CMS to Test ‘Outcome-Aligned Payments’ for Tech-Supported Care
Starting next July the CMS Innovation Center will experiment with a payment approach in traditional Medicare to expand access to new technology-supported care options to help patients manage chronic conditions.
The Innovation Center noted that traditional Medicare has historically lacked a payment option to adequately support novel technology-supported care. Fee-for-service methodologies pay for a defined set of activities that do not typically align with the way technology-supported care is delivered.
The ACCESS (Advancing Chronic Care with Effective, Scalable Solutions) Model will test Outcome-Aligned Payments, a payment option for Medicare-enrolled care organizations. Participating organizations will receive recurring payments for managing patients’ qualifying conditions, with full payment tied to achieving measurable health outcomes. The model focuses on clinical improvement or control of a condition based on each person’s starting point — for example, helping a patient with hypertension lower their blood pressure by 10 mmHg. By rewarding outcomes rather than defined activities (or volume of services delivered), ACCESS gives clinicians greater flexibility to deliver modern technology-supported care in ways that best improve patient health, the Innovation Center said.
ACCESS care organizations are expected to offer integrated, technology-supported care that may include:
• Clinician consultations
• Lifestyle and behavioral support (nutrition, exercise, smoking cessation)
• Therapy and counseling
• Patient education and care coordination
• Medication management
• Ordering and interpreting diagnostic tests and imaging
• 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.
ACCESS will focus on four clinical tracks addressing many of the most common chronic conditions:
• Early cardio-kidney-metabolic conditions (eCKM): 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 (CKM): diabetes, chronic kidney disease (3a or 3b), and atherosclerotic cardiovascular disease, including heart disease
• Musculoskeletal conditions (MSK): chronic musculoskeletal pain
• Behavioral health conditions (BH): depression and anxiety
CMS may consider additional tracks and conditions in the future.
Each track groups related conditions that are commonly treated using similar types and levels of care. 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 tracks include an initial year of care followed by an optional continuation period at a reduced rate, facilitating continued patient support. To promote access in underserved areas, a fixed adjustment will be applied to rural patients in qualifying tracks.
To balance accountability with model accessibility, CMS said it would base payment on the overall share of an organization’s patients who meet their outcome targets, allowing organizations to earn full payment through strong overall performance even if some individual patients do not meet their target. CMS will publish risk-adjusted outcomes, recognizing and rewarding excellent clinical performance.
Patients voluntarily sign up directly with participating ACCESS care organizations, either on their own or upon referral from their provider. To help patients and PCPs choose the most appropriate ACCESS organizations for their conditions, CMS will maintain a directory of all ACCESS participants including the conditions they treat and their risk-adjusted outcomes.
The American Medical Association (AMA) signaled support for the new model. “For too long, outdated payment barriers have made it difficult for physicians to use new tools that can improve care for common chronic conditions,” said AMA CEO John Whyte, M.D., M.P.H., in a statement. “This new model has the potential to give clinicians more flexibility, strengthen care teams, and — most importantly —help patients live healthier lives. The AMA looks forward to supporting physicians as they adopt technology-enabled care models in ways that enhance the patient-physician relationship.”
Rapid cycle testing
In a separate announcement, the Innovation Center said it is launching the “Rapid Cycle Innovation Program (RCIP),” partnering with model participants to administer rapid randomized controlled trials (RRCTs) that focus on real health outcomes.
Instead of just managing symptoms with care as usual, this initiative seeks to quickly identify strategies that empower patients, improve outcomes, and lower costs for everyone.
The first two Rapid Cycle Innovation Program tests include participants from the ACO REACH and Kidney Care Choices models to answer two questions, insights from which will help providers across the care continuum engage patients and families more effectively, support prevention, and reduce chronic disease: How can providers change patient outreach to improve receipt of preventive care? and How can providers improve patient follow-up after discharge to keep patients from having to return to the hospital?
Model participants taking part in the first two RCIP tests are Carolina Kidney Partners, CINQCARE, Genuine Health Group, Kidney Specialists of Southern Nevada, NeueHealth, Nephrology Associates of Northern Illinois and Indiana, RenalCare Associates, Southwestern Health Resources, and The Kidney Experts.
