Introducing the ACCESS Model

Top of Mind

The Advancing Chronic Care with Effective, Scalable Solutions (ACCESS) Model was everywhere on my social media this week starting with its announcement on Monday morning. Let’s cover what it is and what I think you should think about as you judge its merits. I’m writing this after it was announced only five days ago, so there’s more to unfold and my relevant takeaways might evolve.

TL;DR: The ACCESS Model is the Center for Medicare and Medicaid Innovation’s new, 10-year test of how to pay for a wide range of technology solutions that currently have no direct way to receive third party reimbursement in Medicare. The reimbursement strategy in ACCESS is intended to be deflationary over time, and this is key. I believe you should evaluate the model through that lens, as well as think about what ACCESS says about the priorities of the country’s largest payer.

Background on the ACCESS Model

CMS is responsible for the healthcare budget of Medicare and Medicaid that’s around 1.4 trillion dollars per year and growing. They hope ACCESS will be a tool for deflation over time.

The Next Step in CMS’ Health Tech Ecosystem Plan:

CMS has called on industry to voluntarily commit to making progress in advancing health tech and interoperability. They believe health tech can be leveraged to engage beneficiaries themselves in ways in which they are already comfortable. For CMS to make headway, they need data interoperability and accessibility to make progress in spades, and they can’t accomplish that alone.

Here are the categories, and there are specific requirements for plugging into the ecosystem needed to join. More on that here:

• CMS Aligned Networks

• EHR and Providers

• Payers

• Patient Facing Apps

• Friend of the Ecosystem (Individuals and Organizations)

• Patient and/or Caregiver (App Users)

There’s much more to the Health Tech Ecosystem, but we’re talking about the health tech itself today. Some of these companies that directly engage individuals in their health have had a challenging time with reimbursement mechanisms, commonly selling their technology to employers to add to benefits, for example. Some companies sell directly to consumers, also.

The ACCESS Model will unlock reimbursement for this technology for Medicare Beneficiaries

That’s quite an unlock if you are one of these companies. Here are some shared by CMS at their event three days after the model announcement.

Here’s the 2 minute YouTube intro video from Dr. Mehmet Oz and Abe Sutton:

Model Basics

There are several well-written summaries of the model online. Rather than create yet another version, here are a few of the best I saw in the last few days. Check out one or more before you read my perspectives:

Manatt | ACCESS Unlocked: CMS’s Bold New Model for Tech-Enable Chronic Care Management

Holland and Knight | CMMI Launches Voluntary Payment Model for Qualifying Chronic Conditions with Tech-Enabled Care This has a helpful section on ACO considerations, including that starting in 2028, the ACCESS OAPs will be included in ACO benchmark and performance year calculations.

AMA | ACCESS: What this new payment model means for physicians and patients which includes the below helpful video. Why helpful? It is a window into CMMI’s why. If you watch it, look for Abe Sutton talking about:

• the option to waive the copay

• the role of market pressure

• paying for tech in a deflationary way

• the fact that care is local and begins in the community

• a relationship between a provider and patient must be cultivated

• only participate if you think you can deliver better support to your patients than you currently can

• the participants with the best outcomes, posted publicly, will be the ones who get referrals

Then here are organizations supporting health tech to expand access to tech-supported care for patients with chronic conditions:

Some Thoughts:

I see a lot of commentary online about whether the reimbursement will be sufficient, as well as confusion about who and what the model is for. I try to look at something new like this from the perspectives of different stakeholders, and I start with the model developers.

To consider whether or not this is relevant to you or could be, first think about what CMMI is trying to accomplish. What are they offering to whom and why? (And remember, it’s the SCALE of this model’s solution that they believe will enable a significant impact.) 👇️ 

They are offering patients a chance to choose an organization to help them manage their chronic condition using technology. They are offering the ACCESS organizations reimbursement for their product solution (CMS left this flexible, but essentially tech plus clinical support in any way they believe will work, including asynchronously) and a chance to partner with (primary care) providers, who can then bill about $100 per patient per year (more if in multiple clinical “Tracks") to co-manage the care.

CMS is also leveraging market pressure by introducing a level of competition in the model. Innovation, strategy, and implementation theoretically win in this scenario, and CMS is counting on this yielding model success (no drop in quality, no increase in costs). Great product and service, data sharing, collaboration, patient engagement should yield lower costs and improved outcomes. Lower costs like less use of ERs, imaging, hospitals, etc, and improved outcomes like slower progression of disease, improved management of disease like lower blood pressure, lower A1C, and improved patient-reported outcomes measures like pain and anxiety.

If I look at this from a health tech company’s perspective, it might be a company looking to become an ACCESS organization and secure the other capabilities, or it might want to partner directly with as many ACCESS organizations as possible and just offer its tech product while the ACCESS organizations offered the clinical support and provide the medical director.

If I look at this from an ACO’s perspective, the result from an attributed patient using an ideal product solution could be a reduced total cost of care for patients whose conditions make up a percent of my population’s spend. I might want to have control over this myself, since I don’t know the actual impact it will have but I DO know that in the near future, those Outcome-Aligned Payments will be part of benchmarks and performance-year calculations.

Here’s a post by Zach Davis where he says “the market will dictate that ACOs must choose ACCESS partners.”

If I look at this from outpatient physical therapists’ perspective, I would see this as a way to put my profession on the larger healthcare map and a step towards accessing more patients who need my expertise sooner. I would know what levers could be pulled to achieve the outcomes established form managing musculoskeletal disorders. Also—

• Ensure I could meet the data-sharing requirements.

• Look for primary care providers with whom to partner to care for referred patients.

• Know which physicians are in an ACO and share how I would help the ACO be successful, too. Know the ACO will be accountable for the Outcome-Aligned Payment (OAP) spend and that the ROI of the OAPs should also be reduced TCOC for the ACO.

• Make sure all the area hospitals and post-acute providers know what the ACCESS org does and how it could be a puzzle piece in a comprehensive transition plan after an acute or post-acute episode of care.

Most of the above also goes for other provider types that apply to become ACCESS orgs, such as behavioral health providers and medical specialists who partner with health tech product solutions.

If I look at this from a Medicare beneficiary’s perspective, I’d see an opportunity to use a tool(s) that would otherwise be an out-of-pocket expense. Many beneficiaries aging into Medicare and choosing Fee-For-Service are used to tech solutions in employer-sponsored plans.

Every year, Medicare beneficiaries age in and become more proficient and comfortable in using technology in day to day life. Check out this article in KFF by Drew Altman entitled “Medicare Beneficiaries are not Luddites. I like this quote:

Here are Some Things I’m thinking About:

Success in implementing the model and leveraging it as part of a larger strategic plan will require a willingness to transform how care is delivered.

It means accepting that costs can’t rise at 2-3 times that of other industries annually forever.

It will depend on successful scaling of the solution(s).

It will require a vision for what partnering more closely with patients and other providers could look like. That means accepting that patient engagement and empowerment are non-negotiables in bending the cost curve.

It is only for stakeholders willing to ramp up their interoperability investments.

It’s for those who are prepared to partner with primary care providers and strengthen their role as quarterbacks of healthcare.

and some predictions 🔮 

I predict not every ACCESS organization will be successful.

I predict health tech companies will have an easier time standing up ACCESS organizations than providers. Or at least many are more prepared to be successful. and know how to pull the levers.

I predict missed opportunities by entities who don’t apply or partner because they do short-term math rather than have a vision for the compounding potential.

I predict Medicare beneficiaries will spread the word and participate at scale, but it will take a few years before it’s something they seek out in large numbers.

I predict primary care providers will view ACCESS orgs as a new tool in their toolbox and will know the providers.

I predict other payers will wait a year or two and then be pressed by providers to offer reimbursement for a similar product solution.

Here’s how I wouldn’t look at the ACCESS Model:

• Something to participate in if I am not prepared to coordinate and collaborate with other providers

• A way to add a FFS revenue stream

• Something I can ignore if I choose not to apply to participate

Additional Resources :

CMS FAQs on ACCESS

Peterson Health Technology Institute (PHTI) Individual Evaluations of Digital Health Companies