For decades, chronic disease management in Medicare has been hampered by a fee-for-service payment system that rewards volume and activity rather than true clinical improvement. This model created friction, rewarded fragmented care, and failed to adequately support the longitudinal patient journey.
But a seismic shift is coming. The CMS Advancing Chronic Care with Effective, Scalable Solutions (ACCESS) Model is set to transform how healthcare organizations deliver and are reimbursed for continuous chronic care. With the model's first performance period beginning July 1, 2026, ACCESS is CMS’s vehicle for testing a radical question: What if we paid for outcomes instead of activities?
If your organization is committed to modernizing chronic care delivery through digital-first capabilities, understanding the strategic imperatives of ACCESS is crucial.
ACCESS: Paying for Results, Not Effort
The ACCESS Model is an ambitious, 10-year voluntary Medicare initiative designed to create a national payment framework specifically for technology-enabled chronic care delivered outside the clinic. It provides a clear, scalable roadmap for organizations to focus on clinical improvement.
The model focuses on four high-impact clinical tracks that represent a large percentage of Medicare’s chronic disease burden:
- Cardio-Kidney-Metabolic (CKM): Covering conditions like diabetes, chronic kidney disease (CKD), and cardiovascular disease.
- Early CKM: Targeting preventative conditions like hypertension and prediabetes.
- MSK: Focused on chronic musculoskeletal pain.
- Behavioral Health (BH): Targeting anxiety and depression.
Participation requires organizations to be Medicare Part B–enrolled providers or suppliers and demonstrate the ability to deliver technology-enabled chronic care, meaning robust remote monitoring, digital tools, and virtual engagement.
The Core Innovation: Outcome-Aligned Payments (OAPs)
The core innovation lies in the Outcome-Aligned Payments (OAPs), which replace the limitations of fee-for-service. OAPs are issued only when clinical outcomes improve or are controlled, as defined by track-specific metrics (e.g., BP, A1c, or PROMs).
Crucially, no CPT codes determine payment. OAPs are recurring payments—a steady per-patient revenue line—as long as the provider meets outcome targets at the population level. This gives care teams the flexibility to use the specific technologies and care approaches (like RPM, virtual coaching, and education) that best support each patient’s needs.
Key Educational Components of the ACCESS Model
For organizations assessing readiness, the educational value of ACCESS is in its structural shifts regarding patient engagement and collaboration:
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Patient Incentives and Direct Enrollment
ACCESS introduces unprecedented flexibility in how beneficiaries interact with the model:
- Direct Beneficiary Enrollment: Unlike many historical models, patients with Original Medicare can enroll directly with an ACCESS organization or be referred by a provider. This removes the historical dependence on claims-based attribution, giving patients significant choice and making patient outreach and enrollment strategy a core competency for participants.
- Cost-Sharing Waiver Option: To remove a primary financial barrier to chronic care adoption (a challenge often cited in RPM), ACCESS participants have the option to waive beneficiary cost-sharing (deductible and co-pays) that would otherwise apply to the OAPs. This is a critical feature for driving patient adoption and engagement.
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Strengthening Care Coordination
CMS designed the model to integrate, not isolate, technology-enabled care:
- PCP Co-Management Payment: To explicitly encourage collaboration, Primary Care Providers (PCPs) and referring specialists can bill a separate co-management payment (with no beneficiary cost-sharing) for reviewing the ACCESS organization's clinical updates and documenting associated care-coordination actions (e.g., medication adjustments). This ensures the RPM-derived data and clinical updates are integrated back into the patient's holistic care plan.
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Integrating Social Determinants of Health (SDOH)
A key mandate of ACCESS is the focus on health equity and addressing social needs. Participant organizations are required to:
- Conduct Health-Related Social Needs (HRSN) screening using CMS-approved tools.
- Document and track closed-loop referrals to community-based organizations (CBOs).
- Stratify and report outcomes across various demographic and equity categories.
This requirement validates the need for platforms that can seamlessly integrate social needs data with clinical data, transforming chronic disease management into true population health.
The Strategic Path to Success: PatientFirst Pathways
The success of the ACCESS model hinges on the provider's ability to maintain strategic, longitudinal care that spans the entire patient journey. This capability is precisely what HRS supports through its enterprise solution, the PatientFirst Pathways care model.
In December 2025, Health Recovery Solutions (HRS) received the prestigious Frost & Sullivan 2025 North American Customer Value Leadership Recognition for its best practices in technology-enabled longitudinal care models. This recognition is highly applicable to ACCESS because the model's core mandate is to establish a national payment framework for the continuous, outcomes-driven chronic care that HRS specializes in delivering.
Designed specifically for hospitals and health systems seeking to drive care continuity beyond acute settings, PatientFirst Pathways is a comprehensive operational and clinical framework built to handle the continuous flow of care required by ACCESS. It defines a seamless transition across various settings, moving patients from intensive, episodic monitoring to lighter-touch digital tools while Chronic Care Management (CCM) or Principal Care Management (PCM) continues.
This strategic model is designed to support the full care continuum, encompassing not only Remote Patient Monitoring (RPM) but also other necessary services for comprehensive disease management, including:
- Chronic Care Management (CCM)
- Principal Care Management (PCM)
- Transitional Care Management (TCM)
PatientFirst Pathways reinforces the longitudinal approach necessary for outcome-aligned care by specializing in key areas such as Neurology, Urology, Cardiology, Nephrology, Endocrinology, and Bariatrics. By using integrated analytics and EHR workflows, the model supports data-driven care that leads to greater system efficiency and fewer readmissions. Since the ACCESS payment is tied to outcomes, a robust, continuous engagement model that goes beyond short-term monitoring is essential to ensure population-level metrics are met.
HRS: Operational Readiness for Outcomes at Scale
Preparing for a performance model like ACCESS requires more than just technology; it requires proven operational infrastructure and clinical depth. HRS has the operational backbone and experience to support organizations through readiness, implementation, and ongoing outcomes management.
Eliminating the Operational Lift
The biggest challenges in ACCESS are data requirements, interoperability, and operational readiness. HRS addresses these with turnkey solutions:
- EHR Integration: HRS provides out-of-the-box integration with every major EHR platform, ensuring clinical data flows continuously and immediately—a necessity for secure data exchange with referring clinicians.
- Logistics & Support (PatientDirect): HRS owns the complex process of device provisioning, inventory management, and technical support. Through PatientDirect, HRS handles the entire logistics lifecycle—including delivery, patient education, and returns—providing greater control and transparency while removing the operational burden from the care team. This infrastructure is backed by 24/7 live technical support for both patients and clinicians. Furthermore, HRS offers high-touch adoption services, including playbooks, protocol templates, and reimbursement guidance, and can deploy in-home setup services (like HomeDirect) to improve activation and adherence for digitally vulnerable patients. The proven reliability of this support is critical for consistent clinical decision-making.
- Population Health Analytics: Robust analytics are crucial for tracking outcomes for cohorts, which is critical since ACCESS payments are tied to population-level performance. HRS provides organizations with a suite of comprehensive clinical and operational reporting and benchmarking and embeds continuous feedback loops through regular performance reviews and optimization consultations to help clients achieve and sustain outcomes.
Your Next Step: Consulting and Preparing for ACCESS Success
The ACCESS model rewards organizations that are able to leverage digital tools, continuous monitoring, and remote engagement. By utilizing a comprehensive, longitudinal model like PatientFirst Pathways powered by HRS's proven technology and operational history, healthcare organizations are positioned not only to meet CMS requirements but also to lead in the new era of predictable, outcome-aligned care. To fully prepare your organization for the ACCESS model and understand all aspects of the program, HRS has a dedicated team of experts ready to consult and assist you with readiness, implementation, and ongoing outcomes management. Contact HRS today to learn more and begin your strategic path to success.