If you're building in digital health, you've heard some version of this before: "Great product. Impressive clinical validation. But who's actually going to pay for it?"

It's the question that kills more promising companies than bad technology ever has. Not because the innovation isn't real. Not because outcomes don't improve. But because the path from clinical value to revenue has always been murky at best.

The Problem We've All Been Fighting

You've built an RPM platform. Your AI predicts diabetic complications. Your digital therapeutic reduces anxiety scores by 40%. The clinical validation is solid.

But here's the problem: providers have to pay you out of their own budget.

There's no CPT code that reimburses them for your continuous monitoring. The value you create (fewer hospitalizations, better HbA1c control) doesn't show up on their P&L. It might appear in some ACO's shared savings calculation two years later, but the CFO needs to justify the expense now.

So you're stuck. The ROI is real but soft. The attribution is messy. And providers keep saying "we love it, but we can't afford it."

Why Previous Value-Based Care Programs Didn't Help

Value-based care isn't new. ACOs, bundled payments, MIPS. These programs have existed for years. But they've been notoriously hard for digital health companies to penetrate because the outcome measures were broad and vague.

"Reduce total cost of care." "Improve quality scores." "Enhance patient experience."

How do you build a product roadmap around that? Which specific data points matter? What's the threshold for success? Most VBC contracts left technology vendors guessing, and providers struggling to operationalize digital tools when they couldn't clearly tie them to reimbursement.

What Changed: ACCESS and the Urgency Behind It

Here's what makes this moment different: providers are out of runway.

Government spending cuts have hit healthcare facilities hard. Clinics, hospitals, and medical practices that relied on traditional Medicare reimbursement are facing closure. Without new revenue pathways, they can't sustain operations.

Digital health products that once seemed like "nice to have" innovations are now potential lifelines, but only if there's a clear path to reimbursement that justifies the investment.

In December 2025, the Centers for Medicare & Medicaid Services announced the Advancing Chronic Care with Effective, Scalable Solutions (ACCESS) model: a 10-year program that pays providers specific, recurring payments for achieving specific, measurable chronic care outcomes. Starting July 5, 2026, Medicare will reimburse for managing hypertension, diabetes, chronic kidney disease, depression, and chronic pain.

But here's the critical piece: proving outcomes requires reporting infrastructure.

The ACCESS Payment Model: Show Your Work or Lose $750K

Let's cut to the financial mechanics:

• 50% of the annual payment arrives quarterly (predictable cash flow)

• The other 50% is withheld until semi-annual reconciliation

• If fewer than 50% of patients hit their clinical targets, CMS claws back up to 50% of the withheld payment

• If more than 10% of patients receive duplicative services elsewhere, providers lose another 25%

A provider managing 1,000 Medicare beneficiaries could see $2-3 million in annual ACCESS payments, but lose $750K to $1.5M if they can't report outcomes properly.

This creates an urgent buyer: Providers facing budget cuts and potential closure who now have ACCESS reimbursement available, but need technology partners who can help them enroll patients, track outcomes, and capture the full payment.

The specific metrics CMS is paying for:

• Blood pressure: <130/80 mmHg or 10 mmHg reduction

• Diabetes: HbA1c improvement or control

• Kidney disease: eGFR and uACR tracking

• Depression/Anxiety: 50% improvement in PHQ-9 or GAD-7 scores

• Chronic pain: Measurable improvement in pain and function

For the first time, you know exactly what to build toward.

But let's be honest about something Christina Farr's (Second Opinion) article pointed out: "This program is going to require marketing to Medicare patients. There are high costs associated with patient acquisition, particularly for this population."

This isn't turnkey. Whether you're positioning as a technology vendor to provider organizations OR considering direct participation as an ACCESS organization yourself, there's real lift associated with enrollment, outreach, and ongoing engagement. As Second Opinion noted, "the clearest target population here is rising-risk patients that are hiding in plain sight."

The companies that will succeed aren't the ones with the flashiest technology. They're the ones that can handle the full patient journey: enrollment, engagement, tracking, and reporting.

With that reality in mind, here are three ways to position your product:

Three Ways to Enhance Your Product and Unlock ACCESS Revenue

Opportunity #1: Add an OAP Dashboard Module

The Gap: Providers in the cardio-kidney-metabolic tracks need continuous biometric data but have no infrastructure to track progress against specific thresholds in real-time.

ACCESS-Ready: If you're in RPM, remote monitoring, or chronic disease management, build a module that:

• Ingests data from connected devices (BP cuffs, scales, CGMs)

• Shows % of panel currently at target vs. trending off-target for each metric

• Sends automated alerts when a patient is at risk of missing their 12-month target

This is exactly what AI-powered RPM systems like KMS Technology have done. They don't just collect ECG, blood pressure, or SpO2 data, they contextualize it against the specific ACCESS thresholds. When a patient's blood pressure readings suggest they'll miss the 130/80 target at their 12-month assessment, the system flags it and triggers a clinical workflow before reconciliation happens.

Revenue Unlock: Sell this as "reconciliation insurance." Your product isn't just monitoring. It's protecting 50% of their withheld payment. A provider with 800 enrolled patients losing 15% to missed targets is leaving $180K on the table. Your $40K/year platform just became an obvious buy.

Opportunity #2: Build a Substitute Spend Prevention Module

The Gap: The substitute spend threshold requires that no more than 10% of a provider's panel receives duplicative services (like a diabetes patient getting a duplicate HbA1c test from an outside endocrinologist). Exceeding this threshold triggers a 25% penalty on the withheld payment. Most practices have no way to monitor this.

ACCESS-Ready: If you're in care transitions, hospital-at-home, post-acute, or care coordination, add functionality that:

• Connects to Health Information Exchanges (HIEs) to track external utilization

• Flags in real-time when a patient seeks care outside the ACCESS network

• Triggers immediate care team follow-up to prevent duplicate services

The sweet spot here is transition of care. Consider how PointClickCare's "Reason for Transfer" AI model extracts clinical context from skilled nursing facility notes and delivers it to ED teams. This prevents the duplicate workups and tests that occur when critical information is siloed during handoffs. If a patient with chronic kidney disease is transferred from a SNF to the ED with Acute Kidney Injury or fluid overload, having that context immediately available prevents duplicate labs and imaging that would trigger the substitute spend penalty.

Similarly, a company like Dispatch.care, which currently focuses on acute care patient communication, could pivot to add a transition-of-care reporting module. Imagine tracking which patients triggered readmissions or ER visits post-discharge and automatically documenting the interventions that prevented duplicative care—turning their bedside communication data into reportable metrics for substitute spend avoidance.

Casera already does this by turning alerts into action through real-time post-acute coordination. By reducing length of stay and cutting avoidable days, they ensure patients don't slip through the cracks and end up seeking duplicative care elsewhere—exactly what ACCESS participants need to avoid the 25% penalty.

Revenue Unlock: Position this as "substitute spend protection." For a 1,000-patient panel, preventing the 25% penalty saves ~$375K annually. Your integration becomes a must-have, not a nice-to-have.

Opportunity #3: Create a PROM Compliance + Medication Optimization Engine

The Gap: Behavioral health and musculoskeletal tracks rely entirely on Patient-Reported Outcome Measures (PHQ-9, GAD-7, pain scales). But most providers struggle with PROM compliance. Patients forget, responses are on paper, and there's no workflow to act on scores. Meanwhile, achieving biometric targets in the CKM tracks often requires medication optimization that most practices can't provide.

ACCESS-Ready: If you're in telehealth, digital therapeutics, or clinical workflow tools, build:

• Automated PROM delivery via SMS/app with completion reminders

• Clinical escalation protocols (e.g., "PHQ-9 >15 alerts clinician within 24 hours")

• On-demand clinical pharmacist access for medication reviews and optimization

ThoroughCare has built this into a single connected platform for Chronic Care Management, RPM, and Behavioral Health Integration. Their analytics highlight care gaps and track PROM scores aligned with reconciliation requirements, giving providers real-time visibility into which patients are on track and which need intervention.

For the medication management piece, platforms like AidRx.app connect organizations with on-demand remote clinical pharmacists who conduct comprehensive medication reviews and resolve Medication Therapy Problems. When a hypertension patient isn't hitting their blood pressure target, an AidRx pharmacist can adjust medications and document the intervention, creating the reportable evidence that the organization took action to achieve the OAP outcome.

Revenue Unlock: Providers literally cannot participate in the behavioral health track without reliable PROM collection. Your platform becomes the enabling infrastructure. And for CKM, medication management directly drives the HbA1c and blood pressure improvements that unlock payment.

Companies that combine AI with human touchpoints, like AidRx with their on-demand pharmacists, have an advantage here. They can handle both the enrollment conversation AND the outcome delivery. A pharmacist reaching out to discuss medication optimization can also enroll the patient, explain the program, and create the ongoing relationship that drives adherence to the metrics over the 12-month performance period.

Your 60-Day Action Plan

The first cohort application deadline is April 1, 2026. Less than two months away. Here's what to consider:

1. Map to ACCESS Metrics Audit your current product outputs against the four clinical tracks. Can you automatically report baseline measurements and 12-month outcomes for the specific metrics CMS is paying for? If not, that's sprint zero.

2. Build FHIR APIs Now ACCESS requires data submission via FHIR-based APIs (45 CFR § 170.315(g)(10)). Manual CSV exports will kill adoption. API-first architecture is table stakes.

3. Reframe Your Sales Pitch Stop leading with "better outcomes." Lead with "protect your withheld payment." Show the financial model: "If 10% of your panel misses targets, you lose $X. Our alerts keep partners above 85% attainment."

4. Partner with Provider Organizations You don't need to become an ACCESS participant yourself. Position as the vendor that enables participation for primary care networks, ACOs, or specialty groups who lack digital infrastructure.

5. Use Urgency Organizations scrambling to meet the April 1 deadline need "ACCESS-ready" solutions now. If you can demonstrate alignment with the reporting requirements, you're solving an immediate pain point.

The Bottom Line

CMS is paying providers for chronic care outcomes using specific, measurable metrics. But those payments are conditional on proof of performance.

Your product is either part of the reporting infrastructure that unlocks $2-3M in ACCESS payments, or you're an expense they can't justify.

The opportunity isn't just to sell your product. It's to become the layer that makes ACCESS participation feasible.

Build the dashboard. Automate the alerts. Generate the FHIR submissions. Help providers prove they delivered outcomes.

That's the pathway to revenue.

The ACCESS application window closes April 1, 2026. If your product touches chronic disease management, now is the time to position it as ACCESS-aligned reporting infrastructure.