Outcome-Aligned Payments Explained

Understanding the new payment approach that rewards results rather than activities.

What Are Outcome-Aligned Payments (OAPs)?

Outcome-Aligned Payments are a new payment approach tested under the ACCESS Model. Instead of paying for specific activities or services, OAPs provide recurring payments for managing a patient's qualifying condition, with full payment tied to achieving measurable health outcomes.

Key Principle: OAPs reward results, not volume—giving care teams flexibility to deliver modern, technology-supported care that drives better patient outcomes.

Fee-for-Service vs. Outcome-Aligned Payments

Traditional Fee-for-Service

•Payment tied to specific activities or devices
•Pays for volume of services delivered
•Prescriptive service requirements
•Activity-based billing codes
•Limited support for technology-enabled care

Outcome-Aligned Payments

✓Payment tied to achieving health outcomes
✓Pays for results achieved
✓Flexibility in care delivery methods
✓Recurring payments for condition management
✓Enables technology-supported care

How OAPs Work

Patient Enrollment

Patient signs up with ACCESS organization directly or via referral from their primary care provider

Baseline Measurement

Organization collects baseline measures (e.g., blood pressure, HbA1c, PHQ-9 score) as benchmarks for tracking improvement

Care Delivery

Organization provides technology-supported care using flexible approaches: telehealth, wearables, coaching apps, lifestyle support, medication management

Outcome Achievement

Organization helps patient achieve defined targets (e.g., 15 mmHg systolic blood pressure reduction, 5-point PHQ-9 improvement)

Payment Determination

CMS determines payment based on overall share of patients meeting their defined outcomes

Payment Structure

Performance-Based Payment

• Payment tied to achieving measurable health outcomes
• Based on overall share of patients meeting targets (not individual patients)
• Compared to minimum threshold that increases each participation year
• Strong overall performance rewarded even if some patients don't meet targets

Continuation Payments

• Most tracks include optional continuation period after initial year
• Reduced payment rate reflects lower resource needs once care is established
• Supports ongoing patient management and maintenance
• MSK track does not include continuation (focused on resolution)

Additional Adjustments

Rural Adjustment: Fixed adjustment applied to rural patients to promote access in underserved areas
Multi-Track Discount: When a patient enrolls in multiple tracks with same organization, CMS applies discount for administrative efficiencies

Example Outcome Targets

Condition	Example Target
Hypertension	Reduce systolic blood pressure by 15 mmHg OR reach control target (<130 mmHg)
Diabetes	Reduce HbA1c by 1 percentage point OR reach control target (<7.5%)
Depression	5-point reduction in PHQ-9 (if baseline ≥10) OR maintain score below 10
Anxiety	4-point reduction in GAD-7 (if baseline ≥10) OR maintain score below 10
Chronic Pain	Demonstrate improvement in pain intensity and function via validated PROM

Cost-Sharing Options

Option A: Waive Cost-Sharing

• Use CMS-sponsored patient incentive safe harbor
• No beneficiary cost-sharing for OAPs
• Must apply uniformly to all beneficiaries

Option B: Collect Cost-Sharing

• Disclose expected payment before enrollment
• Must apply consistently to all patients
• Standard Medicare cost-sharing applies

Note: There is NO cost-sharing for the separate co-management payment billed by PCPs and referring clinicians.