CMS ACCESS Model’s Substitute Service Adjustment: Managing the “First-Step” Dilemma
How CMS defines duplicate services creates complexity, could foster friction, and is meant to drive true value-based care delivery
This is Part 6 of a 12-part Techy Surgeon operator series on the CMS ACCESS Model. To navigate this series start to finish, check the archives if you’re a subscriber or check out this page on Techy Policy.
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The Centers for Medicare & Medicaid Services (CMS) Advancing Chronic Care with Effective, Scalable Solutions (ACCESS) model introduces an innovative payment system for digital chronic care – but with a twist. At its core is the Substitute Spend Adjustment, a mechanism that adjusts payments if patients receive certain “substitute” services outside the ACCESS program. This policy is meant to prevent duplicative care but creates a new operational and relationship challenge for digital health organizations. Below, we explore how the substitute adjustment works, why it targets initial services, and how it’s reshaping relationships between tech-enabled providers and traditional brick-and-mortar clinicians.
How the Substitute Spend Adjustment Works
Under ACCESS, participants receive an Outcome-Aligned Payment (OAP) for a year of managing a patient’s chronic condition. Full payment of that OAP isn’t guaranteed: it hinges partly on keeping patients’ care in-house. The Substitute Spend Adjustment reduces a participant’s OAP if patients obtain specified services elsewhere for the same condition[1][2]. CMS calculates each organization’s Substitute Spend Rate (SSR) – the percentage of their patients who did not receive any listed substitute service from other Medicare providers[3]. To earn 100% of the OAP, an ACCESS participant must meet a benchmark SSR (90% in the first year)[4]. In practice, this means at least 90% of patients should avoid outside “duplicate” services. If the SSR falls below 90%, payment is cut proportionally. For example, if only 80% of patients stayed within the program (SSR = 80%), the participant would receive ~89% of their full OAP (80/90 ≈ 0.89), amounting to an 11% reduction[5]. CMS caps this penalty at 25% of the OAP[6] to limit financial risk, but a hit of up to one-quarter of revenue is still substantial.
Importantly, patients remain free to see other providers – those external services will be paid by Medicare as usual[7]. The onus is on ACCESS participants to coordinate care so that “duplicate” outside services aren’t needed. CMS supports this by giving participants access to real-time claims data (Medicare A, B, D) for their patients[8]. In short, the substitute adjustment is a carrot-and-stick approach: a carrot for comprehensive care (full payment if you cover all needs internally) and a stick for duplicative spending (reduced payment if patients step outside for listed services[9]).
Below paid subscribers get a deeper dive on the substitute spend list, downloadable guide and full ACCESS operator toolkit: deep dives + infographics + downloadable guides, plus full archive access, monthly AMA, interview transcripts, and TechyPolicy.com downloads. In addition a link to a shared NotebookLM resource to “chat” with the RFA and generate additional resources is available for paid subscribers.
