Coverage Gaps ACCESS Aims to Fill: What Traditional Medicare Payment Left Behind

Medicare paid for visits but not for care.

For a long time, Medicare payments have been based on the idea that care happens during visits to the doctor. Payment, documentation, and care delivery all relied on evaluation and management codes, procedures, and encounters.

That structure worked quite well when the healthcare system was mostly about short-term interventions and acute episodes. But the world is very different now.

People with chronic diseases now make up the majority of Medicare recipients. Patients have many conditions that affect each other and change every day. These changes are influenced by factors such as medication adherence, mental health status, functional ability, social circumstances, and access to care between visits. But traditional Medicare payment has stayed tied to one-time visits.

The result is a bigger difference between “what Medicare pays for” and “how care really happens.”

The ACCESS Model—Advancing Chronic Care with Effective, Scalable Solutions—was created to fill those gaps. Instead of adding small fixes to a system based on visits, ACCESS changes what Medicare expects, supports, and rewards in the delivery of chronic care.

The Structural Limits of Traditional Medicare Payment

Traditional Medicare payment didn’t give enough money to or support some important parts of chronic care. These gaps weren’t random; they were the result of a system that was made for encounters, not results.

GAP 1: There is no payment for care between visits.

In the past, when Medicare paid for services, the majority of critical work in chronic care occurred off-clock.

Care teams called patients after their appointments, worked with specialists, looked over lab results, made sure medications were correct, and answered patient questions, all without getting paid. The payment system couldn’t see these activities, but they were important for keeping patients stable.

This made a paradox:  The most beneficial care was free;  The least helpful interactions were often paid for.

ACCESS directly fights this imbalance by saying that “care between visits is not ancillary—it is foundational.”

GAP 2: Not Enough Help for Keeping Patients Engaged

Traditional Medicare thought that patients would take care of themselves between appointments. During visits, education was given, but there wasn’t much infrastructure to help people keep up positive behavior over time.

There was no money to: Keep an eye on trends in adherence.  Spot disengagement early..  Keep up motivation and self-management.

ACCESS fills this gap by tying payment to “ongoing engagement” instead of just one-time instructions. Outreach, monitoring, and follow-up are no longer “extra” parts of care; they are now expected parts.

GAP 3: A Fragmented approach to long-term conditions

In the past, Medicare payments treated conditions and the services that helped them as separate entities. Each visit dealt with a single issue, which was often not connected to the overall plan for care.

This fragmentation caused:  Testing that isn’t needed  Treatment plans that don’t agree  Poor communication between primary and specialty care  Missed chances to deal with the main problems

ACCESS sees chronic care as a “longitudinal responsibility,” which means that different conditions, providers, and treatments need to work together in a single framework.

GAP 4: There is no way to keep track of gradual deterioration.

It is uncommon for chronic decline to happen all at once. Most hospitalizations happen after weeks or months of small changes, like higher blood pressure, less mobility, more glucose variability, or more fatigue.

There was no way for traditional Medicare to pay for:  Find these patterns early.  Take action before things get worse.  Show that things didn’t get worse.

ACCESS clearly says that “visibility between visits is needed for accountability.” Providers need to be able to see what is going on outside of the clinic if they are responsible for outcomes.

GAP 5: Little recognition of care provided by a team

Paying for services Medicare was built around visits to the doctor. Although doctors are still important, chronic care today relies on teams.

Nurses, care coordinators, pharmacists, therapists, and behavioral health professionals all play a role in outcomes, but traditional payment systems didn’t always show that.

ACCESS backs a care model in which:  Teams work at the highest level of their licenses.  Responsibilities are shared fairly.  Doctors are responsible for care instead of doing everything themselves.

This change is necessary for growth and long-term success.

GAP 6: Behavioral health is treated as a separate type of medical care.

Behavioral health has long been one of the most poorly supported parts of Medicare’s chronic care program.

Depression, anxiety, cognitive decline, and social isolation have a direct impact on:  Taking medication as prescribed  Going to therapy  Being reliable when self-monitoring  Long-term results

But traditional payment systems saw behavioral health as separate, which made it challenging to track over time and often poorly integrated.

ACCESS sees behavioral health not as an extra, but as a “multiplier of outcomes.” Ignoring it reduces the effectiveness of all other care efforts.

GAP 7: Outcomes Were Not the Currency of Payment

The most basic difference is that traditional Medicare paid for “what was done” instead of “what changed.”

Documentation that was focused on:  Services provided Time spent Codes sent

It didn’t often catch:  Paths to improvement Stabilization over time Avoided use continued engagement

ACCESS makes it clear that outcomes are no longer optional; they are the basis for accountability.

How ACCESS Addresses These Coverage Gaps

There isn’t just one program called the ACCESS Model. It is a “reorientation of Medicare’s expectations” for long-term care.

From Encounters to Continuity

ACCESS changes episodic accountability into long-term responsibility. Providers are expected to record how well patients do over time, not just write down their visits.

From Action to Results

Payment is based on more than just volume; it also takes into account improvement, stability, and prevention.

From Gaps in Visibility to Ongoing Insight

Remote monitoring, engagement signals, and longitudinal analytics become necessary parts of the infrastructure rather than just nice-to-have tools.

From care that focuses on the doctor to care that is based on the team,

ACCESS makes the role of multidisciplinary team’s official by using technology and coordinating workflows.

ACCESS transforms multidisciplinary teams from fragmented to cohesive.

CCM, PCM, RPM, and APCM are no longer just separate projects. ACCESS tells them how to work together.

What This Means for Practices

While ACCESS sets a higher standard, it also creates opportunities.

Adaptable practices can:

• Cut down on unnecessary use.
• Make the patient experience better.
• Make revenue more stable with predictable care models.
• Get ready for risk-bearing arrangements.

Practices that only use visit-based workflows will have more and more problems with the relationship between effort, outcomes, and payment.

ACCESS Is Not Filling Gaps—It’s Redefining the Floor

The most important thing to remember is that ACCESS doesn’t just fix holes in Medicare payments. It changes the meaning of “adequate” chronic care.

Providers no longer ask, “Which codes can we bill?”

“Can we show that we are getting better over time?”

ACCESS makes it clear that “Medicare’s future is continuous, coordinated, and outcome-driven.”

Conclusion: Why the Gaps Can’t Be Ignored Anymore

Traditional Medicare payment left out the things that make chronic care work: engagement, coordination, monitoring, behavioral insight, and long-term accountability.

ACCESS came about because those gaps were too big to ignore.

ACCESS is a model for what modern chronic care should look like and what payment should support as Medicare moves toward value-based and outcome-aligned models.

Practices that proactively address these gaps will not only adhere to ACCESS.

They will set the standard for the next era of chronic care.

As Medicare moves toward continuous, outcome-based care, it will only work if the right operational foundation is in place. HealthArc is made to assist with this change by helping practices address the shortcomings of traditional payment models through continuous monitoring, organized communication, adaptable care plans, and processes focused on results. HealthArc helps practices follow the ACCESS Model by supporting long-term care across CCM, RPM, AWVs, behavioral health, and team-based coordination. This means that policy expectations become real-world care delivery that lasts.

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