Medicare's ACCESS model expands before it has properly launched

ACCESS is a Medicare experiment. The agency pays approved companies to manage patients with chronic conditions. The program was announced last year and covers diabetes, hypertension, chronic musculoskeletal pain, depression and anxiety disorders, among others. The key change from traditional billing is the so-called outcome-oriented payment: a provider gets more if its patients' condition improves.

On 15 September 2026 regulators announced an expansion of the list of conditions eligible for ACCESS. They added substance use disorders, heart failure, chronic obstructive pulmonary disease, tobacco use and long-term support in musculoskeletal conditions. The new tracks are to start in spring 2027. Officials say that after the expansion about three in four people covered by Medicare will qualify for one of the tracks. The agency also published a directory of 39 providers authorised to treat beneficiaries under ACCESS.

Who gains, who carries the risk

An outcome-based model changes the business logic. Instead of paying for a procedure, it pays for maintaining or improving a patient's condition. Providers that can genuinely manage chronically ill patients, with telemonitoring, education and regular contact, get a chance at stable revenue. For the rest it is a risk: if patients do not improve, revenue falls while the cost of delivering care stays.

The expansion, before the program has properly got going, raises questions about the order of things. At the same time the agency proposes limiting payments for remote patient monitoring, one of the natural tools in chronic care. In other words, one reform widens payments for managing a chronic condition, and another narrows the channel through which that care is often delivered.

Outcome-based payment models also raise the question of patient selection. If revenue depends on improving patients' condition, the provider may prefer people whose improvement is likely. That is why how outcomes are measured and how risk is adjusted matter as much in such programs as the technology meant to support them.

For rural systems struggling with staff shortages, the result of the ACCESS model may be particularly important. If care for diabetes or heart failure can be delivered with partial support from technology, outcome-based payment may be a real source of funding for them. The condition, though, is that the technology be available and accountable, not just declared in announcements.