CMS takes on digitally driven value-based care with ACCESS Model

Is value-based care finally getting with the times? CMS hopes so as it unveils its newest model to promote digitally driven value-based care with a stronger emphasis on patient outcomes for individuals with chronic conditions. 

The voluntary Advancing Chronic Care with Effective, Scalable Solutions (ACCESS) program aims to test a payment structure that integrates telehealth, wearable devices, and apps into chronic condition management techniques to enhance engagement and promote long-term positive outcomes for Original Medicare beneficiaries. 

“For most people with Medicare, the way they get care hasn’t changed much in decades,” said CMS Administrator Mehmet Oz in a video accompanying the announcement. “People increasingly expect technology to help them take charge of their health, whether that’s texting with their doctor, checking blood pressure at home, or using an app to track steps, meals, or sleep. Technology can transform healthcare from something that happens in a doctor’s office to something that’s always within reach.” 

What is new in the ACCESS model?

While value-based care models have always sought to tie reimbursements to targeted outcomes, including clinical improvements and lower costs, many have focused more on checking the boxes of processes (i.e. completing A1C checks or depression screenings for a certain percentage of the patient panel) rather than seeing sustained results in health improvements for individuals. 

ACCESS seeks to take the next step into value-driven payments by more explicitly tying incentives to health outcomes. For example, providers will earn rewards by helping patients achieve specific improvements in chronic condition-related metrics, such as assisting a patient with hypertension lower their blood pressure by 10mmHg within a defined period.  

The use of holistic, patient-centered care strategies, as well as remote care and modern communications technologies, will be core components of the model, CMS says. 

ACCESS care organizations are expected to offer “integrated, technology-supported care” that may include strategies such as lifestyle and behavioral support, mental health counseling, patient education, care coordination, and “use or monitoring of FDA authorized devices, including devices or software, or devices that are subject to FDA enforcement discretion.” 

“Care may be provided in-person, virtually, asynchronously, or through other technology-enabled methods as clinically appropriate,” CMS stresses.  

Primary care providers and referring physicians can refer patients to organizations participating in ACCESS, who will then share electronic updates on patient progress back to these providers. ACCESS participants will need to use secure and interoperable health information exchange systems, including CMS APIs, to manage enrollment, share clinical data, track outcomes, and coordinate care with other members of the care team.  

Who is eligible for participation in ACCESS? 

Initially, the model will zero in on four clinical tracks that encompass many of the most common, high cost, and high-impact chronic conditions, including: 

• Early cardio-kidney-metabolic conditions: hypertension (high blood pressure), dyslipidemia (high or abnormal lipids, including cholesterol), obesity or overweight with marker of central obesity, and prediabetes 
• Cardio-kidney-metabolic conditions: diabetes, chronic kidney disease (3a or 3b), and atherosclerotic cardiovascular disease, including heart disease 
• Musculoskeletal conditions: chronic musculoskeletal pain 
• Behavioral health conditions: depression and anxiety 

For each track, providers will be held accountable to associated measurable improvements, such as control of blood pressure, lipid levels and HbA1C, or validated patient-assessed improvements in pain levels, daily function, or depression systems. 

“Each track groups related conditions that are commonly treated using similar types and levels of care,” the CMS fact sheet says. “Participating organizations are responsible for managing all qualifying conditions in a track, supporting integrated, patient-centered care.  Each track includes a set of condition-specific measures and outcome targets informed by clinical guidelines—such as patient improvement or control in biomarkers like blood pressure, hemoglobin A1c (HbA1c), lipids, or weight, or in validated Patient Reported Outcome Measures (PROMs) of pain, mood, and function.” 

Most of the tracks will include an initial year of chronic condition care, followed up by an optional period of monitoring at a reduced incentive rate to ensure individuals can access continued support.   

Patients with qualifying conditions will be able to sign up directly with participating ACCESS providers, either independently or upon referral from a member of their care team.  CMS will maintain a directory of ACCESS providers to help patients with this process. 

How will reimbursement work?  

CMS will anchor payments to the overall share of an organization’s patients who meet their outcome targets. That way, organizations can earn full incentives even if some of their patients do not meet their individual goals.   

In addition, clinicians who co-manage ACCESS beneficiaries will be able to bill a new ACCESS model co-management service for about $30 per service, subject to geographic adjustment and other methodologies. Onboarding assistance is an extra $10 per patient, with payment limited to once every four months per beneficiary per track, up to approximately $100 per year. 

The agency will publish risk-adjusted outcomes data to recognize excellence, with a fixed adjustment applied to rural patients in qualifying tracks. 

Additional details on reimbursement rates are not yet available. 

What does this mean for chronic condition management providers?

For providers of chronic care management services, including primary care providers and specialists, the model could be a promising opportunity to finally get reimbursed for a huge amount of patient-centered care work they’re already doing – especially the largely underpaid time spent communicating with patients digitally, such as answering emails through patient portals and reviewing device data. 

By actively encouraging integration of remote care, digital health devices, and online communication channels as must-have elements in modernized chronic care management programs, CMS is finally acknowledging the realities of how providers are already working with their patients to support better clinical outcomes. A reimbursement boost aimed in this direction is good news for all concerned. 

It also means CMS may be leaning toward promoting more stability in the uncertain world of telehealth, which has been stymied by a series of precariously short extensions of the pandemic-era flexibilities, which have successfully extended virtual care to millions of individuals. Regulatory solidification of these flexibilities in the next chapter of value-based care models would be a big win for providers and patients who have come to rely on remote care for their chronic care management needs.  

Last but not least, the emphasis on specific, measurable, time-bound improvements to key clinical measurements is a welcome departure from the process-based strategies that have dominated many value-based care models in the past. Getting granular with clinical metrics – and providing much more flexibility for how clinicians achieve those thresholds for their patient populations – is much more aligned with the academic ideals of value-based care models. 

While CMS has been slowly but surely pushing providers into higher degrees of financial accountability and clinical performance through downside risk sharing arrangements, progress has been achingly slow over the past decade and a half.  

It’s encouraging that this latest model places technology front and center in its bid to entice providers to keep moving down the path to broader outcomes-based payments. However, the announcement is still somewhat light on details, and it remains to be seen how the fully-fledged program prioritizes technology while adequately reimbursing participants for their chronic condition management activities. 

Jennifer Bresnick is a journalist and freelance content creator with a decade of experience in the health IT industry.  Her work has focused on leveraging innovative technology tools to create value, improve health equity, and achieve the promises of the learning health system.  She can be reached at [email protected].