CMS’ Advancing Chronic Care with Effective, Scalable Solutions model launched July 5, testing whether paying organizations for outcomes — rather than specific services — can expand access to technology-supported chronic care.
Behavioral health is one of four clinical tracks, alongside musculoskeletal pain and two cardio-kidney-metabolic tracks split by disease stage, putting depression and anxiety management on equal footing with physical chronic conditions in a first-of-its-kind national payment test.
“The biggest shift we’re seeing [in behavioral health] is this movement toward whole health and truly integrated care models,” said Anh Kremer, chief strategy and development officer at Sagent Behavioral Health in New Brighton, Minn. “With this administration, we’re seeing at least some federal focus on coordination between physical health, behavioral health and social determinants of health.”
The model will run for 10 years through June 2036, with CMS accepting applications on a rolling basis through 2033. Participating organizations will receive recurring “outcome-aligned payments” for managing patients’ qualifying conditions, with full payment tied to hitting measurable health targets rather than logging specific billable activities.
For behavioral health, that means tracking symptom improvement using the “patient health questionnaire-9” scale and the “generalized anxiety disorder-7” scale, along with an end-of-period “patient global impression of change” score. A functional outcome measure, the World Health Organization’s Disability Assessment Schedule 2.0, is optional to report during the initial period, which runs through the end of 2027.
CMS’ annual payment per beneficiary guidance is $180 for the initial period of care and $90 for an optional follow-on period, which include both the Medicare-paid portion and beneficiary coinsurance. That’s less than half the cardio-kidney-metabolic track’s $420 and $210, respectively, and on par with the musculoskeletal track’s $180, which does not offer a follow-on period.
Those allowed amounts aren’t fully guaranteed, either. CMS pays organizations monthly, but caps monthly payments at half the Medicare-paid portion of the annual allowed amount; the remaining half is withheld and reconciled until the 12-month care period ends and is only released in full if the organization clears two reconciliation hurdles.
One is a clinical outcome adjustment tied to the outcome attainment threshold, set at 50% for this effective period, meaning at least half of an organization’s aligned beneficiaries must hit their symptom-improvement targets to avoid a payment cut. The other is a substitute spend adjustment, which docks payment if beneficiaries rack up spending on defined “substitute” services from other Medicaid providers, including psychiatric diagnostic evaluations and collaborative care management codes, above a 90% threshold during their ACCESS care period.
That framing landed with Ms. Kremer when CMS first unveiled the model. “I was excited when CMS revealed the ACCESS model earlier this year. I thought it was a significant step forward in aligning incentives between primary and behavioral health,” she said. “Unfortunately, when the actual reimbursement codes came out, I was disappointed. The economics just don’t work. We’re not there yet in figuring out how to make this viable.”
Part of the strain is structural. The model asks participants to give up standard Medicare fee-for-service billing for aligned beneficiaries entirely; only ACCESS-specific codes can be billed during an active care period.
CMS has framed the model as a vehicle for whole-person care, allowing referring clinicians to bill a separate co-management code — worth about $30 per service, capped around $100 per beneficiary per track per year — for coordinating with ACCESS organizations. But for behavioral health organizations already running lean, that combined revenue is a modest return for taking on full accountability for a patient’s outcomes.
CMS has said it will revisit measures and targets as model data comes in, and the agency’s current guidance covers only the period through December 2027.
“There are a lot of organizations that would love to implement a whole-person care approach,” Ms. Kremer said, “But we really need that reimbursement to support that kind of investment.”
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