Chasing the ACCESS Opportunity: Why Smart Money Should Follow CMS Into Primary Care Transformation

DISCLAIMER: The views and opinions expressed in this essay are solely my own and do not reflect the views, opinions, or positions of my employer, Datavant, or any of its affiliates.

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ABSTRACT

CMS has launched ACCESS (Accountable Care and Coverage for the Equity, Sustainability, and Social Determinants), a multi-domain innovation model that represents one of the most significant expansions of value-based care infrastructure in recent memory. The program targets four initial domains (diabetes, maternal health, behavioral health, and musculoskeletal care) with specific attribution methodologies, payment mechanics, and population health requirements that create distinct investment opportunities for digital health companies. This analysis examines the total addressable market for each domain, the structural advantages that position certain business models for success, and the specific capabilities required to capture value under the program’s payment framework. Key findings suggest that the behavioral health domain presents the largest immediate TAM at approximately 8.2 billion dollars annually, while maternal health offers the highest margin potential due to episode-based payment structures. Companies that can demonstrate both cost reduction and quality improvement across attributed populations while managing downside risk will be best positioned to scale through ACCESS participation.

TABLE OF CONTENTS

Understanding the ACCESS Framework and Why It Matters Now

Domain One: Diabetes Care and the Glucose Monitoring Gold Rush

Domain Two: Maternal Health and the Episode Payment Playbook

Domain Three: Behavioral Health Integration and the Coordination Premium

Domain Four: Musculoskeletal Care and the Physical Therapy Paradox

Cross-Cutting Themes and Investment Filters

What This Means for Early Stage Investors

Understanding the ACCESS Framework and Why It Matters Now

The Center for Medicare and Medicaid Innovation has a mixed track record. For every successful program like the Medicare Shared Savings Program that has demonstrated genuine cost savings and quality improvements, there are multiple initiatives that fizzled out after burning through hundreds of millions in demonstration funding. So when CMMI announces yet another alphabet soup program, the rational response from most health tech investors is to file it away in the “wait and see” category and go back to evaluating Series A pitch decks. But ACCESS is different in ways that matter for early stage investment decisions happening right now in late 2024 and early 2025.

The program launched with four specific clinical domains rather than the usual broad population health mandate. This specificity creates clearer product-market fit signals for startups. Instead of building generic care coordination platforms that try to be everything to everyone, companies can focus on narrow clinical use cases with well-defined success metrics. The four initial domains are diabetes, maternal health, behavioral health, and musculoskeletal conditions. Each comes with its own attribution logic, payment methodology, and quality measurement framework. This isn’t academic. These structural details determine which business models can actually make money under the program.

Attribution matters because it defines who gets credit for outcomes. In the diabetes domain, CMS is using a claims-based algorithm that looks at HbA1c testing patterns and diagnosis codes to identify attributed beneficiaries. This means companies need claims data infrastructure and the ability to work with payers on attribution lists. It also means the TAM is somewhat constrained by the ability to accurately identify and engage attributed members. Compare this to the maternal health domain where attribution is essentially automatic for any pregnant beneficiary who receives prenatal care from a participating provider. The ease of attribution in maternal health creates a larger addressable population for intervention.

Payment mechanics drive unit economics. ACCESS uses a combination of per-member-per-month care coordination fees and performance-based shared savings with downside risk in later years. The care coordination fees range from thirty to seventy five dollars per member per month depending on the domain and the level of services provided. This creates a baseline revenue stream that can cover the cost of digital intervention while the shared savings component provides upside if the company actually moves the needle on cost and quality. The downside risk component starting in year three is what separates the wheat from the chaff. Companies that are just providing patient engagement apps without real clinical impact will get destroyed when they have to write checks back to CMS for not hitting savings targets.

The timing of ACCESS is particularly relevant because it intersects with several other structural shifts in healthcare payment. Medicare Advantage plans are under increasing pressure to demonstrate value as the payment benchmarks get squeezed. Commercial payers are watching CMS innovation models more closely than ever because they’re running out of their own ideas for payment reform. If ACCESS shows meaningful results in any of these four domains, there will be rapid diffusion into MA and commercial contracts. This means companies that build for ACCESS requirements today are actually building for a much larger market that opens up in two to four years.

Domain One: Diabetes Care and the Glucose Monitoring Gold Rush