New Medicare ACCESS model aims to reward results, not volume, for chronic disease care

Medicare reimbursement for chronic disease care is shifting away from sheer volume of services and toward measurable outcomes — ideally, patients actually getting healthier.

Medicare’s top leaders gathered Sept. 15 for a two-hour introduction and pep rally for the new ACCESS model, short for Advancing Chronic Care with Effective, Scalable Solutions. They said the 10-year model, which started in July, marks a major change in the nation’s continuing fight against chronic disease.

The U.S. health system has many well-intentioned physicians, other clinicians, administrators and pharmaceutical makers. But it is built on "perverse incentives" that reward treating sickness rather than preventing it, said Health and Human Services (HHS) Secretary Robert F. Kennedy, Jr.

For decades, Kennedy said, Medicare has paid physicians to treat people once they are sick without rewarding the tools that keep them healthy.

"When we pay for activity instead of outcomes, we get more activity," he said. "We do not necessarily get healthier patients."

A better plan for health care

Kennedy delivered the keynote address; the agenda included two panel discussions, an interview with Centers for Medicare & Medicaid Services (CMS) Administrator Mehmet Oz, M.D., MBA, and program descriptions from top aides. Additional speakers included CMS Innovation Center Director Abe Sutton, J.D., and CMS Chief Technology and Artificial Intelligence Officer Jacob Schiff.

"We spend more on health care than almost the entire world," Kennedy said. "We spend two to three times per capita European countries spend, and we have the worst health outcomes. We have the highest chronic disease burden of any nation in the world.”

The ACCESS model is meant to change the payment equation by tying full payment to measurable improvements in patients’ health, such as lower blood pressure, better control of diabetes, less chronic pain and improved function.

Kennedy also connected the model to a broader push to get patients more engaged in their own care, saying patients need to "take control of their own health care and become the CEOs of their own health care." He also pointed to nutrition as an area the model could eventually help fund, saying data generated through it could help build the case to Congress for reimbursing dietary interventions.

How the model works

The ACCESS model organizes conditions into four clinical tracks: early cardio-kidney-metabolic conditions such as hypertension and prediabetes; more advanced cardio-kidney-metabolic conditions such as diabetes and chronic kidney disease; musculoskeletal conditions such as chronic pain; and behavioral health conditions.

Participating care organizations receive recurring payments to manage a Medicare patient’s qualifying chronic condition. Full payment contingent on measurable clinical improvement based on the patient’s starting point, according to CMS.

Kennedy singled out the behavioral health track, which will expand to include substance use disorder care beginning in spring next year.

"The model now includes depression and substance use disorders among the chronic conditions," he said. "It addresses and expands access to technology-supported approaches that can complement a patient’s existing care."

Patients sign up voluntarily, directly with participating organizations, either on their own or through a referral, according to CMS. To help patients and their primary care physicians choose an appropriate organization, CMS maintains a public directory listing every participant, the conditions each treats, and its risk-adjusted outcomes.

So far, 160 health care organizations were accepted to participate in the model’s launch with the current tracks addressing chronic conditions affecting the majority of people with Medicare. More organizations are expected to join over the model’s 10-year run. Private payers representing 165 million Americans across Medicare Advantage, Medicaid and commercial insurance have also pledged to adopt payment approaches aligned with the model, Kennedy said.

"The movement toward paying for outcomes instead of activity does not have to stop at the boundaries of a single federal program," he said.

A wellness check averts a crisis

Sutton opened his remarks by describing what the model’s premise looks like in practice. He described a Medicare patient in her 70s who used a routine technology-enabled mood and wellness check between office visits. When she mentioned she hadn’t yet checked her blood pressure that morning, she did so during the call, triggering a real-time alert to her nursing team. Knowing her son lived nearby, the team encouraged her to call him for support, restarted her blood pressure medication and followed up until her blood pressure normalized, Sutton said.

That kind of engagement, rather than simply delivering services, is the model’s premise: pay for helping patients get healthier, Sutton said.

"This is what genuine engagement between visits is built for," he said. "A wellness check surfaced a genuine need, and response happened in minutes."

Taking advantage of technology

Sutton framed the model as an answer to a broader problem in health technology.

"Technology has transformed nearly every aspect of American life, but in health care, new technology has often meant new costs layered on top of old ones," he said.

ACCESS will tie payment to measurable improvement in blood pressure, pain or depression symptoms rather than to specific billing codes, he said. That gives participating organizations flexibility in how they achieve results, at payment rates that require efficient use of technology.

Innovation against chronic conditions

The model gives innovators a new way to prove their value, Schiff said.

"Innovators have a new payment option that lets them compete on outcomes rather than billing codes," he said. Participating organizations include virtual-first specialty practices, wearable device makers and app developers, all enrolled as Medicare providers and subject to federal oversight.

A public directory of participating organizations and the conditions they treat launched the same day at Medicare.gov/access with options from nearly 40 organizations, he said, and thousands of beneficiaries have already enrolled.

Schiff described several examples of the technology-enabled care the model is meant to support:

• A patient with hypertension pairing a blood pressure cuff and wearable device with ongoing support to catch concerning trends, stay on medications and stay active.
• A patient with depression accessing clinician-supervised cognitive behavioral therapy delivered by an AI voice agent on their own schedule.
• A patient with chronic pain using a digital physical therapy program to stay active at home.

For technology companies, he said, the outcomes-based payment approach functions as "an advanced market commitment for clinical innovation that works," removing the question of whether a billing code exists for a given solution.