Readers Write: Medicare Goes All In on Value-Based Care

Medicare Goes All In on Value-Based Care
By Eugene Gonsiorek, PhD

Eugene Gonsiorek, PhD is VP of clinical regulatory standards for PointClickCare.

If there were any doubts about Medicare’s commitment to value-based care, there shouldn’t be any longer.

Abandoning its former model of rolling out value-based care (VBC) programs one at a time, the Centers for Medicare and Medicaid Services (CMS) between March and December 2025 announced nine new or proposed programs and modifications to five existing programs – an unprecedented pace.

The rush of new programs and the concentrated timing is CMS announcing it is aligning Medicare around VBC to a greater degree than ever before. This is good news for organizations that have been working toward this end and a prompt for those who haven’t made as much progress.

The New Medicare Programs

Let’s take a closer look at the new and proposed programs. 

• ACCESS (Advancing Chronic Care with Effective, Scalable Solutions). A voluntary, 10-year model testing outcome-aligned payments for measurable clinical improvements using technology-supported care for chronic conditions such as hypertension, diabetes, musculoskeletal pain, and behavioral health.
• WISeR (Wasteful and Inappropriate Service Reduction). Launched in mid-2025, this model tests ways to reduce unnecessary services and accelerate prior authorization while safeguarding patients and taxpayers against low-value care.
• GUARD (Global/Universal Accountability in Drug Pricing) and GLOBE (Global Outcomes in Benchmarking and Equity). Proposed mandatory models that aim to test international benchmark-based adjustments to Medicare Part D and Part B drug rebate and pricing systems to help address high drug costs.
• Ambulatory Specialty Model (ASM). Finalized as a mandatory model beginning in 2027 that holds certain specialists accountable for quality, cost, and care coordination outcomes.
• LEAD (Long-term Enhanced ACO Design). Announced as the next generation of accountable care organization models, a 10-year design intended to better support small, independent, and rural providers following ACO REACH (Accountable Care Organization Realizing Equity, Access, and Community Health).
• BALANCE (Better Approaches to Lifestyle & Nutrition). Announced alongside GUARD and GLOBE, this voluntary model is intended to align manufacturers, state Medicaid agencies, and Part D plans to improve metabolic health through GLP-1 access plus lifestyle support, with testing concluded by 2031.

Across these models, several common design features stand out. Time horizons are longer, often extending eight to 10 years. Payment is increasingly tied to measurable outcomes rather than process compliance. Accountability extends beyond primary care into specialty care and pharmaceuticals. In select areas, CMS is requiring mandatory participation to achieve broad system impact.

The ACCESS model illustrates how CMS expectations are evolving. A voluntary 10-year initiative, ACCESS ties payment to demonstrable improvement in chronic conditions such as hypertension, diabetes, musculoskeletal pain, and behavioral health. The focus is no longer service volume or short-term utilization metrics, but sustained clinical outcomes.

Similarly, the WISeR model reframes inappropriate utilization as both a quality failure and a fiscal risk. By targeting low-value services and streamlining prior authorization, WISeR signals CMS’s growing willingness to intervene earlier in care decisions. The goal is not simply to manage spending after it occurs, but to prevent waste before it happens.

Together, these models reflect a clear shift from utilization-based proxies toward explicit accountability for results.

Specialty Care and Pharmaceuticals Move to the Center

Perhaps the clearest departure from earlier value-based care efforts is CMS’s expansion of accountability into specialty care and drug pricing, areas historically insulated from performance-based payment.

The finalized ASM, set to begin in 2027, makes participation mandatory for selected specialists and holds them accountable for quality, total cost of care, and care coordination. This challenges the long-held assumption that VBC is fundamentally a primary care endeavor. It also elevates downstream utilization, including post-acute care, from a secondary concern to a central performance variable.

At the same time, the proposed GUARD and GLOBE models are CMS’s most direct effort to apply value-based principles to pharmaceutical spending. By testing international benchmarking approaches in Medicare Parts B and D, CMS is extending accountability into pricing structures that have traditionally been governed by statute rather than performance expectations.

Long-Term Accountable Care and Prevention as Structural Bets

The LEAD model underscores CMS’s recognition that accountable care requires stability, not churn. By extending participation horizons to 10 years and focusing on small, independent, and rural providers, LEAD acknowledges that organizational transformation and sustained downside risk cannot be achieved on short timelines.

In parallel, the BALANCE model reflects CMS’s growing emphasis on prevention and upstream investment. By aligning manufacturers, state Medicaid agencies, and Part D plans around GLP-1 access combined with lifestyle and nutrition support, BALANCE tests whether earlier intervention in metabolic disease can produce durable improvements in outcomes and spending. By pairing pharmaceutical access with behavioral support, CMS is testing integrated solutions rather than isolated interventions.

The Effects on Patients and Providers

These models collectively raise the bar for providers. Financial accountability is more robust. Timelines are longer. Expectations for care coordination and performance improvement are higher. Independent practices, rural providers, and specialists, groups historically less exposed to mandatory value-based arrangements, are now central to CMS’s policy design.

For patients, CMS’s stated objectives are clear: earlier intervention, fewer unnecessary services, better chronic disease control, and lower drug costs. Whether these outcomes are realized will depend less on policy intent than on execution, particularly provider engagement and the ability to manage care across settings.

From Experimentation to System Design

Taken together, the new model announcements signal that CMS is moving beyond experimentation toward system design. The concentration of releases, the expanded mandatory participation, and the consistent emphasis on outcomes and cost containment all point in the same direction.

CMS is no longer asking whether VBC works. It is redesigning Medicare on the assumption that it must.

As these models move from proposal to implementation, they will shape payment policy, care delivery structures, and provider participation in Medicare well into the next decade. Organizations should prepare themselves for a system in which value-based accountability is no longer optional, but the norm.