New Trump space policy sets 2028 deadline for Moon base, Golden Dome prototype – Breaking Defense

WASHINGTON

President
Donald
Trump
has
released
a
new
executive
order
(EO)
setting
national
space
policy
across
the
civil,
commercial
and
defense
sectors

setting
a
goal
of
establishing
an
“initial”
Moon
base
by
2028
and
reiterating
the
administration’s

Golden
Dome

plans
for
a
comprehensive
air
and
missile
defense
shield
over
America.

Perhaps
the
most
notable
thing
about
the
new
EO
is
the
title,
“Ensuring
American
Space
Superiority,”
especially
as
the
document
focuses
on
civil
space
exploration
rather
than
defense.

The
phrase
“space
superiority”
traditionally
has
served
as
a
military
term
of
art
for
controlling
the
heavens
to
prevent
adversaries
from
taking
actions
to
harm
US
space
assets.
The
Space
Force
defines
space
superiority
as
follows:
“A
degree
of
that
allows
military
forces
in
all
domains
to
operate
at
a
time
and
place
of
their
choosing
without
prohibitive
interference
from
space
or
counterspace
threats,
while
also
denying
the
same
to
an
adversary.”

But
the
EO,

published
Thursday
,
is
primarily
centered
around
specific
goals
for
NASA.
For
example,
it
states
that
America
will
return
to
the
Moon
by
2028,
and
mandates
the
establishment
of
“initial
elements
of
a
permanent
lunar
outpost
by
2030”
to
include
launching
by
nuclear
reactors
for
use
on
the
lunar
surface.

It
further
calls
for
“enhancing
sustainability
and
cost-effectiveness
of
launch
and
exploration
architectures,
including
enabling
commercial
launch
services
and
prioritizing
lunar
exploration.”
Finally,
it
reiterates
the
US
intention
to
abandon
the
International
Space
Station
by
2030.

The
policy’s
three-paragraph
section
on
security
and
the
Defense
Department’s
role,
by
contrast,
is
more
vague

and
reflects
current
Pentagon
policy.

First,
it
reiterates
Trump’s

January
EO

that
launched
the
Pentagon’s
Golden
Dome,
restating
the
goal
to
develop
and
demonstration
“prototype
next-generation
missile
defense
technologies”
by
2028.

Second,
it
calls
for
“creating
a
responsive
and
adaptive
national
security
space
architecture
by
accelerating

acquisition
reform,

integrating
commercial
space
capabilities,
and
enabling
new
market
entrants.”

Lastly,
the
security
section
states
that
the
US
will
strengthen
“ally
and
partner
contributions
to
United
States
and
collective
space
security,
including
through
increased
space
security
spending,
operational
cooperation,
basing
agreements,
and
ally
and
partner
investments
in
America’s
space
industrial
base.”

The
EO
gives
Defense
Secretary
Pete
Hegseth
90
days,
“in
coordination
with”
the
director
of
national
intelligence
and
the
head
of
the
White
House
Office
of
Technology
Policy,
to
report
on
“any
technology,
supply
chain,
or
industrial
capacity
gaps
relevant
to
this
order’s
directive
to
progressively
and
materially
enhance
America’s
air
and
missile
defenses,
and
plans
for
mitigating
such
gaps
within
available
funding.”

Within
180
days,
the
Pentagon
must
“implement
a
space
security
strategy
that
accounts
for
United
States
interests
in,
from,
and
to
space;
addresses
current
and
projected
threats
to
United
States
space
interests
from
very
low-Earth
orbit
through
cislunar
space;
and
incorporates
a
technology
plan
for
detecting,
characterizing,
and
countering
potential
adversary
placement
of
nuclear
weapons
in
space.”
(The
United
States
has

accused

Russia
of
researching
a
space
nuke
to
wipe
out
satellites
in
orbit.)

Also
within
that
timeframe,
DoD
is
to
implement
a
plan
for
a
“responsive
and
adaptive
national
security
space
architecture.”
How
that
may
differ,
if
at
all,
from
the
current
Space
Force
architecture
that
has
gradually
been
shifting
from
small
constellations
of
large
satellites
in
the
geosynchronous
Earth
orbit
belt
some
36,000
kilometers
above
the
surface
to
large
constellations
of
small
satellites
in
various
orbits
remains
to
be
seen.

The
EO
also
addresses
commercial
issues,
most
strikingly
by
the
commitment
to
“attracting
at
least
$50
billion
of
additional
investment
in
American
space
markets
by
2028”

although
no
detailed
instructions
are
provided
about
how
that
it
to
be
done.

The
commercial
section
also
makes
a
pledge
for
“increasing
launch
and
reentry
cadence
through
new
and
upgraded
facilities,
improved
efficiency,
and
policy
reforms.”

It
also
tasks
the
Secretary
of
Commerce
to
lead
an
initiative
“to
assert
spectrum
leadership,
which
shall
include
considering
opportunities
for
reapportioning
and
sharing
spectrum,
as
appropriate.”
The
document
does
not,
however,
explain
what
is
meant
by
“spectrum
leadership.”

Surprising
no
one,
the
EO
kills
the
National
Space
Council,
which
ironically
was
last
resuscitated
in
Trump’s
first
term.
Industry
and
government
officials
have
told
Breaking
Defense
that
unlike
Trump’s
first
vice
president
Mike
Pence,
J.D.
Vance
has
little
interest
in
space
issues
and
did
not
want
the
job
of
chairing
the
council.

The
policy
also
seems
to
put
a
stake
in
the
heart
of
another
Trump
1
initiative
already

facing
dismantlement

due
to
budget
cuts
by
the
Office
of
Management
and
Budget:
the
Commerce
Department
effort
to
develop
a
civil
space
traffic
management
system.
The

Traffic
Coordination
System
for
Space
(TraCSS
)
program
was
designed
to
take
the
burden
of
providing
data
on
the
whereabouts
of
space
objects
and
warnings
of
potential
on-orbit
collisions
to
non-military
operators.

The
2018

Space
Policy
Directive-3

states
that
a
“basic”
data
and
tracking
services
“should
be
available
free
of
direct
user
fees.”
The
EO
would
change
that
language
to
read
“available
for
commercial
and
other
relevant
use.”
It
is
highly
unclear
whether
any
commercial
space
operator
would
be
willing
to
pay
the
government
for
such
services.

Morning Docket: 12.22.25 – Above the Law

*
The
Trump
administration
broke
the
Epstein
files
disclosure
statute,
but
can
anyone
do
anything
about
it?
[The
Guardian
]

*
One
of
the
more
comically
inept
breaches
involved
the
Justice
Department
deleting
one
of
the
photos
they’d
already
released
once
they
realized
it
showed
Trump.
They’ve
now
restored
it,
hoping
everyone
stops
speculating
about
what
photos
the
government
never
released
in
the
first
place.
[CNBC]

*
Yale
Law
names
new
dean.
[Yale
Law
School
]

*
Federal
judge
blocks
law
requiring
retailers
post
air
quality
information
about
gas
stoves
as
a
violation
of
the
First
Amendment.
Tobacco
companies,
here’s
your
chance
to
stick
it
to
that
pesky
Surgeon
General!
[Colorado
Sun
]

*
DOJ
appealing
the
dismissal
of
the
Comey
and
James
cases.
[Law360]

*
Elon
Musk
won
his
appeal
to
pay
himself
more
than
Tesla’s
actually
worth
to
the
delight
of
meme
stock
shareholders.
[Reuters]

*
The
perils
of
data
licensing
in
an
AI
world.
[Legaltech
News
]

*
Are
we
going
to
run
out
of
trial
lawyers?
Fewer
and
fewer
lawyers
are
banking
trial
advocacy
experience.
[On
the
Road
]

Caledonia Mining Corporation Plc: Zimbabwe government amends proposed changes to the royalty and tax regimes

Caledonia
notes
that,
on
December
17,
2025,
the
Zimbabwe
Minister
of
Finance
announced
certain
changes
to
these
proposals
in
the
second
reading
of
the
2026
National
Budget
to
the
Zimbabwe
parliament,
specifically;

  • The
    proposal
    to
    increase
    the
    royalty
    rate
    from
    5%
    to
    10%
    when
    the
    gold
    price
    exceeds
    US$2,500
    per
    ounce
    will
    now
    only
    apply
    should
    the
    gold
    price
    exceed
    $5,000
    per
    ounce.
  • The
    proposed
    change
    to
    the
    tax
    treatment
    of
    capital
    expenditure
    whereby
    the
    current
    100%
    upfront
    deduction
    would
    instead
    be
    spread
    over
    the
    life
    of
    the
    project,
    affecting
    the
    timing,
    but
    not
    the
    total
    amount
    of
    tax
    payable,
    has
    been
    withdrawn.
  • The
    proposed
    change
    to
    levy
    withholding
    tax
    at
    15%
    on
    interest
    payable
    on
    offshore
    loans
    has
    been
    withdrawn.
    Whilst
    this
    provision
    would
    have
    had
    little
    effect
    on
    Caledonia’s
    existing
    operations,
    it
    would
    have
    had
    an
    adverse
    effect
    on
    the
    Bilboes
    Gold
    Project,
    which
    Caledonia
    currently
    expects
    to
    fund
    with
    a
    large
    proportion
    of
    offshore
    debt.

The
revised
proposals,
which
have
not
yet
been
ratified
by
parliament,
but
are
expected
to
be
enacted
before
the
end
of
the
year,
should
result
in
no
change
in
the
financial
outlook
for
Caledonia’s
portfolio
of
assets
in
Zimbabwe
provided
the
gold
price
remains
below
$5,000
per
ounce.


Mark
Learmonth,
Chief
Executive
Officer
of
Caledonia,
commented:


“The
2026
National
Budget
of
Zimbabwe
is
yet
to
be
enacted
into
law.
However,
we
welcome
the
revised
provisions
announced
this
week
which
we
believe
demonstrate
the
Government
of
Zimbabwe’s
support
for
the
mining
sector
and
the
development
of
future
mining
projects
in
the
country.”


Enquiries:


Caledonia
Mining
Corporation
Plc

Mark
Learmonth
Camilla
Horsfall
Tel:
+44
1534
679
800
Tel:
+44
7817
841
793

Cavendish
Capital
Markets
Limited
(Nomad
and
Broker)

Adrian
Hadden
Pearl
Kellie
Tel:
+44
207
397
1965
Tel:
+44
131
220
9775

Camarco,
Financial
PR
(UK)

Gordon
Poole
Elfie
Kent
Tel:
+44
20
3757
4980

Curate
Public
Relations
(Zimbabwe)

Debra
Tatenda
Tel:
+263
77802131

IH
Securities
(Private)
Limited
(VFEX
Sponsor

Zimbabwe)

Lloyd
Mlotshwa
Tel:
+263
(242)
745
119/33/39


CAUTIONARY
NOTE
CONCERNING
FORWARD-LOOKING
STATEMENTS

Information
and
statements
contained
in
this
document
that
are
not
historical
facts
are
“forward-looking
information”
or
“forward-looking
statements”
(collectively,
“forward-looking
statements”)
within
the
meaning
of
applicable
securities
legislation
that
involve
risks
and
uncertainties
relating,
but
not
limited,
to
Caledonia’s
current
expectations,
intentions,
plans,
and
beliefs.
Forward-looking
statements
can
often
be
identified
by
forward-looking
words
such
as
“anticipate”,
“believe”,
“expect”,
“goal”,
“plan”,
“target”,
“intend”,
“estimate”,
“could”,
“should”,
“may”
and
“will”
or
the
negative
of
these
terms
or
similar
words
suggesting
future
outcomes,
or
other
expectations,
beliefs,
plans,
objectives,
assumptions,
intentions
or
statements
about
future
events
or
performance.
Examples
of
forward-looking
statements
in
this
document
include:
our
expectation
that
the
proposed
changes
to
the
royalty
and
tax
regimes
will
be
enacted
as
set
out
in
this
document;
and
that,
as
a
result,
we
expect
no
change
to
the
financial
outlook
for
Caledonia’s
portfolio
of
assets
in
Zimbabwe.
These
forward-looking
statements
are
based,
in
part,
on
assumptions
and
factors
that
may
change
or
prove
to
be
incorrect,
thus
causing
actual
results,
performance
or
achievements
to
be
materially
different
from
those
expressed
or
implied
by
forward-looking
statements.

Security
holders,
potential
security
holders
and
prospective
investors
should
be
aware
that
forward-looking
statements
are
subject
to
known
and
unknown
risks,
uncertainties
and
other
factors
that
could
cause
actual
results
to
differ
materially
from
those
suggested
by
the
forward-looking
statements.
Such
factors
include,
but
are
not
limited
to:
risks
relating
to
estimates
of
mineral
reserves
and
mineral
resources
proving
to
be
inaccurate,
fluctuations
in
gold
price
and
payment
terms
for
gold
sold,
risks
and
hazards
associated
with
the
business
of
mineral
exploration,
development
and
mining
(including
environmental
hazards,
industrial
accidents,
unusual
or
unexpected
geological
or
structural
formations,
pressures,
power
outages,
fire,
explosions,
landslides,
cave-ins
and
flooding),
risks
relating
to
the
credit
worthiness
or
financial
condition
of
suppliers,
refiners
and
other
parties
with
whom
the
group
does
business,
inadequate
insurance,
or
inability
to
obtain
insurance,
to
cover
these
risks
and
hazards,
employee
relations,
relationships
with
and
claims
by
local
communities
and
indigenous
populations,
political
risk,
risks
related
to
natural
disasters,
terrorism,
civil
unrest,
public
health
concerns
(including
health
epidemics
or
outbreaks
of
communicable
diseases
such
as
the
coronavirus
(COVID-19)),
availability
and
increasing
costs
associated
with
mining
inputs
and
labour,
the
speculative
nature
of
mineral
exploration
and
development,
including
the
risks
of
obtaining
or
maintaining
necessary
licenses
and
permits,
diminishing
quantities
or
grades
of
mineral
reserves
as
mining
occurs,
global
financial
condition,
the
actual
results
of
current
exploration
activities,
changes
to
conclusions
of
economic
evaluations,
and
changes
in
project
parameters
to
deal
with
unanticipated
economic
or
other
factors,
risks
of
increased
capital
and
operating
costs,
environmental,
safety
or
regulatory
risks,
expropriation,
the
Group’s
title
to
properties
including
ownership
thereof,
increased
competition
in
the
mining
industry
for
properties,
equipment,
qualified
personnel
and
their
costs,
risks
relating
to
the
uncertainty
of
timing
of
events
including
targeted
production
rate
increase
and
currency
fluctuations,
and
the
other
risks
discussed
in
Caledonia’s
most
recent
Form
20-F
annual
report
and
other
filings
made
with
the
U.S.
Securities
and
Exchange
Commission.
Security
holders,
potential
security
holders
and
prospective
investors
are
cautioned
not
to
place
undue
reliance
on
forward-looking
statements.
By
their
nature,
forward-looking
statements
involve
numerous
assumptions,
inherent
risks
and
uncertainties,
both
general
and
specific,
that
contribute
to
the
possibility
that
the
predictions,
forecasts,
projections
and
various
future
events
will
not
occur.
Caledonia
reviews
forward-looking
statements
for
the
purposes
of
preparing
each
announcement;
however,
Caledonia
undertakes
no
obligation
to
update
publicly
or
otherwise
revise
any
forward-looking
statements
whether
as
a
result
of
new
information,
future
events
or
other
such
factors
which
affect
these
statements,
except
as
required
by
law.

Source:


Caledonia
Mining
Corporation
Plc:
Zimbabwe
government
amends
proposed
changes
to
the
royalty
and
tax
regimes

|
Markets
Insider

Post
published
in:

Business

ZIMRA Abandons Monthly Tax Clearance Requirement After Business Outcry

This
follows
concerns
raised
by
the
Confederation
of
Zimbabwe
Industries
(CZI)
over
Public
Notice
69
of
2025,
which
stated
that
all
businesses
would
be
required
to
obtain
tax
clearance
certificates
every
month.

In
response,
ZIMRA
said
it
is
considering
a
phased
transitional
framework
to
stagger
the
implementation
of
ITF263
in
line
with
the
new
compliance
requirements.

ZIMRA
added
that
its
position
on
nil
returns,
as
outlined
in
Public
Notice
69
of
2025,
remains
unchanged.
Taxpayers
submitting
nil
returns
are
regarded
as
not
trading
and
must
therefore
seek
specific
authorisation
from
the
authority
if
they
require
a
tax
clearance
certificate.

According
to
ZIMRA,
the
transitional
approach
is
designed
to
offer
flexibility
and
ensure
operational
stability
while
consultations
continue
and
systems
are
further
stabilised.
It
added:

“The
concerns
raised
by
industry
regarding
administrative
burden,
system
readiness,
and
proportionality
are
duly
noted,
and
ZIMRA
remains
committed
to
continued
stakeholder
engagement
on
these
matters.

“To
support
a
responsive
and
practical
implementation,
further
consultations
will
be
conducted
during
upcoming
quarterly
stakeholder
meetings,
where
progress
will
be
reviewed
and
refinements
considered
as
necessary.”

Mega Merger Just In Time For The Holidays – See Generally – Above the Law

Cadwalader
Joining
Up
With
Hogan
Lovells:
After
a
few
months
of
merger
chatter,
we
have
a
new
home
for
America’s
oldest
firm.
ICE
Accidentally
Publishes
Enemies
List:
The
agency
briefly
posted
what
looked
an
awful
lot
like
a
watch
list
of
immigration
lawyers,
in
case
you’re
wondering
what
stage
of
dystopia
we’re
at.
Lindsey
Halligan
Gets
Taken
To
The
Woodshed
Again:
Trump’s
favorite
lawyer
continues
her
tour
of
adverse
rulings
and
judicial
side-eye.
Biglaw
Firm
Faces
Serious
Allegations:
Former
associate
accuses
former
partner
of
rape
and
asserts
hostile
work
environment
claims
against
the
firm.
Prepare
Yourself
For
Rankings
Season
Discourse:
U.S.
News
is
back
to
reshuffling
law
schools,
ensuring
everyone
is
furious
for
reasons
no
one
can
fully
explain.
Dershowitz
Spins
Wheel
Of
Nonsense
Legal
Theories…
Lands
On
‘What
If
The
22nd
Amendment
Isn’t
Real?’:
Trump
wants
a
third
term
and
his
favorite
legal
scholar
is
there
to
muddy
up
the
constitutional
waters
.
Man
Arrested
Over
Meme
Takes
His
Case
To
Court:
A
civil
rights
lawsuit
asks
whether
free
speech
still
applies.

Hwedza Civil Registry Offices To Start Processing Passport Applications On 23 December

In
a
notice
released
on
Friday,
the
Civil
Registry
Department
said
the
office
will
now
handle
passport
applications
alongside
the
other
civil
registration
services
it
already
provides.
It
said:

“The
Civil
Registry
Department
wishes
to
advise
its
valued
clients
and
stakeholders
of
the
operationalisation
of
the
Hwedza
District
Passport
Office,
with
effect
from
Tuesday
23
December
2025.

“The
District
Registry
Office
will
now
be
processing
passport
applications
in
addition
to
other
civil
registration
services
currently
being
offered.

“Members
of
the
public
are
therefore
encouraged
to
utilise
the
Office
for
passport
applications
and
related
services.”

The
Hwedza
District
Passport
Office
will
be
open
to
the
public
from
7:45
AM
to
3:00
PM,
Monday
through
Friday.

NAP rejects alignment with Zanu-PF after POLAD defections

NAP
founder
and
president
Divine
Mhambi-Hove
said
his
party
was
not
involved
in
the
move
and
had
no
intention
of
aligning
itself
with
the
governing
party,
insisting
it
would
continue
to
operate
as
an
opposition
force.

POLAD
is
a
government-backed
platform
bringing
together
17
political
parties
that
contested
the
2018
harmonised
elections.
It
was
established
by
President
Emmerson
Mnangagwa
to
promote
dialogue
between
the
government
and
opposition
parties
on
national
challenges.

In
a
statement,
Mr
Mhambi-Hove
said
NAP
was
guided
by
what
he
described
as
five
“non-negotiable”
pillars
that
defined
its
political
identity
and
long-term
goals.

He
said
one
of
the
party’s
core
principles
was
the
pursuit
of
colonial
restitution,
including
economic
redress
for
communal
and
rural
communities
affected
by
historical
dispossession.

“Merging
with
the
political
establishment
would
undermine
our
mission
and
weaken
efforts
to
address
historical
injustices,”
he
said.

Mr
Mhambi-Hove
also
said
the
party
believed
effective
political
accountability
required
remaining
outside
the
ruling
party.

“Checks
and
balances
are
essential
to
a
functional
democracy,
and
these
would
be
dismantled
if
opposition
voices
are
absorbed
into
the
establishment,”
he
said.

On
constitutional
issues,
NAP
reiterated
its
opposition
to
any
proposal
to
extend
the
presidential
term
limit
to
2030,
a
subject
that
has
generated
debate
in
Zimbabwean
politics.

“We
are
committed
to
defending
constitutional
term
limits,
which
are
a
cornerstone
of
democratic
governance
and
political
stability,”
Mr
Mhambi-Hove
said.

He
also
criticised
what
he
described
as
the
“suspicious
distribution”
of
luxury
vehicles
by
ruling
party-linked
benefactors,
arguing
that
such
resources
should
instead
be
directed
towards
public
services.

“These
resources
should
be
channelled
into
fixing
dilapidated
roads,
equipping
hospitals
with
medication
and
revitalising
public
services,
rather
than
being
wasted
on
political
handouts,”
he
said.

Mhambi-Hove
said
NAP’s
manifesto
offered
voters
a
“genuine
alternative”
to
the
current
political
order,
adding
that
joining
the
ruling
party
would
dilute
its
message
and
compromise
its
vision
for
national
development.

Fighting Firm Pays Its Associates Handsomely! – See Also – Above the Law

WilmerHale
Is
Paying
Out
Bonus!:
Having
a
backbone
pays
the
bills!
Associates
At
Top
50
Firm
Can
Make
Up
To
$218k
In
Bonuses!:
MoFo
is
handing
out
the
big
bucks!
King
&
Spalding
Joins
The
Bonus
Train:
Love
to
see
a
match!
Right
Wing
Piracy:
Mike
Lee
wants
to
send
in
pirates
to
fight
the
drug
war.
Not
making
this
up.
No
Time
To
Prepare
For
Biglaw:
Law
students
are
being
made
to
pick
their
career
paths
super
early.

The ‘Severe’ Stress Of Leading An In-House Legal Department – Above the Law



Ed.
Note:

Welcome
to
our
daily
feature

Trivia
Question
of
the
Day!


According
to
a
survey
by
the
Association
of
Corporate
Counsel,
what
percentage
of
surveyed
in-house
legal
department
leaders
say
they
have
“high
or
severe”
levels
of
stress?


Hint:
The
report
warns,
high
stress
levels
“amplify
the
risk
of
attrition
by
a
factor
of
3
to
5
compared
to
moderately
or
mildly
stressed
staff.”



See
the
answer
on
the
next
page.

CMS’ ACCESS Model: A New Push to Rewire Medicare Around Outcomes? – MedCity News

CMS
has
been
trying
to
scale
value-based
care
for
decades
with
mixed
results

but
the
agency’s
newly
announced

ACCESS
model

could
represent
a
more
meaningful
step
toward
aligning
payment
with
outcomes
and
costs.

Over
the
past
20
years,
CMS’
steady
progression
of
payment
and
care
delivery
reforms
include
pay-for-performance,
bundled
payments,
accountable
care
organizations
and
alternative
payment
models.
While
many
of
those
efforts
layered
incentives
on
top
of
providers’
fee-for-service
models,
ACCESS
is
a
more
explicit
attempt
to
rewire
traditional
Medicare
itself
around
patient
outcomes,
total
cost
of
care
and
flexibility
in
how
care
is
delivered.

ACCESS
stands
for
Advancing
Chronic
Care
with
Effective,
Scalable
Solutions.
It
will
allow
providers
to
use
digital
tools,
nontraditional
services
and
care
teams
that
are
not
typically
reimbursed
under
fee-for-service.
Participating
providers
will
take
on
responsibility
for
quality
and
the
total
cost
of
care,
with
the
opportunity
to
share
in
savings
if
they
improve
outcomes
and
decrease
spending. 

The
model,
which
is
slated
to
begin
on
July
1,
is
designed
to
promote
prevention,
continuous
engagement
and
technology-enabled
care
rather
than
episodic
visits. 

Experts
think
it
is
CMS’
clearest
attempt
yet
to
move
traditional
Medicare
fee-for-service
toward
an
outcomes
model,
as
well
as
a
key
effort
to
help
expand
care
beyond
the
four
walls
of
a
hospital
or
clinic.
However,
they
provide
a
caveat:
the
success
of
ACCESS
will
depend
on
sustained
participation,
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
affecting
more
than
two-thirds
of
people
on
Medicare,
including
depression,
diabetes,
high
blood
pressure
and
chronic
musculoskeletal
pain.

Under
the
program,
CMS
will
evaluate
participating
providers
based
on
whether
their
patients’
conditions
meaningfully
improve
over
time
and
whether
those
improvements
translate
into
lower
use
of
costly
services.
That
includes
tracking
changes
in
clinical
metrics
tied
to
each
condition,
as
well
as
downstream
effects
like
fewer
hospitalizations,
fewer
emergency
department
visits
and
lower
overall
Medicare
spending
for
patients
seeing
an
ACCESS-enrolled
provider.

Providers
that
meet
or
exceed
these
quality
and
cost
benchmarks
can
earn
shared
savings,
but
those
that
fall
short
could
face
reduced
payments.

Rather
than
paying
solely
for
individual
visits
or
procedures,
CMS
ties
reimbursement
to
performance
on
these
outcomes

incentivizing
care
that
is
more
preventive
and
coordinated.

The
model
also
encourages
the
use
of
technology
like
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
under
fee-for-service. 

For
this
reason,
companies
providing
tech-enabled
care
are
bullish
on
ACCESS.
One
leader

Ankoor
Shah,
vice
president
of
clinical
excellence
at
virtual
care
provider

Included
Health


said
the
model
is
the
first
serious
move
within
traditional
Medicare
fee-for-service
toward
flexibility,
outcome-based
payment
and
coverage
for
services
that
historically
weren’t
paid
for.

He
pointed
out
that
ACCESS
is
different
from
prior
CMS
initiatives
meant
to
promote
value-based
care.
One
reason
is
that
it
is
focuses
on
Medicare
Part
B
fee-for-service
rather
than
capitation.

Part
B
has
historically
operated
under
a
fee-for-service
model
that
reimburses
providers
for
each
outpatient
visit,
with
little
consideration
for
long-term
patient
outcomes.
Unlike
capitation
models,
which
give
providers
a
fixed
budget
per
patient,
ACCESS
keeps
Part
B’s
fee-for-service
structure
but
ties
payments
to
measurable
outcomes.
This
means
providers
are
still
reimbursed
for
each
service,
but
they
can
earn
additional
shared
savings

or
incur
penalties

based
on
how
well
patients’
conditions
are
managed
over
time. 

This
approach
allows
providers
to
use
technology
and
care
coordination
services
in
ways
that
have
never
been
financially
supported
under
traditional
Part
B,
Shah
declared. 


Connected
devices
can
help
save
money

Shah
also
highlighted
the
new
model’s
emphasis
on
what
happens
outside
clinical
settings,
as
ACCESS
recognizes
that
wearables,
digital
programs,
specialty
care
models
and
ongoing
patient
engagement
all
play
an
important
role
in
outcomes.

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

A
provider
participating
in
ACCESS
might
use
connected
devices

such
as
smart
scales
and
blood
pressure
monitors
to
track
weight
and
blood
pressure
at
home

paired
with
nurse-led
check-ins,
during
which
clinical
staff
can
make
medication
adjustments
and
referrals
to
nutrition
or
cardiac
rehab
programs.

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

CMS’
goal
is
to
generate
savings
from
the
eventual
reduction
in
unnecessary
hospital
stays,
emergency
visits
and
complications,
though
the
magnitude
of
those
savings
has
yet
to
be
determined. 

However,
results
from
the
Medicare
Shared
Savings
Program,
CMS’
largest
and
longest-running
alternative
payment
model,
suggest
there
is
significant
potential
to
bring
costs
down.
CMS
reported

$2.1
billion

and

$2.5
billion

in
net
savings
from
the
program
in
2023
and
2024,
respectively.

Researchers
have
also
been
proving
connected
devices’
ability
to
lower
costs
over
the
past
decade.
One
recent
study,
published
last
year
in
the


Journal
of
Cardiac
Failure
,
found
that
remote
patient
monitoring
for
heart
failure
patients
was
associated
with
a
52%
reduction
in
monthly
healthcare
costs,
mainly
by
reducing
hospital
stays
and
adverse
events
like
heart
attacks.

And
just
last
month,
virtual
care
provider

Cadence

published
a
peer-reviewed

study

on
its
collaboration
with
Mayo
Clinic,
and
it
showed
that
the
startup’s
remote
monitoring
programs
resulted
in
a
27%
drop
in
hospital
admissions. 


Raising
the
bar
on
accountability

Fewer
inpatient
visits
and
shorter
hospital
stays
are
outcomes
that
directly
lower
spending
on
costly
acute
care,
noted
Cadence
CEO
Christopher
Altchek.
CMS
is
looking
for
ways
to
save
money,
which
is
why
ACCESS
fits
into
a
broader
policy
shift,
he
stated.

He
pointed
to
a
couple
of
parallel
developments

higher
2026
reimbursement
for
remote
patient
monitoring
and
advanced
primary
care
management
in
CMS’
Physician
Fee
Schedule,
as
well
as
HHS’

$50
billion
rural
health
transformation
fund

prioritizing
chronic
disease
management.

In
Altchek’s
view,
ACCESS
will
help
raise
the
bar
on
accountability.
Two
implications
stood
out
for
him,
the
first
being
that
CMS
will
publish
annual
standardized
performance
results,
which
will
quickly
separate
high-quality
participants
from
weaker
ones.

The
second
is
that
clinical
outcomes
will
be
measured
by
improvement
over
time.
For
example,
CMS
will
be
paying
attention
to
whether
patients’
blood
pressure
or
A1c
is
lower
at
the
end
of
the
program
than
it
was
at
the
beginning.
Altchek
said
this
is
a
more
precise
and
meaningful
approach
than
current
CMS
Star
Ratings. 

“The
way
Stars
metrics
are
calculated
is
not
detailed
enough.
A
Stars
metric
is
like
what
percentage
of
your
hypertension
population
is
under
control
— 
it
doesn’t
give
you
any
credit
for
the
movement
within
the
population
or
how
effective
you
are.
It’s
a
very
crude
metric.
This
is
a
much
more
precise
metric,
and
that’s
really
helpful
to
have

standardized
at
the
level
of
CMS,”
he
explained.

Altchek
said
ACCESS
could
reset
how
payers
and
providers
evaluate
chronic
disease
management
by
creating
an
“apples-to-apples”
standard
for
outcomes
and
cost
savings.


ACCESS
bets
on
digital
care

but
only
if
the
data
flows

In
addition
to
raising
the
bar
for
accountability,
ACCESS
also
sets
higher
standards
for
digital
health
providers,
said

Lark
Health

CEO
Julia
Hu.
Lark
offers
a
digital
platform
for
chronic
disease
management
and
prevention. 

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

She
thinks
that
data
integration
will
be
the
biggest
challenge
to
adoption. 

“How
do
we
mesh
the
traditional
[primary
care
provider]
channels
with
these
technologies
to
create
a
seamless
experience
for
the
patient
while
working
through
the
clinical
workflow
so
that
providers
can
point
to
the
correct
services?
I
think
that
will
be
a
challenge
that
we
should
all
work
on,”
Hu
remarked.

There
is
time,
though.
She
pointed
out
that
CMS
has
laid
out
a
10-year
timeline
for
this
project.
This
duration
is
critical,
she
said,
because
it
gives
providers
time
to
mature
and
work
through
operational
and
integration
challenges.

Another
healthcare
startup
CEO

Jason
Prestinario,
CEO
of
data
platform

Particle
Health


said
that
the
model’s
success
will
hinge
on
the
ability
to
seamlessly
share
patient
data
across
various
providers
and
care
settings.

He
argued
the
model
cannot
work
without
seamless
data
flow
across
all
those
touchpoints.
While
there
has
been
progress
in
nationwide
data
exchange,
gaps
remain

especially
around
individual
access
and
persistent
information
blocking
by
EHR
vendors,
Prestinario
noted.

“There’s
going
to
be
a
lot
of
different
sources
of
information,
and
ways
and
tools
and
technology
that
providers
are
going
to
use
to
holistically
treat
the
patient

so
we
need
to
make
sure
that
EHRs
can’t
block
that
access
in
ways
that
we
still
see
today.
I
think
we
are
making
a
lot
of
strides
and
a
lot
of
improvements,
but
there’s
still
work
to
be
done,
for
sure,”
he
declared.

Prestinario
called
for
stronger
enforcement
on
the
“supply
side”
of
data.
He
argued
that
CMS
has
focused
heavily
on
stimulating
demand
for
better
data
use
through
its
initiatives
aimed
at
improving
personal
data
access
and
better
clinician
workflows

but
that
it
has
not
done
enough
to
ensure
the
supply
of
data
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
readily
accessible
when
patients
receive
care
across
different
settings.

Prestinario
added
that
he
expects
the
model
to
benefit
value-based
and
digitally
native
providers
first.
He
thinks
providers
that
are
already
focused
on
outcomes

particularly
in
CMS’
target
areas
like
cardiac
disease,
diabetes,
behavioral
health
and
musculoskeletal

will
benefit
most.
He
is
less
certain
how
commercial
payers
and
Medicare
Advantage
will
ultimately
adapt,
given
that
they
have
different
incentive
structures
and
typically
lack
standardized
requirements
around
data
sharing
and
outcomes
measurement. 

Ultimately,
ACCESS
could
give
Medicare
the
tools
to
pay
for
outcomes
instead
of
volume

but
its
success
will
depend
on
how
CMS
follows
through
on
measurement,
enforcement
and
data
sharing.


Photo:
Charday
Penn,
Getty
Images