Presentation (CTI)

OBJECTIVES: The CMS ACCESS Model's Cardio-Kidney-Metabolic (CKM) track offers Outcome-Aligned Payments for managing diabetes, with payment contingent on patients achieving hemoglobin A1c (HbA1c) control or minimum improvement thresholds. This paper presents an illustrative health economic framework demonstrating how diabetes technology manufacturers can model value under ACCESS's margin-based incentive structure using hypothetical parameters.
METHODS: We developed three interconnected model components tailored to the ACCESS CKM track. Using hypothetical parameters (monthly OAP: $200; HbA1c control threshold: <7%; minimum improvement: ≥0.5% reduction; technology cost: $50/patient/month; baseline control rate: 40%), we illustrated the framework's application. The Outcome Contribution Model estimated incremental threshold attainment. The Margin Impact Model calculated net financial position. The Comparative Value Model compared cost per additional patient achieving threshold across interventions.
RESULTS: In the illustrative scenario, a diabetes technology improving HbA1c control rates from 40% to 75% (absolute +35%) would generate incremental OAP revenue of $70/patient/month ($200 × 35%) against $50 technology cost, yielding positive margin (+$20/patient/month). This demonstrates economic viability under ACCESS. The Comparative Value Model showed cost per additional success of $143/patient/month, establishing a competitive benchmark. Sensitivity analyses revealed that margin remains positive provided technology cost stays below $70/patient/month at this efficacy level, or efficacy exceeds +25% threshold attainment at $50/month cost. Threshold attainment rate emerged as the dominant value driver.
CONCLUSIONS: This illustrative application demonstrates that technologies substantially improving clinical outcome attainment can achieve positive margins under ACCESS's outcome-aligned payment structure. The framework enables manufacturers to quantify the efficacy-cost relationship required for economic viability and establish competitive positioning against alternative interventions. This approach supports strategic pricing and evidence generation decisions before definitive CMS parameters become available.