The Centers for Medicare & Medicaid Services (CMS) has introduced the ACCESS model, a significant initiative aimed at reshaping how Medicare reimburses healthcare providers. Scheduled to commence on July 1, 2024, ACCESS, which stands for Advancing Chronic Care with Effective, Scalable Solutions, seeks to align payment with patient outcomes and overall costs, marking a potential shift toward value-based care.
For the past two decades, CMS has attempted to implement value-based care models, such as pay-for-performance and accountable care organizations. However, these initiatives often added layers of incentives to existing fee-for-service structures. In contrast, ACCESS aims to fundamentally change traditional Medicare by focusing on patient outcomes, total costs of care, and enhancing flexibility in service delivery.
Under the ACCESS model, providers will be encouraged to utilize digital tools, nontraditional services, and care teams that are not typically reimbursed in the traditional fee-for-service framework. This model allows participating providers to take responsibility for both quality and the overall cost of care, with the opportunity to share in savings if they demonstrate improved health outcomes while reducing spending.
The primary focus of ACCESS will be on chronic health conditions affecting a significant portion of Medicare recipients, including depression, diabetes, high blood pressure, and chronic musculoskeletal pain. CMS plans to evaluate providers based on whether their patients show meaningful improvement over time, as well as whether these improvements lead to reduced utilization of costly healthcare services.
Transforming Care Delivery
ACCESS is expected to foster a healthcare environment centered on prevention and continuous patient engagement, rather than episodic visits. By promoting technology-enabled care, it encourages the use of remote monitoring and virtual care management, which have proven effective in improving patient outcomes but often go unreimbursed under traditional models.
Ankoor Shah, vice president of clinical excellence at Included Health, noted that the ACCESS model represents a pivotal shift within the Medicare fee-for-service structure. Unlike previous initiatives that promoted value-based care through capitation, ACCESS retains the fee-for-service framework but links payments to measurable health outcomes. This approach allows for reimbursement for each service rendered while also rewarding providers based on the management of patient conditions over time.
The emphasis on care delivered beyond clinical settings is another notable aspect of the ACCESS model. For instance, a Medicare patient with heart failure could benefit from a combination of remote monitoring using smart devices and periodic in-person consultations. Such integrated care is intended to prevent chronic conditions from escalating to the point of hospitalization.
CMS anticipates that the implementation of ACCESS will lead to savings by reducing unnecessary hospitalizations and emergency department visits. While the extent of these savings remains to be seen, previous results from the Medicare Shared Savings Program indicate a promising potential for cost reductions. In 2023 and 2024, the program reported net savings of $2.1 billion and $2.5 billion, respectively.
Challenges and Opportunities Ahead
Despite the promise of the ACCESS model, several challenges may impact its success. The model’s effectiveness will depend on sustained participation from providers, clear performance metrics, and the integration of data and digital tools across diverse care settings.
CMS plans to publish annual performance results, allowing for a transparent assessment of participating providers. This initiative is expected to differentiate high-quality participants from those that underperform. Christopher Altchek, CEO of virtual care provider Cadence, emphasized that CMS’s new approach will focus on measurable improvements in clinical outcomes over time, providing a more precise evaluation than the current CMS Star Ratings.
For digital health providers, ACCESS sets higher standards for accountability. Julia Hu, CEO of Lark Health, expressed enthusiasm for the model’s outcomes-based standards, noting that it could drive underperforming vendors out of the market while rewarding those that demonstrate their value effectively.
However, the integration of patient data across various healthcare settings remains a significant hurdle. Jason Prestinario, CEO of Particle Health, highlighted that seamless data sharing is crucial for the model’s success. He stressed the need for robust enforcement of regulations to ensure that Electronic Health Record (EHR) systems do not obstruct access to essential patient information.
As ACCESS unfolds, its potential to transform Medicare reimbursement practices will hinge on CMS’s commitment to enforcing data sharing and measuring outcomes effectively. If successful, this model could represent a notable shift in how healthcare is delivered and reimbursed in the United States, moving from volume-based care to a more patient-centered approach focused on outcomes.