The wait for CMS’ new ACCESS model payment rates is finally over, but the debate over whether or not they’re financially viable is just getting started.
Advancing Chronic Care with Effective, Scalable Solutions. ACCESS was designed to move more Medicare beneficiaries away from fee-for-service toward outcomes-driven models.
- The program’s core mechanism for accomplishing that is Outcome-Aligned Payments (OAP), a per-beneficiary annual allowed amount to cover integrated care management for chronic conditions.
- The end goal is to get more tech-forward companies to lean in on Medicare by rewarding them for using technology to improve patient outcomes.
That goal might be hard to reach. Here are the annual OAPs by clinical track and care period:
- Early Cardio-Kidney-Metabolic (eCKM) – $360 initial, $180 follow-on
- Cardio-Kidney-Metabolic (CKM) – $420 initial, $210 follow-on
- Musculoskeletal (MSK) – $180 initial, N/A follow-on
- Behavioral Health (BH) – $180 initial, $90 follow-on
Those numbers present some real challenges. They’re considerably lower than expected, and many of the companies that had already announced plans to participate are now being forced to reevaluate the decision.
- For the sake of comparison, Medicare’s average annual Part B spending for a diabetic patient is around $700 under fee-for-service.
- Asking providers to deliver comprehensive, tech-enabled care for half of that is a tall order, especially for services-heavy companies with humans in the loop.
- Companies with an AI-first approach and an established patient pipeline might perform better, but even then the rates are so low that they’ll likely do little to motivate new entrants to Medicare given the infrastructure needed to comply with the program and achieve the desired outcomes.
The Takeaway
CMS has made it clear that it’s going to start taking bigger steps to control costs, but it also has to find rates that actually encourage companies to participate. Striking that balance is an unenviable task, but the initial consensus seems to be that ACCESS missed the mark.
