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.
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Charday
Penn,
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