Image by Gerd Altmann from PixabaySeveral dozen companies focused on musculoskeletal care have been approved to participate in a new federal payment model designed to manage chronic conditions outside traditional settings.
While much still needs to be learned in terms of how the model will play out over time, for ambulatory surgery center (ASC) stakeholders, it’s a development worth watching. In the not-too-distant future, it could impact how Medicare patients with chronic pain are treated before they ever reach a surgeon.
The Centers for Medicare & Medicaid Services (CMS) released the list of approved participants for the Advancing Chronic Care with Effective, Scalable Solutions model – or the “ACCESS model” for short – on April 13. More than 150 health care organizations overall have made the cut.
Broadly, the model covers four clinical tracks, making the group of participants fairly diverse. ACCESS currently includes tracks for early cardiokidney-metabolic, cardio-kidney-metabolic, musculoskeletal and behavioral health, with additional tracks and conditions to be considered for future model years. The musculoskeletal track – or the one most relevant to ASCs – targets patients with chronic musculoskeletal pain (generally defined as pain lasting more than three months affecting bones, joints, muscles, or connective tissue).
It measures success through patient-reported outcomes tracking pain intensity, interference and overall function. If participants miss these benchmarks, their payout shrinks.
Of the 150 approved participants, 61 are enrolled in the musculoskeletal track, either exclusively or alongside other tracks.
The roster skews heavily toward digital health and AI-enabled platforms. Pure-play musculoskeletal names include Bold, JOGO Health, TailorCare, RightMove Health, Redefine Healthcare, Livara Health, Plethy and MSK Access, the latter of which is a joint venture between Limber Health and Revel AI. Broader multi-track platforms like CareHarmony, Castlight, GamePlan Medical, Slingshot AI and Somatus Medical Group are also enrolled in musculoskeletal alongside other tracks (Somatus, for instance, is mostly known as a player in the kidney care space).
Who’s not on the list? Specialized orthopedic practices, hospital systems and ASCs.
The musculoskeletal participant mix isn’t entirely surprising. The organizations approved for the musculoskeletal track are mostly virtual-first or technology-led care models, or the kind of companies that have built their businesses managing patients who might otherwise be referred for physical therapy, imaging and surgery.
The ACCESS model gives these companies a direct financial incentive to keep musculoskeletal patients engaged in conservative, preventative care. Participants receive fixed monthly payments for managing enrolled beneficiaries, with full payment contingent on achieving measurable improvements in pain and function.
Critically, the model includes a “Substitute Spend Adjustment” – a payment penalty triggered if enrolled patients receive duplicative services from other Medicare providers for the same condition.
So, for a bit of a thought experiment, let’s take an ACCESS-enrolled Medicare patient managing chronic knee pain through a digital musculoskeletal platform. If that patient is later referred to an orthopedic surgeon and schedules a knee arthroscopy at a local ASC, the ACCESS participant could face a reduced monthly payment because the surgical visit represents a duplicative service.
More than today, these ACCESS participants are incentivized to keep their patients away from surgery.
The model is voluntary and limited to original Medicare beneficiaries. Its 10-year timeline means near-term volume impact on ASCs is likely modest. But again, it’s still worth monitoring.
What’s more, if ACCESS participants demonstrate measurable outcomes – reduced pain, improved function, lower downstream utilization – other payers will notice.
The model is explicitly designed to support adoption by Medicare Advantage, Medicaid and commercial plans, with CMS publishing reference implementation resources to encourage multi-payer alignment. Payers that have promised to align themselves with ACCESS, for example, already include Blue Shield of California, Blue Cross and Blue Shield of Minnesota, CareFirst BlueCross BlueShield, Centene, Cigna, CVS Health, Devoted Health, Humana and UnitedHealthcare, among many others.
The model officially kicks off July 5 and goes until June 30, 2036.
A final interesting note about ACCESS: Most of the initial approved participants have never served Medicare beneficiaries before.
“Most of the organizations have not previously served Medicare beneficiaries and will bring additional technology-supported care options to help people manage chronic conditions like high blood pressure, diabetes, chronic pain and depression,” CMS wrote in an April 13 update.
