The Trump administration is testing out a new 10-year program for value-based chronic condition management that leans heavily on technology and artificial intelligence to scale to large populations of patients.
Many of the 150 digital health companies tapped to participate in the first cohort of the tech-enabled chronic care model are bullish that it marks an inflection point for connected care and a way to prove out that AI-enabled medical services can move the needle on cost and quality.
The Center for Medicare and Medicaid Innovation (CMMI) announced in December the Advancing Chronic Care with Effective Scalable Solutions (ACCESS) Model as a 10-year payment program to encourage the use of technology to treat chronic diseases. CMS aims for the ACCESS Model to provide stable, recurring payments for technology used to treat diabetes, hypertension, chronic kidney disease, obesity, depression and anxiety.
The ACCESS Model aligns with the Centers for Medicare and Medicaid Services' goal of having all traditional Medicare beneficiaries in an accountable care relationship by 2030. And it also aligns with the Trump administration's focus on putting health technology in the hands of Medicare beneficiaries.
The model breaks down barriers to Medicare patients' access to digital health tech and advances patient choice, many health tech executives said.
"In the current landscape, across all payers, if you want to access to a benefit, like a digital health program, you're very limited to the choice of what your payer has contracted with. What ACCESS is doing here is creating a free Medicare app store, essentially, where you can access the program that fits you best," said Patrick Sheehan, vice president of value-base care at Withings Health Solutions, an ACCESS program participant.
The CMS ACCESS Model creates a new category of Medicare Part B providers, ACCESS organizations, that can receive outcome-aligned payments for managing qualifying chronic conditions. The model shifts away from remote patient monitoring (RPM) and chronic care management (CCM) billing codes that offer payments for specific activities.
"This access model introduces an alternative approach, which is, you get rid of the billing codes altogether, and you have these new outcomes-aligned payments," said Aneesh Chopra, chair of the Arcadia Institute.
Chopra, who served as the first U.S. Chief Technology Officer, asserts that the ACCESS model redefines value-based care as it eliminates complexity and makes value-based care scalable.
The use of AI technologies enables companies and providers to take a scarce resource—care management—and make it abundant, Chopra noted, to scale it to more patients living with chronic conditions.
"These AI agents can touch far more patients with better quality of engagement, such that you can almost speak to every uncontrolled hypertensive patient when perhaps you would only stratify those to high-risk patients in the past," Chopra told Fierce Healthcare.
"CMMI is accelerating new technologies into the Medicare program through a deflationary business model with a simplified implementation approach and a playbook that is easier to scale with other payers on day one. It's a thoughtful, coordinated approach to bring abundant care management throughout the country," he noted.
Ashul Govil, M.D., medical director at Story Health, a digital specialty care platform with health system inroads, asserts the company is set up to succeed in an outcomes-based model like ACCESS.
"The technology we use already scales care. You need to be able to deliver care to a larger scale of patients relying on fewer resources but still get the outcomes. We've already proven that we'd be able to do that. The technology platform we have fits into medical records, fits into pharmacy data, it really brings all the data in one place to make easier decision-making for any clinician," Govil said.
He added, "In some ways, [the ACCESS model] is going to be a test of AI-enabled care at scale. You're really going to test to see if this AI-enabled care really does improve outcomes and lower costs. It's also an evolution of value-based care, shifting value-based care really towards that outcomes-oriented model," Govil said.
Sheehan points out that opening up access to digital health apps and AI-enabled tools for Medicare patients has a potential downside.
“Where I think we need to be concerned is if we don't do this in a responsible way, and we over-optimize for this direct-to-consumer muscle that a lot of us in this ACCESS pool have, it might lead to fragmentation of care. It might lead to poor outcomes in this first cohort,” he said. “So that's really where I'm looking at right now is, how does us as a first cohort, not just Withings, work with the primary care physicians and make sure this is not another piece of fragmentation that's occurring?”
The tracks in the ACCESS Model include early Cardio-Kidney-Metabolic (hypertension, dyslipidemia, obesity, and prediabetes); Cardio-Kidney-Metabolic (diabetes, chronic kidney disease, atherosclerotic cardiovascular disease); Musculoskeletal (chronic musculoskeletal pain); and Behavioral Health (depression and anxiety).
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, CMS said. For the 2026–2027 performance period, at least 50% of aligned beneficiaries must meet all required outcome targets for the participant to receive full payment.
The model will kick off July 5 and run through June 30, 2036.
Digital health companies have conflicting views on payment rates
The first cohort of the ACCESS Model program consists of a mix of digital health and connected care companies along with AI-native startups, ACO enablement companies and tech-enabled health plans. Among the 150 participants there's AI doctor startups like Doctronic, virtual nutrition therapy provider Berry Street, tightly integrated Medicare Advantage plans like Devoted Health, accountable care organization (ACO) enablement companies like Aledade and Guidehealth, connected device company Withings and wearable maker Whoop.
Many scaled digital health companies are conspicuously absent from the list of participants.
The payment rates (PDF) for the ACCESS model, unveiled back in early March, were lower than the industry expected and fall below current billing models. The rates range from $90 to $420 per beneficiary per year (i.e., $7.50 to $35 per month), depending on model track.
Both Omada Health and Hinge Health, two digital health companies that went public last year, chose not to apply for the ACCESS Model this year, executives confirmed to Fierce Healthcare. Sword Health, another scaled company that works with more than 1,000 enterprise clients, also is currently not participating.
"While we chose not to participate in the first cohort, we believe that the program structure – outcome-aligned payments for technology-supported chronic care in Medicare – is right on target. That vision hasn't changed, and neither has our enthusiasm for it," Wei-Li Shao, president of Omada Health, told Fierce Healthcare.
"Unfortunately, our assessment is that the payment levels don't cover the cost of delivering the high-quality, evidence-based care Medicare beneficiaries deserve. As the payment structure stands today, the rates would not make it feasible for us to provide sustainable outcomes for people with chronic conditions," Shao said.
He added, "Equally, our assessment is that providers who would be ACCESS partners and referring patients to the program have similar concerns about viability. We're rooting for the program to succeed, and for now, our efforts will be pointed toward where we currently support government-sponsored plans — Medicare Advantage."
The lower-than-expected reimbursement rates introduces the risk of negative profit margins for model participants, according to a research note from strategy firm Capstone.
Many ACCESS model participants noted the payment rates will require providers to lean heavily on tech and AI and to focus on being efficient in their operations.
"If you want to build a model of care that truly scales the reimbursement and incentivizes technology, and ultimately incentivizes the use of AI, [the reimbursement rates] have to be low there," said Neil Batlivala, co-founder and CEO of Pair Team, an ACCESS model participant. "I do agree that this is the right way to provide an AI care manager and AI companion to everyone and really incentivize that."
“I think we should just stop whining about the reimbursement rates and figure out how to deliver care more efficiently,” quipped Brandon Ballinger, co-founder of Empirical Health, an AI-native preventive heart health startup. “I think Medicare has set the reimbursement rates such that you have to use software, not just headcount, to deliver care. Our system has to go in that direction. We have a massive primary care shortage.”
He added, “If we’re going to tackle the number one cause of death, which is heart disease, we need to do it in a way that's scalable. We must do it in a way that makes use of software. And, of course, it needs to have oversight and guidance by clinicians; it doesn't replace them, but we have to be thinking about things that are fundamentally more efficient than just hiring a whole army of people. I think Medicare has done a good job of using policy and regulation for what it should be, which is to create a force in the market that lets the best solutions emerge.”
Sheehan said the reimbursement rates fit Withings’ cost profile, "but we are also very lucky to both be a device manufacturer and also having little to no marketing costs because of our consumer base and our health system partnerships," he said.
Chopra asserts that CMS hit the payment rates "just right." "This just sets us off in a new direction for how we reimburse health outcomes, away from the traditional shared service actuarial approach and more towards an alternative to unit fee-for-service activities. We're buying outcomes that are tightly defined," he noted.
He added, “Even if we get break-even on cost, and we get the quality improvement, that may still be a home run for the system.”
Govil with Story Health noted that the ACCESS model may not work for healthcare entities that rely on fee-for-service payments. “I think that's one reason for health systems, and traditional providers, it's going be difficult to participate as a result, which is unfortunate, because at the end of the day, those are the ones who have a proven track record of delivering care in appropriate ways," Govil said. "What's interesting about the announcement of 150 companies, the majority of them have never really delivered care or shown any real outcomes for patients yet and now they're going to be taking all these new patients. It's going to be a big question of whether, sure, they might be able to do it within the context of the financials, but what can they actually do in terms of the context of doing the right thing by patients? It’s an open question, for me at least."
Govil added, "I do think in the long term the only way a program like CMS' ACCESS is successful is through pretty heavy use of AI. The question is, how do we safely get there? If you want to do this responsibly, you're going to be willing to take a hit up front on the financials and learn what's safe. And how do you deliver AI care safely so that eventually you can actually scale and build something that's more AI-forward, and maybe AI-first?"
How the ACCESS model could spur health plan and employer adoption
In February, CMS announced that commercial payers representing 165 million members across Medicare Advantage, Medicaid and commercial coverage have also agreed to align with the ACCESS Model's payment approach.
These commercial payers agreed to make arrangements with providers that will provide consistent, outcome-aligned payments for the use of healthcare technology. The plans also agreed to work with primary care and referring providers, a hallmark of the CMMI ACCESS model.
“While this is for CMS, the commercial populations oftentimes do have some follow-through based off of it. It might not be immediate. The employer market is definitely different. There's a whole different sort of calculus there, but oftentimes there's a lot of inspiration from programs that do take off,” said Richard Fu, chief commercial officer at Berry Street, a nutrition therapy platform that is participating in ACCESS. “We are seeing a lot of excitement from the commercial employer world that kind of leans into more value-based sort of discussions and value-based types of arrangements. So not necessarily directly tied to ACCESS, but if ACCESS is accessible, I do think there's something where commercial might be looking to adopt something similar.”
Berry Street is participating in ACCESS to demonstrate its focus on outcomes and care delivery, Fu noted.
“It validates our focus of making sure that everyone has nutrition care in their pocket, nutrition care anytime they want,” he said.
In its 2027 carrier call letter to federal employee health benefit plan carriers, the U.S. Office of Personnel Management outlined a "clear shift toward prevention, wellness and long-term health outcomes." In a press release, OPM specifically called out digital therapeutics, promoting cost-effective sites of care and reducing unnecessary or low-value services. OPM's technical guidance (PDF) mentioned the Wasteful and Inappropriate Service Reduction (WISeR) Model, a program that tests the use of tech and AI to review the appropriateness of select services in six states over a six-year trial period.
“That’s a pretty interesting feedback loop where CMMI hasn't even launched yet, and a self-insured employer, the federal government, is asking to incorporate these capabilities almost in parallel,” Chopra noted. “It is a win for the agency to take this as a multi-payer approach with an explicit eye towards self-insured employers in that if you looked at the payers who signed up to take this commitment, there were a lot of Blues plans, United and Cigna that also have a pretty healthy employer mix.”
How companies are prepping for July 5
Many health tech executives participating in the ACCESS model say that working closely with primary care physicians and providers will be key to success in the program.
The ACCESS model allows Medicare Part B clinicians to receive a co-management fee of roughly $30 per review—up to $100 annually per beneficiary—for coordinating care with ACCESS organizations.
“What hasn't been figured out is what that co-management workflow is between a PCP and an ACCESS provider—that's still very much up for grabs,” Batlivala with Pair Team said. “I think the PCPs are going to want to work with ACCESS providers that are easy to implement and have high-quality outcomes. I think they are also looking 'can the ACCESS providers help with my other value-based needs?'”
As part of its model of care, Story Health already partners with providers and health systems and can connect patients back to traditional brick-and-mortar care providers for more advanced levels of care.
“We’re preparing our partners, the health systems we work with, the clinics and the ACOs, on here's how we're going to actually structure you getting your patients over to us. You can continue delivering the great care that you already provide for them, and we can supplement that with getting to the patients these outcomes that ACCESS is focusing on, and so just making sure that we have the correct referral patterns from them and then back to them if needed,” Govil said.
Withings is also focused on integration with ACO and health system partners to set up effective co-management workflows, Sheehan said.
“I think this is a really powerful initiative, and we're in a great position to do this, but we need to collaborate and partner deeply with primary care and the ACOs,” he said.
“I think what keeps me up at night is this is allows for directed beneficiary marketing. It allows for a lot of patient choice about what they want to use. But if we don't do it responsibly, we don't want ACCESS to be dead on arrival because we didn't partner with the organizations that are managing this patient's day-to-day as well,” Sheehan noted. “But, what gets me excited is that we're in a position where, if we do figure out the integration workflows, if we do figure out the right collaborative model, I think there's so much potential here.”