The federal government is in full experimentation mode when it comes to payments for managing chronic care. This year, the CMS Innovation Center (CMMI) announced  ACCESS, which stands for Advancing Chronic Care with Effective, Scalable Solutions, a 10-year Medicare model that will reimburse participating chronic disease management programs based on clinical outcomes. 

The model is getting rolled out first in Medicare, which provides healthcare to millions of seniors. But Second Opinion is convinced, after talking to more than a dozen experts, that there’s a big opportunity in Medicaid. 

“The high-level concept of increasingly paying for outcomes, as opposed to volume, is really exciting, and warrants being tested across a range of populations,” Dr. William Gordon, the senior Advisor at Manatt Health and a former CMMI policy official, told us. 

The model is, at its core, a departure from how traditional Medicare is reimbursed. Payers, providers, and patients will wait to see whether an outcomes-based approach improves care long term and lowers costs. Because of the way the payment model is structured, the model heavily favors companies that leverage AI versus solely relying on human providers. 

CMMI didn’t comment directly on expansion plans in Medicaid, but we did discuss the concept with senior officials. 

“Ultimately, success means millions of beneficiaries gaining access to new, affordable care options that help them better manage — and even prevent — chronic disease, while bending the cost curve for taxpayers,” said Abe Sutton, the director of CMMI. He adds that the team has “set an ambitious goal for participation” to ensure outcome measurements are robust. 

Despite some concerns about the pricing being on the low end of what the industry expected, over 150 have already raised their hands. 

Given the need to support Medicaid beneficiaries with chronic conditions – especially in light of looming cuts – we asked the question: 

Could similar state-led value-based models for low-income Americans fill necessary gaps, or is another approach required altogether? And if so, how?

Medicaid is the largest single source of health coverage in the country, providing coverage to about one in five Americans. With proposed cuts, seven and a half million people are expected to be newly uninsured by 2034 due to new work requirements for state Medicaid programs, according to the Kaiser Family Foundation’s report. 

Medicaid states are already under tremendous cost pressure, which is where an ACCESS-like model that can decrease spending has potential. 

Gordon, the former CMMI official, described a plausible future where state Medicaid agencies could stand up their own ACCESS-like models that are helpful for their own goals and their own populations. The states don’t need CMS to do that, he explained, and could also focus across chronic conditions but with their own unique measures and structures. 

Patrick Sheehan, vice president of value-based care at Withings Health Solutions, an ACCESS participant, added that because ACCESS applies to the dual-eligible beneficiaries of Medicaid and Medicare, states could use the Medicaid patient data to understand how the model could apply more broadly. 

ACCESS participant Pair Team, the sponsor of this piece, is also bullish on the model’s potential expansion into Medicaid. The company’s platform addresses systemic barriers to care for Medicare and Medicaid patients with “Flora,” a 24/7 AI-enabled health coach and advocate that helps patients improve their chronic disease control and navigate social supports, such as shelter and food access. Nate Favini, the chief medical officer at Pair Team, calls the model an “AI-led safety net” and believes it can do so much more for people who rely on the safety net than the current system, “at a fraction of the cost.” 

Assuming a model like this one could make social care the new “front door,” Favini described a process to reorganize the healthcare system around an “AI orchestration layer” to expand needed care to millions. 

Pair Team’s executives said they’ve already started to have conversations with Medicaid managed care plans about what an agentic-first service could look like. 

The company’s cofounder and CEO, Neil Batlivala, is actively talking to state health departments and Medicaid directors. “We are convening state Medicaid Directors, managed care executives and providers to accelerate adoption of the ACCESS model in a way that's aligned with [CMMI],” he says. “We want to bring this into managed care, which includes Medicaid-managed care.”

One area of enormous need is in maternal health. Research suggests that cuts to Medicaid could increase maternal mortality, according to the Commonwealth Fund. The situation is urgent given that Medicaid covers 40% of U.S. births.

Dr. Gordon says an ACCESS-like model could address gaps in care for pregnant women on Medicaid. For example, digital tools can monitor women for diabetes and hypertension following birth. These conditions require very close monitoring, and patients may prefer to select between multiple options, whether tailored towards lifestyle, medications or other ways to improve their care.  

Research has suggested that continuous monitoring for hypertension postpartum could reduce racial inequities in maternal outcomes, but models have so far not been affordable or sustainable. 

A key barrier to these models’ widespread implementation and adoption is related to third-party reimbursement, one report found via AJOG Global Reports. 

For that reason, several of the experts cited in this piece felt that the ACCESS Model is well poised to support pregnant and postpartum mothers. Another benefit would be the potential flexibility around how patients receive treatment and care. Many patients on Medicaid do not get adequately monitored because they lack the paid time off to go to their obstetrician or midwife, or they do not have childcare for their existing children. Remote options, including AI-based coaching and devices to monitor patients from home, could fill in at least some of that gap in care. 

Above all, ACCESS could help shape the future of tech-driven chronic care management. There’s also a consumer aspect to it, because unlike other models, the ACCESS model doesn’t require a clinical referral. 

“The potential for technology to improve healthcare outcomes and affordability has never been greater,” Jacob Shiff, the Chief AI & Technology Officer at the CMS Innovation Center, told us. 

For Sheehan of Withings Health Solutions, the model is about asking: What is the new layer of care? Several of the experts referred to this layer as a “front door” of sorts. And yet, how this all plays out in practice is still an open question. 

“What are we to the patient? We don't really know yet,” he said. “We're trying to figure out, are we the coach? Are we the extended pharmacist to the patient?” 

For Alex Vannoni, the head of healthcare product at WHOOP, a wearable healthtech company and ACCESS participant, models such as this one can validate that continuous monitoring and coaching are not just consumer tools. They can prove that consumer wearables can become vital components of chronic care management, and start to find reimbursement opportunities outside of cash pay. 

The big opportunity involves tying “data and insights with clinical workflows,” to help providers take action, he said. 

Tom Pickett, the CEO of Headspace, another ACCESS participant, says the model could also support broader access to tech-enabled services in Medicaid and beyond, including mental health tools. For many digital health companies, it’s an opportunity to expand their services beyond the commercial market. 

“At the end of the day, if we can show this model improves access and outcomes for more people, that’s a win not just for us,” he said. “But for the entire health care system.”