Medicare’s Access Model Is a Worthy Experiment | American Enterprise Institute
The authority the Affordable Care Act (ACA) conferred on the Center for Medicare and Medicaid Innovation (CMMI) to run novel experiments is arguably too broad and unconstrained. With minimal guardrails, the temptation for both Democratic and Republican administrations is to use CMMI to get around legal impediments to favored policies. But there are also some tests that are worth conducting that might not surface without something like CMMI allowing them to proceed. Such is the case with the Trump administration’s Advancing Chronic Care with Effective, Scalable Solutions (ACCESS) Model. It is a genuine experiment with uncertain but potentially meaningful positive results, and also a design that should allow for objective evaluation.
Chronic diseases are a major factor in Medicare, with 69 percent of the beneficiaries having two or more of the most common conditions. ACCESS, which launched in July, is a ten-year test of technology-assisted approaches to managing the important clinical indicators of the most common of these diseases. The first four conditions targeted are enhanced chronic kidney disease (with a risk of advancement to end-stage renal disease), chronic kidney disease, musculoskeletal pain, and behavior health challenges.
Although many Medicare beneficiaries live for years and sometimes decades with multiple chronic ailments, it is not easy for physicians to manage these conditions well in a fragmented fee-for-service environment. The standard approach is to use office visits to monitor symptoms and adjust treatment plans based on what is discovered. Physicians get paid for the time spent during these visits, but the fees are low. In many cases, a chronic disease might be better managed with near-continuous monitoring of symptom even if done remotely. ACCESS is intended to test whether rapidly advancing and technology-heavy approaches to care management could deliver better results for patients than the traditional model.
A few key ACCESS details will influence how well it works in practice:
- For each of the four chronic conditions that are the initial focus, CMMI has specified a new Outcome-Aligned Payment (OAP) which will go to a provider or supplier eligible to receive funds from Medicare. The amounts are higher at initial enrollment and then drop in follow-on periods when it is presumed a condition has become better managed. Half of the annual OAP amounts paid by Medicare are distributed in monthly installments, with the other half withheld and paid only when certain health status benchmarks are met. The usual Medicare requirement of 20 percent co-insurance charged to the beneficiaries applies but can be waived by the participating companies. As an example, CMMI has set an introductory OAP for chronic kidney disease management at $420, with 80 percent coming from the Medicare program. With half of that amount withheld for a outcome-determined payment, ACCESS participants would get $168 in equal monthly installments over the course of a year for each patient, and then up to another $168 for every patient for which there is sufficient clinical improvement to qualify for a performance bonus. For overall costs, the relevant question is whether the model leads to fewer hospitalizations or other costly interventions which more than offset the added spending associated with OAPs.
- ACCESS’s main innovation is the introduction of beneficiary choice into the selection of non-traditional entities as care managers. Companies were given the opportunity to be listed as eligible ACCESS providers through the Centers for Medicare and Medicaid Services (CMS), which qualifies them to receive payments directly from the program, and also to partner with traditional Medicare-eligible entities such as health systems, primary care clinics, and ACOs. At the program’s launch in July, over 150 companies had been approved as ACCESS participants.
As with most payment tests, there is a concern that ACCESS can be manipulated to drive up total costs. Specifically, the OAPs are intended to reflect the acuity of average patients, but the participating companies might be adept at signing up beneficiaries who are at low risk of experiencing deterioration. Thus, risk selection could once again lead to higher overall Medicare spending rather than lower costs. It is also possible that, in some cases, ACCESS will create a new payment stream for services that would have been provided through the standard model anyway. In other words, the new spending will be paying for care that is built into Medicare’s existing baseline. If that is the case, the health status of ACCESS-affiliated patients may not improve sufficiently to justify the added spending.
Despite the uncertainty around its ultimate results, ACCESS should be given a chance to succeed. After decades of improved treatment of acute conditions, the Medicare population is living longer but with more chronic disease. New technology might improve the management of the symptoms of these conditions. The potential payoff more than justifies the risk of potentially doing no better than the status quo.
