Optimizing Outcomes in the ACCESS Model: Why Provider Integration is Critical to Long-Term Success

The Center for Medicare & Medicaid Innovation Center Advancing Chronic Care with Effective, Scalable Solutions (ACCESS) Model was announced on December 1, 2025, with the aim of optimizing clinical outcomes for chronic conditions by aligning outcome-based payments with access to technology-supported care. This model harnesses technological advances in health care, such as telehealth, wearable devices, smartphone apps, digital therapeutics, and asynchronous care platforms, to prevent and manage chronic disease. The goal is to target undertreated diseases such as hyperlipidemia, hypertension, and diabetes—critical components of cardio-kidney metabolic (CKM) syndrome—and thus substantially reduce the development of conditions such as end-stage renal disease, coronary artery disease, stroke, and heart failure, which have high morbidity and mortality. Given the potential to optimize clinical outcomes for these chronic diseases across populations of patients, the ACCESS model could be transformative to American health care, where adoption of new technology has moved at a slower pace than other sectors. ¹

Currently, the Center for Medicare and Medicaid Services (CMS) has proposed that provider groups or health systems participating in the ACCESS model cannot bill for any fee-for-service (FFS) care for enrolled beneficiaries, leaving provider group or health system participation implausible. Instead, model participation is focused on health care technology organizations that provide clinical oversight with secure IT interoperability and compliance with appropriate federal and state regulations. Traditional FFS incents volume and has not been focused on clinical outcomes, conflicting with the total cost of care accountability, limiting care model innovation, and preventing true integration of services. With ACCESS, CMS highlights the opportunity to shift from volume to outcomes: “Rather than generating revenue through visit volume, providers receive population-based and performance-aligned payments that reward care coordination, prevention, and integration across medical, behavioral, and social needs.” The exclusion of provider groups and health systems is a missed opportunity, as these groups are critical to the engagement, support, and sustainability of this innovative care delivery model, and exclusion results in further fragmentation in an increasingly disjointed health care ecosystem. The scope of implementation for the ACCESS model should be widened by incorporating a health system/provider group track to ensure the model has the greatest odds of success in demonstrating the effectiveness of technology-supported care.

The ACCESS model builds on published research on the impact of technology-care delivery on improving outcomes. A remote, technology-enabled hypertension and hyperlipidemia management program among 10,000 patients using algorithm-based hypertension and lipid management paired with cellular blood-pressure cuffs was developed at a large academic health system. ² Key programmatic elements included (1) patient navigators communicating with patients, gathering data, and coordinating care; (2) pharmacists ordering labs and adjusting medications based on established algorithms developed with physicians; (3) supervising physicians supporting complex clinical situations; (4) a technology-enabled platform integrated within the electronic health record (EHR). Systolic blood pressure was reduced by nearly 10 mmHg (on average) with sustained improvement for those in the program for 1 year, and low-density lipoprotein cholesterol (LDL-C) levels were reduced by 35%, with 94% of patients achieving target LDL-C. The program created an environment of trust for the patients and health care providers by ensuring all communication and clinical decisions were visible within the system’s EHR. This remote, technology-based program not only demonstrated the feasibility of the care model as scalable across populations but also that the connection to the provider network and “single front door” for the patient was key to establishing trust and increasing utilization.

These efforts have continued to grow and have evolved to include programming (now titled Cardiac Kidney Metabolic Compass) to support patients in our Medicaid, Medicare, and Commercial Accountable Care Organizations (ACOs), representing over 600,000 patients. As the impact of the CKM Compass program on clinical outcomes across heterogenous populations continues to be rigorously evaluated, the individual patient-level outcomes are clear. A recent case involved a patient with significantly elevated hypertension, with profound hypokalemia on routine lab work ordered by the program, subsequently found to have abnormal serum renin and aldosterone, leading to an ultimate diagnosis of primary hyperaldosteronism. The CKM Compass team communicated directly with an endocrinologist in our provider network, who provided additional management recommendations and facilitated an urgent in-person visit—made seamless by integration within the health system. Not only did the program result in blood pressure improvement to goal for this patient but also enabled effective communication and timely connection to specialty care for additional or adjacent management. The identification of patients and effective connection to definitive treatments for hypertension can substantially reduce long-term hypertension-related morbidity and mortality, resulting in improved cost savings. This experience demonstrates that remote, tech-enabled programming to improve chronic care management can be effective when implemented as part of a health system or provider network. The important role that innovative technology-supported care developed within a health system and suggests that this is an important delivery model to test within ACCESS.

This firsthand experience is consistent with established literature related to integrated care, promoting timely access, improved clinician communication, and higher quality clinical care. In Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys of ACO beneficiaries, patients in integrated care settings perceived more timely care and better communication between clinicians than patients in FFS environments. ³ Integrated care has dramatically transformed care for conditions such as ST-elevation MI (STEMI) care, where outcomes are dependent on the time to treatment. Integrated regional hub-and-spoke models that leverage common protocols between sites to decrease time to treatment are now the gold standard for STEMI care.^4,5 Patients in integrated, team-based care practices have demonstrated better outcomes in chronic care settings as well. Oschner Health, another large integrated health system, demonstrated similar impacts with respect to improvements in hypertension outcomes with a digital, pharmacist-led model. ⁶ In addition, a screening program leveraging fecal immunochemical testing at Kaiser Permanente, a highly integrated health system network, resulted in a lower risk of death from colorectal cancer, specifically due to the nature of system integration and ability to follow up abnormal testing. ⁷

The ACCESS model has the potential to transform health care delivery across populations by meaningfully improving clinical outcomes and reducing long-term health care costs. However, we strongly advocate for the development of a track within ACCESS specifically for health systems and provider networks to diversify participation and test the impact of fully integrated care models. First, the literature to date demonstrating the most meaningful impact of a technology-enabled chronic management model on clinical outcomes has been based in integrated health systems, offering the opportunity to build on seminal learnings.^2,6 Second, there will undoubtedly be greater trust in, increased referral to, and adoption of the ACCESS model, if provider networks are participants. Distrust of non-provider-based care delivery and technology is 1 reason for late adoption of tech advancements within health care, and ensuring providers can be embedded in an ACCESS model track is critical to overcoming these biases. ¹ Technology-based solutions developed internally by health systems and provider groups may even lay the foundation for systems to partner with external vendors due to improved trust in non-traditional care. Third, as outlined above in the programmatic experience, integration within a broader health system improves communication, mitigates fragmentation, and ensures timely downstream care is delivered without unintended care gaps or safety issues. Finally, ACCESS participation aligns well with system imperatives to improve access to chronic condition-based care as well as value-based care; CMS should encourage efforts to synergize across care delivery improvement efforts.

Additional operational frameworks within the ACCESS Model offer a greater likelihood that this important value-based care model can be successful and allow for comparisons of implementation methods. Mechanistically, CMS could create a track for provider and health system participation by specifying exclusions for FFS billing within specific condition-based tracks (i.e., CKM track participation would exclude the provider network participant billing FFS for directly related care). This would create a feasible opportunity for multi-specialty provider groups and health systems to participate. Ensuring provider networks and health systems are at the table for the ACCESS model will ultimately allow for improved trust, engagement, and confidence in this innovative care delivery model.