Access, OAPs, and the Illusion of Easy Money: A Strategic Guide for Health Tech Investors and Operators
Abstract
This essay examines the CMS Advancing Chronic Care with Effective, Scalable Solutions model and its Outcome Aligned Payment rates through an investor and operator lens.
Key points:
1. Breakdown of annual allowed amounts across eCKM ($360/$180), CKM ($420/$210), MSK ($180), and BH ($180/$90) tracks and the implications of the 50% withhold structure.
2. Analysis of Clinical Outcome Adjustment and Substitute Spend Adjustment mechanics and their capital intensity implications.
3. Detailed review of measure validity windows, baseline requirements, and FHIR-based reporting infrastructure demands.
4. Strategic positioning guidance for founders and investors considering participation, enablement, or infrastructure plays around the model.
5. Discussion of multi-payer alignment and how technical requirements reshape product architecture and underwriting risk.
Table of Contents
The Payment Is Small, the Risk Is Not
Understanding the Outcome Aligned Payment Mechanics
Clinical Outcome Adjustment and the Fifty Percent Threshold
Substitute Spend and the Shadow P and L
Measure Engineering and Data Plumbing
Track Level Economics: eCKM and CKM
Track Level Economics: Behavioral Health
Track Level Economics: Musculoskeletal
Operational Friction: Reporting Windows and API Reality
Multi Track Discount and Portfolio Strategy
Who Should Play and Who Should Run
Closing Thoughts on Positioning Inside the Innovation Program
The Payment Is Small, the Risk Is Not
The headline numbers look modest enough to dismiss. Three hundred sixty dollars for early cardio kidney metabolic in the initial period. Four hundred twenty for full cardio kidney metabolic. One hundred eighty for musculoskeletal. One hundred eighty for behavioral health with a follow on at ninety. Those are annual allowed amounts per beneficiary, inclusive of Medicare and coinsurance. At first glance this feels like rounding error against total cost of care in any of these populations.
That reaction is precisely where the trap sits.
These payments are not fee for service add ons. They are recurring payments tied explicitly to outcome attainment and subject to both a clinical outcome adjustment and a substitute spend adjustment. Monthly disbursement equals one twelfth of the Medicare portion, but only half of the annual Medicare payment is released prospectively. The other half is withheld and reconciled after the twelve month care period. That single detail changes the entire underwriting logic.
In other words, ACCESS is a small capitation with a delayed earn out. The real margin is not in the three hundred sixty dollars. It is in whether an organization can consistently clear the fifty percent outcome attainment threshold while avoiding substitute spend leakage that drags down the reconciled amount. Capital allocators need to stop thinking about this as a new revenue line. It is a risk bearing micro contract with embedded data and compliance obligations that most operators are not ready for.
Understanding the Outcome Aligned Payment Mechanics
Outcome Aligned Payments are structured around initial and follow on periods. Initial reflects higher resource intensity. Follow on is lower, recognizing that baseline control may already be achieved. For eCKM the drop is from three hundred sixty to one hundred eighty. For CKM it is four hundred twenty to two hundred ten. Behavioral health halves from one hundred eighty to ninety. Musculoskeletal has no follow on period at all.
This tiering alone creates a non trivial intake triage problem. Participants qualify for initial period payment when it is the first time treating the beneficiary in that track within two years and at least one required measure is not at target. That language forces careful intake screening. A beneficiary already at control for all required measures is economically unattractive in the initial period. Conversely, someone far from control carries outcome risk but unlocks higher initial payment. Good luck designing care team incentives around that tension without accidentally engineering adverse selection into your panel.
Monthly payment cadence has improved versus the original quarterly concept from version one of the request for applications. That helps working capital meaningfully. But the fifty percent withhold remains the real capital constraint. A growth stage operator enrolling ten thousand CKM beneficiaries in the initial period effectively front loads only about one hundred sixty eight dollars per member per year in Medicare cash flow, with the rest contingent on year end reconciliation. Scale that to fifty thousand members and the withhold receivable becomes a material balance sheet item with clinical performance covenants attached. Investors modeling this need to treat the reconciled fifty percent as a receivable, not as guaranteed revenue.
Clinical Outcome Adjustment and the Fifty Percent Threshold
