ACCESS Model: The Digital Health Payment Experiment That Might Actually Matter
Abstract
CMS launched the ACCESS Model in December 2025, creating a new payment pathway for technology-enabled chronic disease management tied to clinical outcomes rather than billing codes. The model offers recurring condition-specific payments based on risk-adjusted improvements in validated measures like blood pressure control, A1c reduction, and depression response. Payment levels appear modest compared to existing RPM and CCM codes, with roughly $100 per beneficiary annually plus co-management fees around $30 per primary care review. This structure favors automated, lower-touch interventions over labor-intensive care models. The opportunity exists primarily for companies that can deliver scalable digital solutions achieving measurable clinical improvements while maintaining unit economics under constrained reimbursement. Implementation barriers include upfront infrastructure costs that may exclude smaller practices and safety-net providers, risk of selective enrollment gaming, and unclear coordination mechanisms with traditional delivery systems. Success depends on whether payment levels support meaningful chronic care transformation versus incentivizing documentation optimization. For investors and entrepreneurs, ACCESS represents a potential wedge into Medicare chronic disease management if approached with realistic expectations about margins, target populations, and care model design constraints.
Table of Contents
Why ACCESS Actually Matters This Time
The Payment Math That Changes Everything
Who Wins Under This Structure
The Infrastructure Problem Nobody Wants to Talk About
Gaming Mechanics and Why They Matter
What This Means for Product Development
The Equity Issue That Could Kill the Model
Investment Thesis and Reality Check
Why ACCESS Actually Matters This Time
CMS has been running payment experiments through CMMI for over a decade now, and the track record is pretty brutal. The Congressional Budget Office concluded that CMMI increased federal spending by more than five billion dollars in its first decade instead of generating savings. Most models showed modest or transient effects because organizations optimized documentation and patient selection rather than actually redesigning care delivery. So when CMS announces another demonstration project, the appropriate response is usually skepticism mixed with mild curiosity about whether anyone makes money before the model gets shut down.
ACCESS is different in one specific way that matters for digital health companies. Instead of bolting outcome requirements onto existing fee-for-service billing or creating complex attribution schemes within ACO frameworks, ACCESS creates a standalone reimbursement pathway explicitly designed for technology-enabled longitudinal care. The model pays recurring condition-specific amounts tied to measurable clinical improvements in hypertension, diabetes, chronic pain, and behavioral health conditions. This is not another pilot program asking whether digital tools can theoretically improve outcomes. This is CMS saying they will pay for digital chronic disease management if it demonstrably works.
The timing reflects two converging realities. Medicare beneficiaries increasingly need continuous management for multiple chronic conditions, but fee-for-service mechanisms remain poorly suited for technology-enabled care that does not fit into discrete 15-minute encounters. Existing codes for remote patient monitoring and chronic care management have been narrowly defined and administratively complex, limiting utility for sustained engagement. Digital health companies have spent years trying to wedge their products into billing codes designed for completely different care models, leading to tortured compliance interpretations and perpetual uncertainty about reimbursement sustainability.
ACCESS attempts to solve this by creating payments explicitly intended for digital tools, remote monitoring, app-based interventions, and virtual care teams. The structure aligns payment with sustained clinical improvement rather than specific activities or time thresholds. This is the payment model digital health has been asking for since companies started pitching remote monitoring solutions a decade ago.
The Payment Math That Changes Everything
The economics determine everything else about this model. CMS outlined outcome-aligned payments whose total depends on the proportion of patients achieving guideline-informed targets. Organizations receive approximately $30 for each documented primary care review, a one-time $10 onboarding payment, and a cap around $100 per beneficiary per year. These figures matter because they define which business models are viable.
Compare this to existing reimbursement pathways. National average RPM payments include roughly $48 monthly for treatment management and $43 to $47 monthly for device supply and transmission. That works out to around $546 to $570 annually just for the monitoring components. CCM pays approximately $60 monthly for 20 minutes of care management with an additional $45 for each extra 20-minute increment, reaching $720 annually at baseline. ACCESS payments are substantially lower than either established pathway.
This gap has immediate implications for care model design. A company building a hypertension management service needs to cover costs for patient onboarding, ongoing monitoring, care team time, technology platform, clinical oversight, and administrative overhead while generating enough margin to be worth building. At $100 annually per patient, the unit economics only work if labor costs are minimized through automation and asynchronous engagement. Synchronous video visits, intensive care coordination, or relationship-based coaching models become difficult to sustain without supplementary revenue.
The structure incentivizes specific technical architectures. Automated alerts, standardized protocols, and passive monitoring become more economically viable than personalized care planning. Companies that can identify clinical deterioration through algorithms and route only high-risk patients to human clinicians will have better margins than those requiring regular touchpoints. The payment level effectively selects for lower-touch interventions regardless of what might produce better clinical outcomes.
This creates interesting dynamics around patient selection and enrollment. The model ties payment to proportion of patients achieving clinical targets, so organizations have clear incentives to enroll individuals most likely to improve. Someone with uncontrolled hypertension taking no medications represents both higher potential for measured improvement and higher likelihood of requiring intensive intervention to achieve it. The optimal patient from a financial perspective probably falls somewhere in the middle, sick enough to show meaningful improvement but not so complex that achieving guideline targets becomes difficult. Companies will need to think carefully about target populations and enrollment criteria because the business model only works if enough patients hit clinical thresholds.
Who Wins Under This Structure
