From Pledge to Practice: Outcomes-Based Payment for Tech-Enabled Care

The ACCESS Model (Advancing Chronic Care with Effective, Scalable Solutions), slated to launch in July, is a CMS Innovation Center model that introduces outcomes-based payments for technology-enabled chronic disease management. ACCESS is designed to evaluate whether paying for health improvement—rather than discrete services—can better support preventive, longitudinal, person-centered care while improving outcomes and lowering costs. Payment rates for participants in ACCESS range from $180 to $360 per year, per patient, assuming outcome thresholds are met, far below current market rates for these technology-enabled services.

While paying for outcomes has been a long-standing goal in payment reform, ACCESS is the first CMS program to bring this idea to the forefront. ACCESS, however, is limited to beneficiaries under Original Medicare. In February, CMS announced that major health plans covering roughly 165 million people had signed a ‘Payer Pledge,’ committing to adopting outcomes-based payment for technology-enabled chronic care by 2028.

The pledge leaves implementation decisions to participating plans. It requires these organizations to offer an outcomes-based option for technology-enabled chronic care, but does not specify which conditions to target, which outcomes to measure, which vendors to work with, or how the model should be operationalized. These decisions are left to each plan to determine based on its own member population, capabilities, and priorities. While CMS has indicated it will offer some operational support in the form of sample provider agreements, claims codes, and data collection infrastructure, many of the specifics will require significant planning and resource allocation to implement successfully.

Ultimately, choices around where to focus, how to structure payment, what outcomes to measure, and how to engage partners will determine whether these payment models meaningfully improve cost and quality outcomes. We outline some of these key considerations below.

Where to focus: Identifying high impact clinical areas

Prioritizing disease areas is the most important first step. Health plans should first evaluate alignment with existing ACCESS clinical tracks. ACCESS launches with four tracks: early cardio-kidney-metabolic, cardio-kidney-metabolic, behavioral health (depression and anxiety), and musculoskeletal conditions. Additional conditions beyond ACCESS—such as COPD or substance use disorders—may also represent strong opportunities with high or rising spend, outcome variability, access challenges, and evidence supporting technology-enabled interventions. Plans should avoid starting with too many conditions simultaneously—selecting 2–3 to start is a good target. Early success will likely depend on narrowing focus to a limited number of disease areas where outcomes can be measured clearly and operational workflows can be standardized.

Designing payment structures to align with outcomes

A central design question is how payment is structured in relation to outcomes. ACCESS provides one example of this approach: up to 50% of the payment is tied to outcome achievement, and there are additional offsets related to patients receiving similar services while enrolled. ACCESS also includes a fee-for-service exclusion which prevents a participant (or financially affiliated entity) from payment for anything other than ACCESS-related codes for that beneficiary.

These design choices are intended to ensure that payment models meaningfully incentivize high quality care while preserving the economic advantage of an outcomes-based approach. Health plans should consider starting with the ACCESS structure, and adjusting for plan-specific considerations, for example, softening the fee-for-service exclusion to allow more providers into the payment model, or removing the substitute spend adjustments to decrease operational complexity.

Defining the right clinical measures and targets

Outcomes-based payment models should prioritize clinical outcome measures rather than process-oriented measures. The strongest measures are clinically meaningful, simple to collect administratively, and capable of being assessed within a practical reporting timeframe. In ACCESS, CMS primarily relies on well-validated laboratory, physiologic, and patient-reported outcome measures, including hemoglobin A1c, LDL cholesterol, blood pressure control, weight, and standardized patient-reported assessments.

Where possible, plans should prioritize measures that are reasonably accessible in existing provider workflows—for example, through claims or laboratory data, as opposed to requiring new processes. Certain conditions, such as hypertension and diabetes, have established lab or physiologic outcomes. Other areas, such as musculoskeletal care or behavioral health, may require greater reliance on patient-reported outcomes or more longitudinal measures tied to downstream utilization.

Cross-payer alignment on outcome measures may also reduce administrative burden and improve comparability across programs—health plans are unlikely to benefit from competing on measure construction itself. Absent a compelling reason otherwise, plans should leverage CMS clinical outcome measures, if they have been created for that disease area.

Partnership versus market competition

Health plans should approach outcomes-based payment models as a network strategy as opposed to a one-time vendor procurement strategy. While selecting a single vendor within a disease area may simplify short-term contracting and implementation, this approach could limit innovation and member choice while reducing longer-term pressure on performance and cost. ACCESS has dozens of participants in each track, creating significant patient choice and provider competition.

A hybrid approach allows for a smaller set of curated technology partners aligned to specific clinical priorities. This smaller set could still foster competition and price pressure, while simultaneously allowing for more sophisticated financial arrangements (like delegated risk structures) and reasonable attribution, contracting, and integration concerns. Over time, health plans should consider whether a more open participation model will create meaningful advantages. Technology-enabled care is evolving rapidly, and allowing multiple organizations to participate within the same clinical area will support greater innovation, stronger price and quality competition, more personalized member engagement strategies, and a better overall member experience.

Infrastructure needs to support outcomes-based payments

Outcomes-based payment models require new capabilities, from measure collection to oversight and new contracting needs. To launch ACCESS, for example, CMS has had to build new reporting infrastructure and implement several complex changes in its claims processing systems to handle the various model requirements. At a minimum, a health plan will need the ability to collect and track outcomes from technology partners, both at baseline and throughout a member’s care episode. Additionally, depending on how the contract specifics are structured, a health plan may want to incorporate new billing codes for tracking care delivery. For example, while the ACCESS model involves CMS collecting patient-level data from participants, it also requires monthly G-code claim submissions from participants to indicate an ongoing treatment relationship with the patient.

The extent of investment needed will depend on a plan’s existing data collection capabilities, current vendor partnerships, and support from CMS, who has indicated a set of collateral that will be made available at a later date (like contract artifacts and data collection capabilities).

Conclusion

The transition toward outcomes-based payment for technology-enabled care represents a meaningful shift in how chronic disease management will be financed and delivered. The challenge for health plans is no longer whether technology-enabled care will become part of the care delivery landscape, but how to structure payment models to reduce costs while improving clinical outcomes.

The above considerations are just some of the strategic decisions and choices health plans will face as they move to operationalize outcomes-based payments. Additional considerations include marketing (how to make members aware), network provider engagement, and fraud, waste, and abuse considerations.

While building an outcomes-based payment program is complex, the potential upside, as measured by improved access and quality while decreasing costs, is worth investing in. Starting now will ensure health plans can invest in the right resources and build the right model to best serve its members and providers.