Before ACCESS: The Economics and Incentives Behind Chronic Care's Structural Problems

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CMS has spent twenty years testing ways to make fee-for-service Medicare work better for chronic disease. The results have been mixed. The newly announced ACCESS (Advancing Chronic Care with Effective, Scalable Solutions) Model represents the agency's newest theory: pay for outcomes rather than activities, and let technology-enabled organizations figure out how to deliver the care.

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The Scale of the Problem

The numbers are stark. According to the CDC, chronic diseases and mental health conditions account for 90% of the $5.3 trillion the U.S. spends annually on healthcare. Furthermore, at least 40% of Medicare fee-for-service beneficiaries and 55% of dually-eligible Medicare and Medicaid beneficiaries live with multiple chronic conditions. The Milken Institute estimates that when including lost productivity, chronic disease costs the U.S. economy at least $3.7 trillion annually—roughly 19.6% of GDP.

These aren't just large numbers. They reflect a fundamental structural problem. Yet the system designed to serve these patients was built for something else entirely.

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Fee-for-Service and the Episodic Mindset

The core challenge isn't that clinicians lack commitment or skill. It's that the traditional payment model creates specific incentives that work against longitudinal care.

Under fee-for-service, providers are paid for discrete services rendered, like office visits, procedures, tests, imaging. This creates several well-documented problems for chronic care management:

Visibility gaps between visits. A patient with diabetes, hypertension, and early kidney disease may see their primary care physician four times per year. That leaves roughly 361 days when the system has no structured way to monitor how they're actually doing. Blood pressure may drift, medication adherence may slip, and diet and exercise intentions may fade. The clinician sees the patient intermittently while the condition progresses continuously.

Unreimbursed coordination work. Managing complex chronic conditions requires reviewing results, coordinating with specialists, following up on referrals, answering patient questions, and adjusting treatment plans. Much of this work happened between visits and, until 2015, had no billing pathway in Medicare. Practices absorbed these costs or simply did less coordination.

Volume incentives. Fee-for-service rewards activity. A practice that generates more billable services and procedures generates more revenue, regardless of whether those activities improve outcomes. This isn't cynicism, but rather basic economics. When a payment system rewards volume, volume increases.

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The CCM Experiment and Its Limits

CMS introduced Chronic Care Management (CCM) billing codes in 2015, creating a payment pathway for non-face-to-face care coordination. The theory was sound: pay practices approximately $42 per patient per month (CPT 99490) for at least 20 minutes of care management services, and they would invest in the infrastructure needed to support patients between visits.

The reality was more complicated. According to a study in the Journal of the American Geriatrics Society, fewer than 4% of eligible Medicare beneficiaries had claims for CCM between 2015 and 2019, and other studies have shown the same minimal uptake. The barriers were predictable. CCM requires upfront infrastructure investment—staff time, care management workflows, documentation systems—before any revenue materializes.

When CCM did work, results were encouraging. A CMS-commissioned study by Mathematica found that patients receiving CCM services had lower hospital admission rates, used emergency departments less often, and, after excluding patients who only received one month of service, cost Medicare $95 less per month than matched controls. The program saved CMS an estimated $38 million over its initial period.

But these savings went unrealized for most patients because adoption remained low.

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The Challenge of Multiple Contributors

As chronic illness patterns became more complex, the number of parties involved in each patient's care multiplied. Primary care physicians shared responsibility with cardiologists, endocrinologists, nephrologists, behavioral health professionals, pharmacists, and sometimes remote monitoring programs or virtual care teams.

Each of these contributors operated under different payment arrangements, with different documentation systems, and often without shared visibility into what others were doing. A patient might have excellent diabetes management from their endocrinologist while their depression went unaddressed because the primary care physician didn't know about medication changes that affected mood.

This fragmentation created inefficiencies and gaps, but fragmentation wasn't primarily a failure of coordination software or communication protocols. It reflected the underlying incentive structure: no single entity was accountable for the patient's overall trajectory, so no single entity had a financial reason to invest in integration.

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What the Outcome Data Shows

The limitations of activity-based payment for chronic care are visible in population-level outcomes. Despite spending more on healthcare than any other developed nation, the U.S. has lower life expectancy than peer countries. The Commonwealth Fund reports that compared to other high-income nations, the U.S. has the highest chronic disease burden, the highest number of hospitalizations from preventable causes, and the highest rate of avoidable deaths.

These outcomes aren't caused by fee-for-service alone. Health-related social needs, access barriers, and coverage gaps all contribute. But the payment structure shapes what the system prioritizes, and activity-based payment prioritizes activity.

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The Structural Gap ACCESS Attempts to Fill

The ACCESS Model, announced in December 2025 and launching July 2026, represents CMS's attempt to create a payment structure that aligns with how chronic care actually needs to work. Rather than paying for services rendered, ACCESS tests "Outcome-Aligned Payments" (OAPs), which are intended to be recurring payments tied to whether patients achieve measurable health improvements.

The model focuses on four clinical tracks covering conditions that affect an estimated two-thirds of Medicare fee-for-service beneficiaries: early cardiometabolic and kidney conditions (hypertension, dyslipidemia, obesity, prediabetes), established cardiometabolic and kidney disease (diabetes, CKD, cardiovascular disease), musculoskeletal chronic pain, and behavioral health (depression and anxiety).

Participating organizations will receive predictable monthly payments for managing qualifying conditions. Full payment depends on the share of patients meeting condition-specific targets, which include blood pressure control for hypertension, HbA1c improvement for diabetes, functional improvement for chronic pain. The model explicitly allows flexibility in how organizations deliver care, including telehealth, remote monitoring, digital coaching, and asynchronous communication.

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What ACCESS Changes and What It Doesn't

ACCESS creates a different incentive structure. Instead of rewarding volume of interactions, it rewards demonstrated improvement or stability in patient conditions. This theoretically frees organizations to invest in whatever combination of technology, staffing, and care processes actually works, rather than whatever generates billable encounters.

The model also creates a co-management payment for primary care and referring clinicians—approximately $100 per year per patient, when they coordinate with ACCESS participants. This attempts to reduce friction between technology-enabled care organizations and traditional practices.

What ACCESS doesn't do is solve the coordination problem through mandate. The model creates financial incentives for results but doesn't prescribe how different contributors should work together. Organizations that figure out effective collaboration may succeed; those that don't may struggle to hit outcome targets.

ACCESS also operates within the existing fee-for-service Medicare infrastructure. It's a voluntary model running through the CMS Innovation Center, accepting applications for the model that will run through 2033. If evaluation shows it improves quality without increasing costs, it may eventually be expanded or made permanent. If not, it will join the list of payment experiments that didn't scale.

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The Context for ACCESS

ACCESS arrives at a specific moment in CMS's value-based care journey. The agency has stated goals of having all Medicare beneficiaries in accountable care relationships by 2030 that have been renewed from administration to administration. The Innovation Center has tested dozens of alternative payment models over the past 15 years, with results ranging from promising to disappointing.

What distinguishes ACCESS is its focus on technology-enabled care delivery—a recognition that remote monitoring, digital therapeutics, and virtual care have matured enough to potentially deliver meaningful chronic care support at scale. The model explicitly targets the gap between what technology companies can now deliver and what traditional fee-for-service Medicare will pay for.

Whether ACCESS succeeds will depend on execution details not yet fully specified, on organizational capabilities that vary widely across the healthcare landscape, and on whether outcome-aligned payment actually produces better outcomes at sustainable cost. The model is an experiment, not a solution.

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Looking Forward

The problems ACCESS addresses are real: chronic disease consumes the vast majority of healthcare spending, fee-for-service payment creates incentive misalignments for longitudinal care, and existing programs like CCM have achieved limited uptake despite promising results where implemented.

ACCESS fits within a broader ecosystem of value-based care models. Its primary target is the roughly 40% of Medicare beneficiaries who remain in traditional fee-for-service without an accountable care relationship, a population that has largely been unreachable by existing value-based arrangements. For beneficiaries already aligned to ACOs, ACCESS isn't off-limits: CMS has indicated that ACOs can refer their patients to ACCESS participants, and beginning in 2028, ACCESS expenditures will be incorporated into ACO benchmark calculations. But the model's core bet is on reaching people that existing structures haven't.

What's clear is that the status quo, fragmented, episodic, volume-driven care for conditions that require continuous, coordinated management, hasn't produced the outcomes we need at costs we can sustain. ACCESS is CMS's latest attempt to create different conditions. The next decade will determine whether it works.