It’s amazing how the Trump HHS under the direction of Robert F. Kennedy, Jr is bringing innovation into the Center for Medicare & Medicaid Services for PAYING FOR OUTCOMES to providers thus helping to keep seniors and other Americans healthier not just treating their chronic diseases through prescriptions. These innovations in moving America from the SICK CARE MODEL to the WELL CARE MODEL. For 30 years, health professionals have found that health promotion does pay well but keeping Americans sick does.

The Centers for Medicare & Medicaid Services has introduced the ACCESS Model—Advancing Chronic Care with Effective, Scalable Solutions. Its most important feature is a fundamental change in how participating healthcare organizations are paid.

https://youtu.be/LAnRiI7AoiQ?si=58rqS9gESaAgHYX-

Instead of paying only for every appointment, test or procedure, Medicare will connect payments to measurable improvements in patients’ health.

Under ACCESS, participating organizations receive recurring payments to help people manage qualifying chronic conditions. Receiving the full payment is tied to achieving defined health goals.

Examples may include:

•  Improving blood sugar and A1C
• Lowering or controlling blood pressure
• Improving cholesterol levels
• Reducing chronic pain
• Improving physical function
• Reducing symptoms of depression or anxiety

This is called an Outcome-Aligned Payment system. In simple language, Medicare rewards participating healthcare organizations for helping patients get healthier—not simply for delivering more services.

HOW DOES TECHNOLOGY-ENABLED CARE FIT INTO THE PROGRAM?

Technology-enabled care means using digital tools to provide patients with continuing support between traditional medical appointments. It may include:

• Virtual medical visits
  • Remote blood-pressure or glucose monitoring
  • Smartphone health applications
  • Connected medical devices and wearables
  • Virtual nutrition, exercise or health coaching
  • Medication monitoring
  • Mental-health counseling and education

Technology-enabled care provides the tools and ongoing support. Outcome-aligned payment rewards participating organizations when that care produces measurable health improvement.

For example, a patient may enter the program with uncontrolled high blood pressure. The care team could provide a connected blood-pressure monitor, virtual consultations, medication management and lifestyle counseling. The patient’s progress would then be measured against an established, individualized blood-pressure goal.

It is important to understand that Medicare pays the participating healthcare organization—not the patient—for achieving outcomes. The program does not guarantee that every patient will reach every goal. Health outcomes can be affected by disease severity, genetics, social circumstances and many other factors.

WHAT CONDITIONS ARE INCLUDED?

The initial ACCESS tracks cover qualifying cases involving:

• High blood pressure
  • Abnormal cholesterol or other blood lipids
  • Prediabetes
  • Obesity or certain cases of overweight
  • Diabetes
  • Stage 3a or 3b chronic kidney disease
  • Atherosclerotic cardiovascular disease
  • Chronic musculoskeletal pain
  • Depression and anxiety

Beginning in April 2027, CMS plans to add tracks for heart failure, chronic obstructive pulmonary disease—COPD, substance-use disorders and tobacco cessation.

WHO CAN PARTICIPATE

ACCESS is currently available to qualifying people enrolled in Original Medicare. People with Medicare Advantage are not included, although their plans may offer similar programs.

Patients may enroll directly with a participating ACCESS organization or be referred by a healthcare professional. Participation is voluntary, and patients maintain their Medicare coverage and freedom to see other Medicare providers.

Patients should ask about costs before enrolling. A participating organization may waive Medicare cost-sharing, but another may collect it. The expected patient cost must be explained before enrollment.

The ACCESS Model represents a potentially important shift from our traditional sick-care system toward a system that rewards prevention, better chronic-disease management and demonstrable health improvement.

The crucial questions will be whether CMS measures outcomes fairly, protects patients’ privacy and ensures that technology supports—not replaces—the relationship between patients and their trusted healthcare professionals.

Paying for better health outcomes instead of simply paying for more healthcare services is a change healthcare professionals have advocated for over many years. Now we need to watch carefully and determine whether ACCESS delivers on that promise.

Learn more: https://www.medicare.gov/ACCESS

How Will CMS Determine Whether ACCESS Is Working?

CMS will assess the ACCESS Model at two different levels:

1. Whether individual participating organizations are producing measurable patient improvements.
2. Whether the overall national model improves quality and reduces—or at least does not increase—Medicare spending.

1. Condition-specific health outcomes

Each patient’s measurements will be recorded at the beginning of care and compared with results after treatment.

Patients do not all have to reach the same numerical result. A person may qualify by reaching a guideline-informed control level or demonstrating a required improvement from their own baseline.

For example, CMS gives the example of a patient with hypertension lowering systolic blood pressure by 15 mmHg or reaching an established blood-pressure goal. CMS ACCESS overview

2. Percentage of patients reaching their goals

CMS will calculate the percentage of each organization’s patients who meet all required targets for their clinical track.

During the first model year, the Outcome Attainment Threshold is 50%. An organization can earn its full outcome-based payment if at least half of its assessed patients achieve the required outcomes.

If only 40% achieve their targets against a 50% threshold, for example, the organization would receive 80% of the full payment. CMS says the payment reduction is capped at 50%. Thresholds may increase in later years.

This evaluates an organization’s overall performance without assuming that every individual patient will respond identically. CMS ACCESS technical FAQs

3. Medicare spending and healthcare use

To determine whether the entire program works, CMS will examine:

• Total Medicare spending
• Hospital admissions and readmissions
• Emergency-department visits
• Other healthcare-utilization patterns
• Potentially avoidable medical care
• Whether technology-supported care replaces unnecessary services or simply adds new expenses

CMS will compare ACCESS participants with a control group receiving regular Medicare care. A small percentage of eligible applicants may be randomly placed in that control group specifically to support this evaluation.

4. Quality, safety and patient experience

CMS will also assess:

• Patient-reported health and functioning
• Quality of care
• Patient choice and access
• Care coordination with regular physicians
• Rural and underserved-community access
• Privacy and data security
• Compliance with licensing, HIPAA and applicable FDA requirements
• Safety problems or adverse outcomes
• Whether patients remain engaged and complete the program

Information will come from Medicare claims, clinical data, patient surveys and other evaluation sources. CMS may remove organizations that fail to satisfy quality, safety or outcome requirements. CMS ACCESS Request for Applications

5. Public reporting and risk adjustment

CMS plans to publish participating organizations’ risk-adjusted outcomes. Risk adjustment is important because organizations treating older, sicker or more medically complicated patients should not automatically appear less successful than organizations treating healthier populations.

The ultimate test

ACCESS will be considered successful if it can:

Improve healthcare quality without increasing Medicare spending—or reduce Medicare spending without harming quality.

If the evidence supports one of those conclusions and the CMS Office of the Actuary certifies the findings, HHS may consider expanding the model or making it permanent.

The real test should therefore extend beyond blood-pressure readings and other biomarkers. CMS must determine whether patients are healthier, more functional and more satisfied—while experiencing fewer preventable hospital visits and receiving better value for Medicare dollars.

Medical Disclaimer: This information is for education only and is not medical advice. Always talk with your healthcare provider about what is best for your health.

Note: I used ChatGPT for the graphics and pulling this blog together for this topic, but I also check the information carefully to ensure the health information is correct. In order to get the right answers & the development of these health blogs when using ChatGPT effectively, you must know how to pose the correct questions.  

This content was generated with assistance from ChatGPT, an AI language model by OpenAI