Presentation (CTI)

OBJECTIVES: The new CMS ACCESS (Advancing Chronic Care with Effective, Scalable Solutions) Model introduces Outcome-Aligned Payments (OAPs) for technology-supported chronic care management in Original Medicare, launching July 2026. This conceptual paper proposes a health economic modeling framework specifically designed for the ACCESS incentive structure, which differs fundamentally from traditional payer cost-effectiveness logic.
METHODS: We analyzed ACCESS Model payment mechanics as described in CMS documentation (December 2025) to identify the economic decision framework facing ACCESS participant organizations. Unlike traditional payers evaluating cost-effectiveness from societal or healthcare system perspectives, ACCESS participants receive fixed recurring payments contingent on the share of patients meeting clinical outcome thresholds. We developed a conceptual framework comprising three model types aligned with this margin-based incentive structure.
RESULTS: The proposed framework includes: (1) an Outcome Contribution Model quantifying a technology's incremental effect on the proportion of patients achieving ACCESS-defined clinical thresholds; (2) a Margin Impact Model projecting net financial position under OAP payments by comparing incremental revenue from improved outcome attainment against technology costs; and (3) a Comparative Value Model evaluating cost per additional patient achieving threshold across competing interventions. Key inputs include baseline patient severity distribution, absolute clinical effect sizes mapped to threshold definitions, and OAP payment rates. Critical parameters pending CMS publication include exact payment amounts, threshold specifications, risk adjustment methodology, and performance trajectory requirements.
CONCLUSIONS: Traditional cost-effectiveness and budget impact models inadequately address ACCESS participants' core question: whether deploying a technology improves margins under outcome-contingent payment. The proposed framework enables manufacturers to prepare model structures operationalizable once CMS publishes the Request for Applications with definitive parameters. This represents a necessary evolution in health economic evidence generation for outcome-based payment models.