ACCESS model, part 2: The payment numbers are out. Here's how the industry is reacting.

In our January post, we covered the structure of the ACCESS model—its four clinical tracks, its outcome-aligned payment (OAP) logic, and the questions that remained unanswered (chiefly, what the payment amounts are and what the improvement targets are) as applications opened.

Well, we now have some answers. CMS just released 21 pages of more detail about ACCESS model payments and targets for the first performance period (July 5, 2026-December 31, 2027). And on February 12, CMS announced that 14 major private health plans signed the ACCESS Payer Pledge, committing to offering payment models aligned with ACCESS core principles by 2028.

The industry response to this additional information has been swift and, like the speculation that preceded it, mixed. We've been tracking the rollout of the model because it's not only another definitive push on value-based payments, but it's also one of the first examples we're seeing of MAHA priorities (namely, chronic illness management and technological investment) being reflected in a payment model. The "technology-first" design is also novel and one that we could well start to see replicated.

In this blog post, we'll cover what we now know and what it means for providers, payers, and vendors.

What we know about ACCESS model payments now

Let’s start with answers to three big questions we had at the time of publishing the last post: 1) Will the private insurance sector be enthusiastic about this approach? 2) What are the metrics and performance targets defining the outcomes of interest for full payment? 3) The all-important: What will payments be?

We're seeing momentum in the private insurance sector

We knew from the RFA that ACCESS invited private insurers to adopt similar approaches, and we named as an open question in our last post whether insurers would follow CMS’ example. We now have a strong signal that many will.

Right around when the payment details dropped, CMS announced that 14 health plans signed the ACCESS Model Aligned Payer Pledge, committing to offer outcomes-based payment in a manner consistent with the ACCESS design by 2028.

This pledge is an important signal. CMS is effectively predicting that ACCESS will be a success and is, accordingly, facilitating multi-payer adoption though the model is in the very early stages of implementation. CMS has committed to publishing reference documents (provider agreement templates and payment adjustment codes), the billing codes for each track, and a Fast Healthcare Interoperability Resources (FHIR)-based reporting API for payers to minimize technical burdens around reporting.

The performance targets are calibrated to clinically meaningful change rather than aspirational targets

The next question was how CMS would define the outcomes and improvement targets. This is important because it indicates how ambitious (read: hard to achieve and therefore hard to get paid) the outcomes are. The more ambitious the targets, presumably the less likely curious organizations are to participate. (For a full list of the improvement targets, see pages 9-14 of the payment amounts and performance targets document.)

CMS announced targets for minimum improvement and for control—and the target is “met” if either measure is achieved. Now, just because the targets are calibrated for practicality rather than aspiration doesn’t mean that they will be easy to achieve. (For instance, some of the observed commentary flags the weight loss requirement as a likely challenge for the cardio-kidney-metabolic (CKM) tracks.)

A few important notes about the targets:

• To count towards the outcome attainment rate, all the measures for the track have to be reported on time with the targets met—no partial credit. Reminder that participants can only receive full payment if the outcome attainment rate and substitute spend adjustment are satisfied. For the outcome attainment rate, a minimum percentage of beneficiaries (50 percent in year one) need to see the improvements.

• There’s protection against adverse selection. Targets are defined relative to each patient’s baseline, so ACCESS should not disadvantage providers with a pool of sicker or otherwise more complex patients. Plus, the 50% minimum outcome attainment rate means that organizations can earn the full amount if at least half of their pool meets all targets (which makes an allowance for patients whose engagement in the program might drop off).

• CMS has also provided for the option of early success reporting, meaning that if providers see the target results early, they can submit their data early (90 or 180 days depending on the track), and then any clinical worsening after reporting success won’t change the payment.

The payments are...not very high

The biggest question we and many others had was: “What would the payments be?” Obviously, the program's success hinges on participation, which is largely dependent on adequate payments. Well now we have our answer: Payments are not as high as many industry experts expected (and many providers hoped for).

Let’s remember what the payments are for: Providers get paid for managing their patients’ chronic conditions. Earning the full payment is contingent on enrolled patients seeing improved outcomes. Payments for the initial period of care (the first year) are twice as high as they are for any follow-on periods (if applicable) to reflect the additional resources required for onboarding the patient and seeing initial improvements. (We did know from the RFA that payments in the follow-on maintenance period would be lower.)

ACCESS payment amounts by track, per patient

Track	Initial Period	Follow-on Period
Early cardio-kidney-metabolic	$360	$180
Cardio-kidney-metabolic	$420	$210
Musculoskeletal	$180	N/A
Behavioral health	$180	$90

A few important comments on these rates:

• Rates represent the total allowed amount, which covers Medicare’s 80% share and the Medicare beneficiary’s paying 20% coinsurance. Providers have been given the option to waive coinsurance (incentivizing participation and promoting access). If they do that, though, they’ll only receive 80% of the listed amounts.

• CMS will pay monthly, which is a change from the initial announcement that the payments would be made quarterly. Still, each monthly payment won’t exceed 50% of the Medicare portion of the allowed amount, since the remaining 50% is allocated at the end of the year of care depending on the outcomes achieved.

• If a patient is eligible for multiple ACCESS tracks (in other words, has multiple chronic conditions covered in the model), then CMS will discount the monthly payment by 5% of the lowest (or two lowest) cost track(s) due to the administrative efficiencies presumably involved.

Themes in industry reactions

Since the additional details dropped, there has been a flurry of industry responses. Across industry publications, policy newsletters, and professional networks, a few key themes have emerged.

Theme 1: The rates are lower than many expected, and the financial feasibility is in question for some organizations.

The published rates seem to reflect CMS’ intent to rein in inflation in chronic care management. And, given the payment amounts (which assume patient cost sharing and could be 20% lower), many technology-forward companies that were tracking the model with interest might reconsider whether it’s financially viable. The concern is not simply that the OAPs are modest. It’s that the total possible revenue needs to be considered in the context of enrolling in Medicare (for digital health companies), securing clinical leadership for the program, and marketing to Medicare patients. All of that is expensive and hard to do effectively (though companies with a strong direct-to-consumer marketing strategy might be in a good position).

There have also been concerns that the model inadvertently shifts care to digital health firms (given the incentives for technology-enabled care), possibly eroding primary care margins and provider-patient relationships.

Theme 2: The model favors technology-led, clinician-supervised models over more person-hours.

Given the modest payment rates, it seems that ACCESS  is favoring approaches that lean heavily on technology for care management (as those solutions are lower cost than, say, hiring multiple case managers). The payment architecture (fixed amounts regardless of number of visits or care utilization) is most aligned with organizations that are able to engage and monitor patients at a low marginal cost—software, tech-enabled coaching, remote monitoring are all useful facilitators in this case. In contrast, there is an incentive for primary care involvement, even indirectly, that is separate from incentivizing technology investment. Health systems considering participation are incentivized by the fact that PCPs can bill a co-management payment for the reviewing ACCESS-related updates about their patients—a component of the program that encourages referrals and might be a financially valuable path to managing complex patients.  

Theme 3: The payment structure—notably the decrease after year one—does not reflect many individuals’ chronic disease trajectory. Further, risk pool in rural areas is likely not as diversified.

Commentary from industry and clinical experts has validated the ACCESS approach to move away from episodic visits but raised concerns about the model’s failure to acknowledge the progressive nature of many chronic illnesses, particularly as patients age. So, paying for improved clinical outcomes might be a strong short-term incentive but, in the end, hurt participants whose patient pools are liable to get less healthy over time.

The fact that 50% of the ACCESS payments hinge on outcomes (and reduced fragmentation—patients not seeking comparable treatment elsewhere) favors systems that are reasonably well-resourced and can tolerate the risk and the wait to see full payments. For rural and/or small providers, the risks lie in not having a range of disease states in the patient population and the costs involved in getting technologically up to speed. (The extra $15 for for distributing connected devices doesn’t cover all of the challenges for rural providers.)

What senior leaders can consider now

Here’s how different stakeholders can consider how to best take advantage of the model. The release of additional information confirmed our prediction that companies/providers with strong digital health tools (or partnerships) and robust data infrastructure are the “winners” in that they are best set up for success with less up-front investment. Smaller organizations and/or those not accustomed to reaching Medicare patients are more apt to struggle.

Digital health: Digital health companies will need to consider whether their business model can generate positive financial results when being paid $180-420 per patient per year when considering costs associated with Medicare enrollment, HIPAA compliance, data infrastructure requirements (including possibly developing the infrastructure), and marketing and outreach to gain patients. Organizations already enrolled in Medicare, engaged in population management, and/or reaching Medicare patients are the best candidates.

Health systems: The co-management payment is a relatively low-friction opportunity to refer patients to ACCESS participants and bill for the care coordination review. The larger strategic question is whether to participate directly—which requires selecting technology, developing the data infrastructure relatively quickly, and assigning a clinical director.

Industry overall: The Payer Pledge is significant. If major commercial and MA plans adopt the ACCESS-aligned payment arrangements in the next few years, then the infrastructure that CMS has developed around the model might become the standard (as might outcomes-based payments for chronic care management). That would be a significant change in incentives, including around adopting new technologies.

The administration clearly continues to bet big on technology over more traditional industry stakeholders to achieve its priorities concerning chronic care management while controlling costs. And we're continuing to watch how the rollout goes. We'll be tracking participant announcements, early success signals and challenges, and payer program details as they come out.