ACCESS,
Chronic Care, and the CMMI Savings Paradox
When Better Care for Under-Managed Patients May Cost More
|
CMS’s ACCESS model is a serious
attempt to modernize Medicare payment for technology-enabled chronic care.
Rather than paying for visits, devices, app clicks, or care-management
minutes, ACCESS pays organizations for measurable improvement in chronic disease
outcomes — an elegant and potentially important idea. But it also exposes a
deeper CMMI paradox: under-managed Medicare patients may need more care, not
less. Better management can mean more drugs, physical therapy, behavioral
health, monitoring, labs, and specialist follow-up. Judged too narrowly on
savings, ACCESS may reward low-cost metric improvement while discouraging the
costly care activation patients actually need. |
Bruce Quinn
Associates LLC · June 8, 2026
CMS’s ACCESS model is one of the most intellectually coherent CMMI models
in recent years, and one of the most revealing. On its surface it is a
voluntary Medicare demonstration for technology-supported chronic care,
creating new payments for organizations that manage common chronic conditions:
hypertension, dyslipidemia, obesity, prediabetes, diabetes, chronic kidney
disease, atherosclerotic cardiovascular disease, chronic musculoskeletal pain,
depression, and anxiety.
That description is accurate but too small. ACCESS is better understood as an attempt to build a new Medicare payment architecture for modern chronic care — to test whether Medicare can pay for longitudinal, digital, remote, asynchronous, hybrid, and AI-enabled care without simply creating another fee-for-service volume engine.
That is the real problem. Chronic disease management increasingly runs on
software, devices, messaging, remote monitoring, coaching, medication
management, behavioral support, and algorithmic triage — activities that do not
map onto the traditional office visit. If CMS responds with a separate code for
every digital touch, monitoring transmission, or coaching minute, it recreates
the old problem in new clothing: the system optimizes for billable activity.
ACCESS instead tries to move the unit of payment from activity to outcome.
That is the conceptual leap. CMS is not primarily paying for a visit, a
device, a software license, a care-management minute, or a data stream. It is
paying for measurable improvement or control in a defined chronic disease
domain, through its central instrument, the Outcome-Aligned Payment: a
recurring payment to a Medicare-enrolled care organization, with full payment
tied to clinical results.
This is why ACCESS matters even at modest scale. If it works, it could
become a template for how Medicare pays for digital chronic care, AI-enabled
diagnostics, connected devices, and hybrid virtual care outside the physician
office — and a reference architecture for Medicare Advantage, Medicaid managed
care, commercial payers, and ACO-adjacent contracting.
But ACCESS also exposes a contradiction in CMMI’s statutory design. CMMI
models are expected to reduce Medicare spending without reducing quality, or to
improve quality without raising spending. That sounds reasonable in the
abstract. Yet in under-managed chronic disease, better care often means more
care: more medication adherence, more appropriate drugs, more physical therapy,
more behavioral health, more labs, more monitoring, more specialist input, more
follow-up. A poorly managed patient can look cheap only because the system has
been failing quietly. If ACCESS finds that failure and fixes it, spending may
rise. That is not a flaw at the model’s edge. It is the core paradox.
The Problem ACCESS Is Trying to Solve
Original Medicare has never had a clean payment pathway for much of
modern chronic care. Fee-for-service pays for defined services — visits,
procedures, tests, drugs, devices, time-based care management — which works
when the service is discrete and codeable. It works poorly when care is
continuous, distributed, digital, behavioral, remote, or team-based.
Chronic disease is not organized around fifteen-minute increments. A
patient with hypertension, diabetes, CKD, chronic pain, or depression needs
ongoing engagement, monitoring, medication adjustment, adherence support,
coaching, escalation, de-escalation, and coordination across clinicians — much
of it between visits, much of it performed by nurses, pharmacists, behavioral
health clinicians, coaches, navigators, software, and devices. The office visit
remains important but is no longer the natural unit of care.
CMS has tried to patch the mismatch with codes for chronic care
management, remote physiologic and therapeutic monitoring, and telehealth.
These are useful but reveal the problem: once CMS defines and prices an
activity, the system learns to produce it. Time thresholds, documentation
rules, device transmissions, and staff minutes become the commercial object,
and a model meant to support better care becomes a model for generating more
billable units.
The Shiff/Sutton JAMA Perspective makes the point clearly. Health-care
technology is often directed toward documentation, billing optimization, and
shifting clinician time into reimbursable categories — not because technology
is inherently low-value, but because the payment system rewards monetizable
activity. Technology that generates billable services is adopted faster than
technology that quietly prevents worsening blood pressure, improves depression,
or slows progression from prediabetes to diabetes.
ACCESS tries to change the target of innovation. The organization is paid
not for app clicks, readings, messages, minutes, or visits, but because
patients improved or reached control on defined measures. That is the cleanest
version of the idea: pay for outcome production, not activity production.
The Basic Design
ACCESS is a ten-year CMMI model in Original Medicare beginning in July
2026, starting with four broad clinical tracks. The early
cardio-kidney-metabolic track covers hypertension, dyslipidemia, obesity or
overweight with central obesity, and prediabetes. The cardio-kidney-metabolic
track covers diabetes, stage 3a or 3b CKD, and atherosclerotic cardiovascular
disease. The musculoskeletal track focuses on chronic MSK pain. The behavioral
health track focuses on depression and anxiety.
The breadth matters. CMS is not paying for a single app, device, or
digital therapeutic; it is paying organizations to manage clusters of related
conditions that share intervention types and outcome measures. A narrow
technology-specific payment would reproduce the “one technology, one code”
problem; a track-based payment pushes organizations to build care systems.
Participating organizations must enroll in Medicare Part B as providers
or suppliers (excluding supplier types such as DMEPOS and laboratories),
designate a physician clinical or medical director, and comply with state
licensure, HIPAA, and applicable FDA requirements — or operate within FDA
enforcement discretion. Care may be delivered in person, virtually,
asynchronously, or through technology-enabled means, and may include clinician
consultations, lifestyle and behavioral support, therapy and counseling,
patient education, care coordination, medication management, diagnostic
ordering and interpretation, and use or monitoring of FDA-authorized or
enforcement-discretion devices and software.
Patients enroll voluntarily, directly or by referral. Medicare Advantage
patients are excluded, though MA plans may create similar arrangements. Some
beneficiaries attempting to enroll are randomized into a control group —
essential, because ACCESS is not only a payment pathway but an experiment: CMS
must eventually show whether it improves quality and what it does to spending.
ACCESS is designed to complement traditional care, not replace it.
Patients keep their ordinary Medicare rights and may see any Medicare provider.
ACCESS organizations must share care plans and updates with primary care and
referring clinicians, who may bill a separate co-management payment for
documented review and coordination. The result is a new kind of Medicare
participant — not quite a vendor, ACO, health plan, or physician practice, but
a Medicare-enrolled, clinically accountable, technology-supported chronic care
entity paid through condition-track outcomes.
Outcome-Aligned Payments: The Core Innovation
The central mechanism is the Outcome-Aligned Payment. Organizations
receive recurring payments for managing a qualifying condition track, with full
payment depending on measurable clinical improvement or control relative to the
patient’s baseline.
The baseline-relative design is one of the model’s most important
features. Paying only for absolute control would reward enrolling easy
patients; ignoring baseline would punish organizations that accept harder ones.
ACCESS threads the needle: patients must have at least one uncontrolled measure
to qualify for full initial payment, and organizations are paid for meaningful
improvement or guideline-informed control.
The model also uses portfolio logic, setting payment by the share of an
organization’s patients who meet outcome targets. An organization can perform
well overall even if some patients do not improve — which is clinically
realistic. Chronic care is noisy: patients may not respond, may disengage, may
have side effects, or may face food insecurity or transportation barriers. A
model demanding success for every patient would be unworkable; paying for
aggregate performance is more plausible.
This is not full capitation or total-cost-of-care risk. It is
condition-track, outcome-contingent payment — an attempt to capture some
advantages of value-based care without requiring every digital health or
chronic care company to become an insurer or ACO. That makes ACCESS a possible
middle layer between fee-for-service and full population risk: many
organizations cannot accept total-cost-of-care risk but may accept outcome risk
for a defined domain such as cardiometabolic disease, MSK pain, or behavioral
health.
Why ACCESS Is Different from Prior Digital Health Payment
ACCESS departs from earlier Medicare approaches in four ways. It is not
built around CPT code proliferation — no code for every digital activity,
because activity codes generate activity inflation. It is not a device add-on;
the model does not pay because a device is novel, connected, or FDA-cleared,
since devices and software are tools inside the care model rather than the unit
of payment. It is not merely telehealth expansion; it reaches beyond live
virtual visits to asynchronous care, remote monitoring, coaching, therapy,
education, diagnostic interpretation, and medication management. And it does
not depend on bespoke ACO-vendor contracting.
That last point matters most. Risk-bearing entities struggle to contract
with technology-enabled chronic care organizations because savings are
condition-specific, attribution is hard, and transaction costs are high. ACCESS
creates a standardized, claims-based Medicare pathway that can sit alongside
ACO arrangements. An ACO could refer patients to an ACCESS organization without
negotiating a custom cardiometabolic or MSK contract; CMS can fold ACCESS
expenditures into ACO reconciliation while the participant bills Medicare
directly. In effect, ACCESS could become a payment rail — a standardized
interface between chronic care vendors and the Medicare payment system.
The Fee-for-Service Exclusion: The Guardrail That Makes the Model Real
ACCESS is explicitly an alternative to fee-for-service billing, not an
add-on. During the care period, the participant and its affiliates generally
may not bill ordinary FFS claims for other services to that beneficiary; they
may bill only ACCESS-specific codes.
This is one of the model’s most important provisions. Without it, an
organization could collect outcome-aligned payments while also billing remote
monitoring, telehealth, chronic care management, and evaluation-and-management
claims for the same patient. CMS appears to understand that such stacking would
undermine the model immediately.
The exclusion is beneficiary- and participant-specific: an organization
may treat one patient under ACCESS and another under ordinary FFS, but cannot
do both for the same patient during the care period. Beneficiary choice is
preserved — patients may still see other Medicare providers, who bill normally
— but that creates a hard boundary problem. When is outside care complementary
and when is it duplicative? If an MSK organization is managing chronic pain, is
outside PT duplicative or necessary? If a cardiometabolic organization is
managing diabetes and CKD, is a nephrology visit duplicative or appropriate?
CMS tries to address this through substitute-spend adjustments for
certain overlapping services, but it will be hard to operationalize. Chronic
disease patients often need multiple forms of care, and the same outside
service may be wasteful in one patient and ethically necessary in another. This
becomes central to the model’s moral and economic challenge.
The Co-Management Payment: Small Dollars, Large Signal
ACCESS includes a modest co-management payment for primary care and
referring clinicians who review ACCESS updates and document coordination. The
dollars are small; the signal is not. CMS recognizes that the traditional
clinician’s attention is part of the infrastructure for technology-supported
chronic care.
Digital health companies often fail because they sit outside the
patient’s real care team. They generate recommendations, dashboards, and
alerts, but the primary physician may not know what is happening, may not trust
the vendor, may lack time to review the material, or may not be paid to act on
it. ACCESS builds a bridge: the organization must share updates, and the
clinician may bill for reviewing and coordinating. This will not transform
primary care economics, but it acknowledges that chronic care cannot be split
cleanly between a digital vendor and a physician office. If ACCESS works, it
will be because technology-supported organizations become integrated extensions
of traditional care rather than parallel systems competing for the patient’s
attention.
ACCESS and FDA: A Payment Model as Regulatory Sandbox
ACCESS has an unusually important FDA dimension. Participants must comply
with applicable FDA requirements or operate within enforcement discretion, and
CMS has connected the model to FDA’s TEMPO pilot, which may let certain
technology-enabled products operate under enforcement discretion while
real-world performance data are collected in the model context.
This is potentially a major bridge between payment policy and product
regulation, which are usually separate. A digital tool, connected device, or AI
diagnostic may not need its own Medicare payment code if it becomes part of an
outcome-producing care system. That is especially important for early detection
and AI diagnostics, which face a business-model problem: finding prediabetes,
early CKD, uncontrolled hypertension, or depression is not enough without a
reimbursable pathway for acting on the finding. ACCESS supplies that downstream
pathway. The diagnostic or device is not the revenue center; the
outcome-producing care model is. The strategic question shifts from “What code
pays for our product?” to “What measurable outcome can our product help a Medicare-enrolled
organization achieve?”
The Applicant List: Market Validation, Not Proof
The accepted-applicant list offers early market validation: more than a
symbolic cohort, spanning digital-first chronic care companies, behavioral
health platforms, cardiometabolic firms, MSK organizations, nutrition and
weight-management brands, remote-monitoring companies, virtual care groups,
nephrology practices, community organizations, provider-affiliated entities,
and multi-track platforms.
This does not prove the model will work — CMS cautions that inclusion is
not endorsement and that enrollment, participation agreements, and final
approval remain necessary — but it shows ACCESS has created a commercially
legible pathway. The strongest signal is that many accepted organizations have
not previously served Medicare beneficiaries. ACCESS is not just another
billing mechanism for existing providers; it invites nontraditional chronic
care organizations into Original Medicare under Medicare enrollment, physician
oversight, privacy, licensure, reporting, and quality obligations.
The mix also reveals where the market sees opportunity. Cardiometabolic
care looks especially attractive, and reasonably so: hypertension,
dyslipidemia, obesity, prediabetes, diabetes, CKD, and ASCVD are huge Medicare
problems with measurable biomarkers that map naturally to remote monitoring,
medication management, nutrition support, and coaching. Behavioral health is
also heavily represented — depression and anxiety have validated measures,
large access gaps, and a strong virtual-care precedent — but may be harder to
risk-adjust, since PHQ-9 and GAD-7 outcomes are affected by pain, loneliness,
sleep, cognition, substance use, social stress, and comorbidity. MSK is present
but carries a more complicated savings story: a technology-supported program
may substitute for imaging, orthopedic visits, procedures, or prolonged
therapy, yet MSK care also overlaps with ordinary PT, pain management, surgery,
and behavioral health, and the line between substitution and necessary
complement may be contentious. Across the board, many organizations appear to
see ACCESS less as a narrow chronic disease code than as a general payment
chassis for longitudinal virtual or hybrid care.
Lessons from the Oncology Care Model
The Oncology Care Model is a useful cautionary comparison. CMS’s first
major oncology alternative payment model, OCM ran from 2016 to 2022, paying
participating practices monthly enhanced oncology services payments and
allowing performance-based payments for reducing spending and meeting quality
benchmarks.
A 2026 JAMA evaluation found OCM associated with modest gross reductions
in Medicare spending during six-month treatment episodes — about $616 per
episode, or 2.1 percent of baseline — with savings growing in later performance
periods. But after enhanced-services and performance-based payments were
counted, the model produced an estimated net loss to Medicare of $639 million
over six years, and most utilization and quality measures did not significantly
change.
OCM is not ACCESS — oncology episodes differ from chronic disease tracks
— but it teaches four lessons. First, gross savings are not net savings; a
model can reduce claims spending and still lose money once model payments are
counted, and ACCESS faces the same arithmetic. Second, savings may take time;
OCM’s reductions grew in later years, and chronic disease prevention may take
even longer, since improvements in blood pressure, weight, lipids, pain,
function, or mood may not quickly reduce admissions or ED visits. Third,
quality measurement may miss what matters; OCM may have changed care delivery
without producing broad measurable quality gains, and although ACCESS uses more
direct clinical measures, it still must show that measured improvement becomes
durable health benefit and lower spending. Fourth, voluntary models attract
selected participants; OCM practices were not random, ACCESS participants will
not be random, and early results may reflect who entered as much as what the
model achieved. The larger lesson is sobering: a model can be clinically
serious, operationally complex, and still fail the net-savings test.
Liao’s Critique: The Right Kind of Skepticism
Joshua Liao’s Health Affairs critique is valuable because it avoids both
hype and reflexive cynicism. He recognizes the real problem — Medicare’s
fee-for-service architecture is poorly suited to continuous chronic care —
while emphasizing that payment models inevitably generate optimization
behavior.
That is the mature way to assess ACCESS. The question is not whether
distortions will occur; they will. Fee-for-service rewards volume, capitation
rewards restraint, risk adjustment rewards diagnosis capture,
documentation-based quality measurement rewards documentation, and
outcome-based models reward selection, measure optimization, and denominator
management. The real question is whether ACCESS can generate enough clinical
improvement to justify its distortions. No payment system is neutral; the fragmented
status quo is also a policy choice. ACCESS should not be rejected merely
because it will create strategic behavior, but it must be evaluated with a
clear view of predictable failure modes.
Liao also draws a crucial distinction between scalable chronic care and
intensive multimorbidity management. ACCESS may work best for a middle
population — patients with measurable, improvable conditions who can engage
with technology-supported care through standardized workflows — and less well
for the sickest, least connected, most socially complex, or most multimorbid
beneficiaries. That matters because the most economically attractive ACCESS
patient is not necessarily the neediest: it is the patient uncontrolled enough
to qualify, reachable enough to engage, likely enough to improve, and unlikely
to require expensive downstream care. This is where ACCESS optimism meets the
ACCESS paradox.
The Savings Paradox: Under-Managed Patients May Need More Spending
ACCESS is expected to improve outcomes and reduce spending, on a two-part
theory. First, better clinical control may reduce downstream costs: better
blood pressure, weight, HbA1c, lipids, pain, function, and mood may eventually
cut acute utilization, complications, and high-cost care. Second, ACCESS may
substitute for more expensive traditional care — a technology-supported MSK
program reducing some specialty visits, imaging, or procedures; a behavioral
health platform creating lower-cost access; a cardiometabolic program
preventing deterioration that would otherwise surface later in high-cost
settings.
Both theories are plausible. Both collide with a competing reality:
under-managed patients often have unmet needs that cost money to address. A
patient with uncontrolled diabetes may need medication intensification,
nutrition counseling, renal testing, eye and foot care, CGM, or closer
follow-up. A CKD patient may need appropriate labs, SGLT2 therapy where
indicated, nephrology input, and careful medication review. A chronic-pain
patient may need PT, behavioral support, imaging, injections, surgery, or medication
changes. A depressed patient may need therapy, medication management, safety
assessment, and repeated follow-up. Some of this care reduces future spending;
some improves quality of life without saving money; some increases spending
indefinitely because the patient is finally receiving appropriate care. That is
not failure. It is medicine.
Consider adherence. ACCESS may discover that a patient is not taking a
clinically important $5,000 medication — unaffordable, misunderstood, side
effects, or a refill never completed. The right intervention is to restart and
maintain therapy. But when adherence improves, pharmacy, monitoring, and
follow-up costs rise. The patient is better treated; the model looks worse
financially. ACCESS organizations are paid to improve outcomes at fixed payment
while the model is expected to reduce overall Medicare costs, yet the ethically
correct response to under-treatment may be to activate expensive care. This is
the paradox in operation: the model is designed to find and manage chronic
disease, but properly managing it may raise Medicare spending.
Waste Reduction Versus Need Activation
“Savings” is too blunt a word for chronic care, because good management
does two opposite things. It reduces waste — preventing avoidable admissions,
duplicative imaging, and low-value procedures, replacing unnecessary visits
with lower-cost support, deprescribing harmful drugs, and preventing acute
deterioration. And it activates need — increasing appropriate medication use,
PT, behavioral health treatment, diagnostic monitoring, lab testing, specialist
referral, and patient support. Both can signal better care. One lowers
spending; the other raises it.
A serious evaluation must distinguish the two. If spending rises because
the model induces low-value utilization, that is a problem. If it rises because
the model corrects underuse of high-value care, that may be success. The claims
file alone may not tell them apart. Increased use of guideline-directed
cardiometabolic drugs raises Part D spending; increased PT raises Part B
spending; better adherence raises pharmacy costs — and these increases may be
exactly what good care requires. The policy question should not be “Did ACCESS
raise or lower spending?” but “Did ACCESS reduce waste while increasing
appropriate care where care had been missing?” That is harder to answer, and it
is the question that matters.
Medicare Advantage as a Mirror Image
Medicare Advantage shows a different way payment can separate information
from obligation. MA plans are famously incentivized to find and document
diagnoses, because more diagnoses can raise risk-adjusted payment. The result
is a large industry built around coding intensity — chart reviews, home visits,
health risk assessments, suspect-condition analytics. The plan is rewarded when
the patient is shown to be sicker.
But the payment system does not automatically require a proportionate
treatment response. A plan may document diabetes with complications, vascular
disease, depression, COPD, CKD, frailty, or pressure ulcers and gain revenue,
without a symmetric demand that the patient then receive optimal drugs, PT,
nutrition support, behavioral health, wound care, or specialist follow-up.
Quality measures and star ratings provide some counterweight, but the
diagnosis-capture incentive is more direct and comprehensive than the treatment
obligation. MA’s failure mode is diagnosis capture without proportional care.
ACCESS has the opposite failure mode. It is not rewarded for finding
diagnoses; it is rewarded for studying, engaging, managing, and improving
measurable outcomes. But it may not be rewarded for triggering expensive care
even when expensive care is best. MA monetizes illness recognition; ACCESS
monetizes measurable improvement. MA risks coding without care; ACCESS risks
management without escalation. In both, the intermediary is rewarded for
knowing more about the patient — but the patient’s interest is not being known,
coded, monitored, or measured. It is receiving the right care. The ethical
question is the same: once the system knows, what is it obligated to do?
Selection: The Ideal ACCESS Patient
Every payment model creates an ideal patient. For ACCESS, that patient is
uncontrolled enough to qualify, reachable enough to engage, stable enough to
manage through technology-supported workflows, likely enough to improve on
measured outcomes, and not so complex that improvement requires expensive
outside care. That is a narrow sweet spot. A patient already controlled may not
qualify for full initial payment; one far from target may be hard to improve;
one with severe social barriers may not engage; one with cognitive impairment
may be hard to manage digitally; one needing repeated specialist care or
expensive drugs may improve clinically while worsening the model’s financial
story.
CMS has built guardrails — baseline-relative targets,
uncontrolled-measure requirements, limits on participant-initiated
disenrollment, public reporting of risk-adjusted outcomes, rural adjustments,
and monitoring. These matter, but no guardrail eliminates selection pressure;
organizations will learn which patients perform well. That does not invalidate
ACCESS — many “improvable” patients genuinely need help — but it should shape
expectations. ACCESS may be strongest as a scalable improvement model for a large
middle population and weaker for the most complex, least connected, most
socially vulnerable, or most clinically unstable patients. The danger is not
that ACCESS serves the middle well, which would be valuable. The danger is that
policymakers mistake that success for solving chronic disease management
broadly.
Outcome Measurement: Better Than Activity, Still Imperfect
ACCESS’s greatest strength — paying for outcomes rather than activities —
carries its greatest vulnerability: measured outcomes can themselves become
objects of optimization. Blood pressure, HbA1c, lipids, weight, pain PROMs,
PHQ-9, and GAD-7 are clinically meaningful and far better targets than app
clicks or staff minutes. But they remain measures, and measures can be selected
around, documented around, repeated strategically, and optimized narrowly. An
organization may chase patients across thresholds rather than improving broader
health, favor patients likely to improve on measured variables, pursue
short-term score movement over durable outcomes, or improve the measure while
leaving unmeasured problems untouched.
Behavioral health shows the challenge: PHQ-9 and GAD-7 are validated and
widely used, but scores move with life events, loneliness, pain, sleep,
substance use, cognition, housing instability, and comorbidity, so outcomes
stay noisy even after risk adjustment. MSK raises similar issues — pain
intensity, interference, and function are meaningful, but chronic pain is
heterogeneous, and a model that improves PROMs may select patients whose pain
is most responsive to low-cost intervention. Cardiometabolic tracks have more
objective biomarkers but other concerns: aggressive medication intensification
can improve measures while causing hypotension, hypoglycemia, falls, or
polypharmacy, and reluctance to use expensive medications may preserve spending
while failing the patient. Outcome payment is better than activity payment. It
is not magic.
What CMS Should Watch
CMS should watch six issues. Selection: are organizations enrolling
patients most likely to benefit, or most likely to be profitable?
Under-escalation: when organizations identify unmet need, do they trigger
appropriate care even when it raises spending? Outside spending: are
organizations shifting costs to unaffiliated providers, or are outside services
appropriate complements? Primary care integration: are PCPs meaningfully
engaged, or receiving electronic clutter in exchange for small payments? Durability:
do improvements persist after the initial care period, or are they short-term
threshold effects? Equity: are rural, low-income, cognitively impaired,
socially complex, digitally limited, and multimorbid patients served, or
quietly bypassed?
Under-escalation deserves special attention because it is less visible
than overuse. Claims data can show increased imaging, PT, drugs, or specialist
visits; it is harder to see the care that should have happened but did not. A
model can look financially disciplined precisely because necessary care was
never activated. That is why CMS cannot rely on claims and summary outcome
measures alone. It will need audits, clinical review, patient-level safety
monitoring, referral-pattern and medication-use analysis, disenrollment
monitoring, and perhaps focused studies of underuse.
Political Durability
ACCESS has a politically interesting profile: voluntary, outcome-based,
technology-forward, prevention-oriented, and focused on chronic disease, with
emphasis on patient choice, rural access, private-sector innovation, measurable
results, lower costs, and expanded behavioral health and chronic care support.
That gives it cross-administration appeal. It can be described in
Republican-friendly terms — innovation, competition, technology, private-sector
solutions, outcome accountability, fiscal discipline — and in
Democratic-friendly terms — access, prevention, behavioral health, equity, and
Medicare modernization.
But durability is not guaranteed. As a ten-year model beginning in 2026,
ACCESS will cross administrations, and its survival will depend on early
execution, stakeholder support, operational feasibility, and the avoidance of
visible abuse or runaway spending; the randomized design will help, but
definitive results may take years. The early applicant pool signals strong
market interest, which cuts both ways. If ACCESS becomes associated with
opportunistic vendors, weak oversight, patient selection, or spending growth
without visible benefit, it will be vulnerable. If it produces credible outcome
improvement, real patient engagement, and tolerable spending, it could become a
major precedent.
Likely Winners
The best-positioned organizations are neither pure software companies nor
ordinary provider groups with little digital infrastructure, but hybrids that
combine clinical operations, software, patient engagement, measurement
infrastructure, and disease-specific workflows. Cardiometabolic platforms may
be especially well positioned, since the conditions are common, measurable, and
amenable to medication management, nutrition support, monitoring, and coaching.
Behavioral health platforms may benefit from access gaps and validated measures
despite risk-adjustment and engagement challenges. MSK companies may benefit if
they can demonstrate substitution for more expensive care while maintaining
functional improvement. Remote-monitoring firms, nutrition and obesity-management
companies, nephrology-adjacent groups, virtual primary care organizations,
ACO-adjacent service companies, and provider-affiliated digital care teams may
also find ACCESS attractive.
AI diagnostic and device companies may benefit indirectly, but the
device, algorithm, or software is not the payment unit; it must become part of
an accountable care model that improves outcomes. That is a strategic shift,
changing the reimbursement question from “What code pays for our technology?”
to “What outcome can our technology help produce, and who is the
Medicare-enrolled organization accountable for producing it?”
Bottom Line
ACCESS is CMS’s attempt to build a new Medicare payment rail for
technology-enabled chronic care. Its strongest idea is clear: pay for
measurable improvement or control, not for visits, clicks, devices, minutes, or
billing activity. Its key guardrails — the fee-for-service exclusion, physician
oversight, Medicare enrollment, FDA and HIPAA compliance, care coordination,
public outcome reporting, substitute-spend adjustments, and randomized
evaluation — are serious. The model addresses a real defect in Medicare’s
payment architecture, may create a new category of Medicare-participating
chronic care organizations, may become a reference model for private payers,
may help CMS and FDA learn to handle AI-enabled and software-supported care,
and may shift digital health strategy from code capture toward outcome
production.
But it also exposes the contradiction in CMMI’s savings logic. Many
chronic disease patients are under-managed, and under-management looks
inexpensive only until someone manages the patient correctly. Better care may
require more medication, PT, behavioral health, monitoring, labs, specialist
input, and adherence support; some of that spending eventually prevents
complications, some improves life without saving money, and some is simply the
appropriate cost of treating Medicare beneficiaries well. That is the paradox:
the model is built to find and manage chronic disease, but managing it properly
may increase spending.
Medicare Advantage is the mirror image. MA is rewarded for finding and
documenting illness but not equivalently for treating it; ACCESS is rewarded
for improving measurable outcomes but may be financially uncomfortable when the
best care is expensive activation. MA risks coding without care; ACCESS risks
management without escalation. The patient needs neither merely to be coded nor
merely to be monitored, but to receive the right care.
That should be the standard for judging ACCESS — not whether it is
elegant, creates a new digital health market, or saves money in a narrow
window, but whether it can improve chronic care while resisting the predictable
pressure to select easy patients, optimize measures, avoid costly escalation,
and confuse low spending with good care. If it succeeds, it could become one of
Medicare’s most important payment innovations of the decade. If it fails, the
failure will still teach a lesson: outcome-based payment is not enough unless
the model can distinguish waste from unmet need, savings from underuse, and
measurable improvement from ethically adequate care.
