CMS's ACCESS model: A new push to realign Medicare around outcomes?

CMS has been trying to expand value-based care for decades with mixed results, but the agency's newly announced ACCESS model may represent a more meaningful step toward aligning payments with outcomes and costs.

Over the past 20 years, CMS has steadily advanced payment and care delivery reforms, including pay-for-performance, bundled payments, accountable care organizations, and alternative payment models. While many of these efforts offer incentives on top of a provider fee-for-service model, ACCESS is a more explicit attempt to realign traditional Medicare itself around patient outcomes, total cost of care, and flexibility in how care is delivered.

ACCESS stands for Advancing Chronic Disease Care through Effective, Scalable Solutions. It will allow providers to use digital tools, non-traditional services and care teams that are not typically reimbursed on a fee-for-service basis. Participating providers will assume responsibility for the quality of care and total costs, with the opportunity to share in savings if they improve outcomes and reduce spending.

The model, set to begin on July 1, is designed to promote prevention, ongoing engagement and technology-enabled care rather than occasional visits.

Experts believe it is CMS' clearest attempt yet to shift traditional Medicare fee-for-service toward an outcomes model and a key effort to help extend care beyond the four walls of a hospital or clinic. However, they offer a caveat: ACCESS's success will depend on sustained engagement, clear metrics, and the ability to integrate data and digital tools across fragmented care settings.

How does the model work?

CMS said its ACCESS program will initially focus on conditions that affect more than two-thirds of Medicare enrollees, including depression, diabetes, hypertension and chronic musculoskeletal pain.

Under the program, CMS will evaluate participating providers based on whether patients' conditions improve meaningfully over time and whether those improvements translate into reduced use of costly services. This includes tracking changes in clinical metrics associated with each disease, as well as downstream impacts such as fewer hospitalizations, fewer emergency room visits and lower overall Medicare spending for patients who see ACCESS-enrolled providers.

Providers who meet or exceed these quality and cost benchmarks receive shared savings, but those who fall short may face payment reductions.

Rather than just paying for individual visits or procedures, CMS will tie reimbursement to performance on those outcomes—incentivizing more preventive and coordinated care.

The model also encourages the use of technology such as remote monitoring, digital behavioral health programs and virtual care management teams. All of these are known to help improve patient outcomes but are not typically reimbursed on a fee-for-service basis.

As a result, companies that provide technology-enabled care are bullish on ACCESS. One of the leaders, Ankoor Shah, vice president of clinical excellence at virtual care provider Included Health, said the model is the first major move away from the traditional Medicare fee-for-service model and is designed to enable flexibility, outcomes-based payment and coverage of historically unpaid services.

He noted that ACCESS is different from previous CMS initiatives aimed at promoting value-based care. One reason is that it focuses on Medicare Part B fee-for-service rather than capitation.

Part B has historically used a fee-for-service model, reimbursing providers for each outpatient visit with little regard for long-term patient outcomes. Unlike the capitation model, ACCESS retains the Part B service fee structure but ties payments to measurable results. This means providers can still be reimbursed for each service, but they can receive additional shared savings or suffer penalties based on how the patient's condition is managed over time.

Shah asserts that this approach allows providers to use technology and care coordination services in ways that traditional Part B has never been financially supported.

Connected devices help save money

Shah also emphasized the new model's emphasis on what happens outside the clinical setting, as ACCESS recognizes that wearables, digital programs, specialized care models and ongoing patient engagement all play a role in outcomes.

For example, the new coverage would allow Medicare patients with heart failure to receive a combination of remote monitoring and in-person care, rather than relying solely on office visits.

Providers participating in ACCESS may use connected devices such as smart scales and blood pressure monitors to track weight and blood pressure at home, combined with nurse-led check-ins during which clinical staff can make medication adjustments and make referrals to nutritional or cardiac rehabilitation programs.

These types of interventions can help prevent chronic conditions from worsening to the point of hospitalization, Shah said.

CMS' goal is to save money by ultimately reducing unnecessary hospitalizations, emergency visits and complications, but the amount of savings has not yet been determined.

However, results from the Medicare Shared Savings Program, CMS's largest and longest-running alternative payment model, suggest significant potential for cost reductions. CMS reports that the program will achieve net savings of $2.1 billion in 2023 and $2.5 billion in 2024.

Over the past decade, researchers have also been demonstrating the ability of connected devices to reduce costs. A recent study published last year in Heart Failure Journalfound that remote patient monitoring of heart failure patients could reduce monthly medical costs by 52%, primarily by reducing hospital stays and adverse events such as heart attacks.

Just last month, virtual care provider Cadence released a peer-reviewed study of its work with Mayo Clinic, showing that the startup's remote monitoring program resulted in a 27% drop in hospitalizations.

Raise accountability standards

Cadence CEO Christopher Altchek noted that fewer hospital visits and shorter hospital stays can directly reduce expensive acute care spending. He said CMS is looking for ways to save money, which is why ACCESS fits into a broader policy shift.

He pointed to several parallel developments — higher reimbursements for remote patient monitoring in 2026, advanced primary care management in the CMS physician fee schedule, and HHS's $50 billion Rural Health Transformation Fund prioritizing chronic disease management.

Altchek believes ACCESS will help raise the bar for accountability. For him, two implications stand out. The first is that CMS will publish annual standardized performance results, which will quickly separate high-quality players from weaker players.

The second is that clinical outcomes will be measured by improvement over time. For example, CMS will focus on whether a patient's blood pressure or glycosylated hemoglobin is lower at the end of the program than at the beginning. Altchek said this is a more precise and meaningful approach than the current CMS star ratings.

“The way the Stars metric is calculated is not detailed enough. The Stars metric is like the percentage of the population with hypertension under control, it doesn't say anything about changes within the population or your effectiveness. It's a very rough metric. It's a more precise metric, and standardizing it at the CMS level would really be helpful,” he explained.

Altchek said ACCESS could recalibrate how payers and providers evaluate chronic disease management by creating “apples to apples” standards for outcomes and cost savings.

ACCESS bets on digital health – but only if data flows

Lark Health CEO Julia Hu said that in addition to raising the bar for accountability, ACCESS also sets a higher standard for digital health providers. Lark provides a digital platform for chronic disease management and prevention.

Hu said she welcomes compliance with tougher, outcomes-based standards and believes ACCESS could force out underperforming digital health and AI vendors while rewarding those that can prove their value.

She believes data integration will be the biggest challenge to adoption.

“How do we interact with traditional [primary care provider] Channels that use these technologies to create a seamless experience for patients throughout the clinical workflow so providers can point them to the right service? I think that's going to be a challenge that we should all be grappling with. ” Hu Jintao said.

But there is still time. She noted that CMS has set a 10-year timeline for the project. This duration is critical, she said, because it gives providers time to mature and address operational and integration challenges.

Another healthcare startup CEO, Jason Prestinario, CEO of data platform Particle Health, said the model's success will depend on the ability to seamlessly share patient data across different providers and care settings.

He believes the model cannot work without seamless data flow across all these touchpoints. Prestinario noted that while there has been progress in the national data exchange, gaps remain, particularly regarding individual access and ongoing information blackouts by electronic medical record vendors.

“Health care providers are going to be using many different information sources, methods, tools and technologies to comprehensively treat patients, so we need to make sure that electronic medical records don't block that access in the way that we still see today. I think we're making a lot of progress and a lot of improvements, but there's definitely a lot of work to be done,” he declared.

Prestinario called for stronger enforcement on the “supply side” of data. He argued that CMS has focused on stimulating demand for better data use through initiatives aimed at improving access to personal data and better clinician workflows, but it has not done enough to ensure that the data supply is actually available.

He said value-based care models like ACCESS will only work if regulators more aggressively enforce information-blocking rules and require EHR vendors and providers to make patient data accessible as patients receive care in different settings.

Prestinario added that he expects the model to benefit value-based and digitally native providers first. He believes providers who already focus on outcomes — especially in areas targeted by CMS such as heart disease, diabetes, behavioral health and musculoskeletal — will benefit the most. He's less sure how commercial payers and Medicare Advantage plans will ultimately adapt, since they have different incentive structures and often lack standardized requirements around data sharing and outcome measurement.

Ultimately, ACCESS could provide Medicare with the tools to pay for outcomes rather than volume, but its success will depend on how CMS implements measurement, enforcement and data sharing.

Photo: Charday Penn, Getty Images