactly where selection pressure enters. The ideal ACCESS patient, economically, is not necessarily the neediest patient. It is the patient who is cheap to engage, easy to document, likely to move a metric, and unlikely to trigger large downstream utilization.
So the policy question is not merely, “Will ACCESS save money?” It is:
What kinds of patient improvement count as success when the clinically correct intervention increases spending?
If CMS insists on near-term savings, ACCESS may subtly reward shallow chronic-care management: better dashboards, more engagement, cleaner medication lists, improved blood pressure readings, better patient nudges. Those are not trivial. But the hard cases — the ones where the right answer is costly reactivation of care — sit uneasily inside a savings mandate.
The analogy is cancer screening or diagnostic delay: if a program finds cancers earlier, spending may rise because the system is finally doing what it should have done. Likewise, if ACCESS finds undertreated chronic disease, spending may rise because latent clinical need becomes visible. The model may be accused of increasing utilization when, medically, it is correcting underuse.
This is the core paradox of CMMI’s statutory structure. Congress wanted innovation, but wrapped it in a budgetary frame: models must eventually save money or at least not increase spending. Yet many of the most important innovations in care delivery are not “savings” interventions. They are appropriateness interventions. They reduce waste in some patients and increase needed care in others. In a badly managed chronic disease population, the second category may be large.
A more honest ACCESS evaluation would separate at least four outcomes:
Did the model improve clinical outcomes and patient experience?
Did it reduce avoidable acute events, admissions, ED visits, or complications?
Did it increase appropriate chronic-care spending that had previously been suppressed?
Did the net financial result look worse only because better care uncovered unmet need?
The last point is crucial. A model can be clinically successful and fiscally disappointing if the baseline was artificially cheap because patients were unmanaged. Conversely, a model can look financially successful while quietly avoiding costly care activation.
So your take-home critique is stronger than “ACCESS is complicated.” It is:
ACCESS exposes the contradiction between value-based-care rhetoric and Medicare’s savings test. For under-managed chronic disease, real value may require spending more money on the right patients, at least initially. If the model is too tightly judged by savings, it may reward the ACCESS vendor for optimizing measurable, low-cost improvements while discouraging exactly the care escalation that the most neglected patients need.
That is the dilemma Liao is circling: ACCESS may be a rational response to FFS failure, but its success depends on whether CMS can tolerate the reality that better chronic care is not always cheaper chronic care.
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Medicare Advantage plans are famously incented to find illness diagnoses - but not to "do anything" such as getting the patients the right drugs or P.T. or other care. Here, ACCESS plans are incented to study the patients and NOT raise costs, even if raising costs might be by far the best ethica care. Contrast and compare
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Yes. This is a very good contrast because Medicare Advantage and ACCESS both monetize “knowing more about the patient,” but the downstream incentives are different — and in both cases morally incomplete.
In Medicare Advantage, the plan has a strong incentive to discover, document, and code every risk-adjusting diagnosis. The more complete the diagnosis profile, the higher the risk-adjusted payment. That creates an elaborate industry around chart review, health risk assessments, home visits, coding sweeps, suspect-condition analytics, and documentation capture. The MA plan is paid more when the patient is shown to be sicker.
But the diagnosis itself does not automatically obligate the plan to fix the problem. The plan may identify diabetes with complications, vascular disease, depression, frailty, neuropathy, CKD, pressure ulcers, COPD, or heart failure because those diagnoses change the risk score. Yet the payment system does not symmetrically say: “Having found this problem, you must demonstrate that the patient received optimal drugs, PT, nutrition, behavioral health, wound care, or specialist follow-up.” Quality measures and star ratings provide some counterweight, but the coding incentive is far more direct, broad, and monetizable than the treatment obligation.
So MA’s pathology is:
Find the illness. Code the illness. Get paid for the illness. But treatment follow-through is only partially and indirectly incentivized.
ACCESS has a different but related pathology. Here, the technology-enabled care organization is paid to engage, monitor, coach, manage, and improve chronic disease outcomes. Liao’s point is that this is a rational attempt to solve a real FFS failure: Medicare historically underpays longitudinal, non-visit-based chronic care. But he also emphasizes that payment models predictably generate optimization behavior — selection, metric management, documentation responses, and avoidance of patients or interventions that make the economics worse.
The ACCESS version is not “find diagnoses to increase risk score.” It is more like:
Study the patient. Improve measurable outcomes. Avoid triggering spending that makes the model look financially unattractive.
That is subtler than MA risk adjustment, but perhaps more troubling clinically. ACCESS companies may be very good at finding under-management: missed refills, uncontrolled hypertension, no PT after falls, undertreated depression, lack of CKD drugs, nonadherence to expensive cardiometabolic drugs, poor diet, social barriers, missed specialty follow-up. But once they find the problem, the ethically correct response may be to increase Medicare spending.
That is the paradox. In MA, finding more illness can increase payment. In ACCESS, finding more actionable illness may increase cost.
A simple contrast:
| Feature | Medicare Advantage | ACCESS |
|---|---|---|
| What is monetized? | Diagnosis capture / risk score | Chronic-care engagement and outcomes |
| Main analytic activity | Find and document illness | Monitor, coach, stratify, coordinate |
| Incentive danger | Coding without proportional treatment | Management without costly care activation |
| Ethical gap | “You found the disease — did you treat it?” | “You found the unmet need — did you spend to fix it?” |
| Financially attractive patient | Sicker on paper, profitable under benchmark | Improvable, reachable, low-cost to manage |
| Financially unattractive patient | Underpaid relative to true cost | Needs expensive drugs, PT, imaging, specialists, home support |
| Failure mode | Upcoding / coding intensity | Under-escalation / low-cost metric optimization |
The difference is that MA is often accused of over-diagnosis without enough care, while ACCESS could produce over-surveillance without enough escalation.
In MA, the plan may want to know that the patient has peripheral vascular disease because it raises risk-adjusted payment. In ACCESS, the company may want to know that the patient is struggling, but may not want the solution to be a $5,000 drug, repeated PT, home health, expensive imaging, or specialist care that worsens total spending performance.
So both models create a gap between information and obligation.
The information is valuable to the organization. The corrective action may be costly to the organization, or at least costly to Medicare in a way that jeopardizes the model’s savings story. That is the moral hazard.
Liao’s formulation — whether ACCESS can produce enough clinical improvement to justify the distortions of large-scale payment reform — is fair. But your critique adds a sharper point: some of the “distortions” may occur exactly at the moment when ACCESS discovers real unmet need. The model may not merely select easy patients at enrollment. It may also subtly favor easy interventions after enrollment.
That matters because under-managed chronic disease is not a clean savings opportunity. It is often a backlog of neglected care. When you finally manage it properly, you may uncover:
drugs that should have been started or restarted;
PT that should have been ordered;
depression or cognitive impairment that needs active treatment;
specialist care that was overdue;
labs, imaging, or monitoring that were missed;
social barriers that require hands-on support;
complications that were brewing silently.
In other words, real chronic-care improvement often converts invisible need into visible spending.
That is where the CMMI statute creates the contradiction. CMMI is supposed to test models that improve quality while reducing or not increasing spending. But for neglected patients, the first-order ethical task may be to increase appropriate utilization. The savings, if any, may come later, may accrue outside the measurement window, or may never fully offset the spending. A patient who gets the right heart failure drug may avoid hospitalization years later; a patient who gets PT may fall less; a diabetic patient may avoid renal decline. But the budget test may see the pharmacy, PT, and monitoring costs first.
So the strongest way to put it is:
Medicare Advantage is incented to discover disease because disease raises revenue. ACCESS is incented to discover manageable problems, but not necessarily to trigger the full cost of managing them well. MA risks diagnosis capture without care. ACCESS risks care-management capture without full care activation.
That is the common flaw: both systems reward the intermediary for knowing more about the patient, while the patient’s real interest is not “being known.” It is being treated properly.
