Despite its good intentions, CMS is getting some cautionary signals from health plans and providers on reform models
There is little question that reforming the antiquated Medicare fee-for-service (FFS) system is important. The Centers for Medicare and Medicaid Services (CMS), with its Center for Medicare and Medicaid Innovation (CMMI), has been very active under the Trump administration in announcing reform models at a fever’s pitch.
A number of policy wonks, including me, have been critical in the past of the plethora of models introduced by CMS’ CMMI. Providers were confused by the multiple reforms and quality and savings benchmarks. Populations they served overlapped across models. Many urged paring down the models and focusing on a set of quality and cost benchmarks.
But as noted, the Trump administration has gone the opposite direction. The acronym-ridden healthcare system has dozens of new labels that have been added to the alphabet soup of healthcare. So much so that there are several websites now dedicated to taking the mystery out of all of this.
One reason for all the reforms is that Trump’s healthcare folks want to change the paradigm within CMMI – moving from a more traditional approach to innovation under Biden to one that is more cutting edge and accelerates value-based care (VBC) and leverages emerging healthcare market trends, including technology. I have backed off my criticism of the number of models because of it. I reason that if a few models truly take off and show promise, the investment all around will be worth it. The rewards: transforming the Medicare FFS system, lower cost trends, and better outcomes.
But health plans and providers are beginning to show some fatigue with all the pilot announcements. The model announcements have come with accelerated timelines to apply and launch. While Trump’s folks have tried to keep them rather simple and flexible, they still mean a great deal of complexity for plans and providers in terms of analyzing the value to an organization, applying, and then implementing.
A few examples of signs of ongoing fatigue:
The Advancing Chronic Care with Effective, Scalable Solutions (ACCESS) Model was announced to much fanfare in early December 2025. The application deadline was April 1, with the first contracts awarded shortly thereafter and a preliminary launch date of July 5.
The model has great promise: it teams technology companies up with FFS providers to monitor and control chronic disease states. It promotes personal responsibility on the part of beneficiaries, challenging them to leverage technology and take stock in their health via better nutrition and fitness as well as more frequent clinical monitoring. While about 150 organizations were approved after the April application deadline, CMS has extended the filing to May 15 in an effort to get more companies interested. Apparently, initial approvals may have had too few covered beneficiaries in the model.
That is understandable. Tech companies are new to Medicare rules. Most providers invest little in remote monitoring and chronic care management. The quality barometers are relatively simple but at the same time somewhat different from traditional metrics. And building partnerships between tech and traditional providers is not easy.
The good news here is that CMS contemplates rolling additions of technology companies and participants over time, but how well things go early on is important for ultimate success.
While the Long-term Enhanced ACO Design (ACO LEAD) Model applications are not due until May 17, we are already hearing of anxiety over tight deadlines and the ability to synthesize all the changes in the proposed payment model. The model was announced in late March, with applications by mid-May and an implementation period beginning in mid-September. The program would launch as the successor to ACO REACH on January 1, 2027.
The model makes a number of important reforms that encourage broader provider participation, including the elimination of rebasing and a 10-year horizon for greater stability. At the same time, it broadens to more Medicare-Medicaid dual populations. Again, the move is a good idea, but the question is whether swift timelines will hold back participation right now.
Last, the Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth (BALANCE) Model was announced by CMS in late 2025 as a voluntary initiative to increase Medicare and Medicaid access to GLP-1 weight-loss medications for obesity while pairing them with lifestyle interventions.
I am a convert on broadening availability beyond core disease states. I supported the Trump administration’s initial rejection of the Biden-era expansion of the drugs to obesity given sheer costs short-term in the program. Yet President Trump has mapped an extraordinary and swift initiative to lower overall brand drug costs. After years of successive administrations’ kowtowing to Big Pharma, no one thought the progress Trump has made was possible. He has executed on major negotiations with the largest 17 brand drug makers and introduced most-favored-nation drug pricing pilots. He also wants to overhaul the opaque drug channel. This gives the administration the ability to expand coverage in Medicare and Medicaid at much lower prices than before. Studies increasingly are showing the strong likelihood that access to these drugs will help reduce healthcare costs in the long term.
Adoption of GLP-1 drugs is surging. Truveta research finds that nearly 8% of all prescriptions in March 2026 were for GLP-1s. First-time anti-obesity medication prescribing increased 21.7% from December 2025 to March 2026. The study found that almost 2.86M patients were prescribed a GLP-1 between January 2019 and March 2026, with 14.7M total prescriptions during this period.
The problem is that the model came at a very tough time for health plans. They face huge utilization spikes, rising risk due to membership erosion in some lines, rate challenges in still more, and a financial meltdown created in part by a fundamental lack of discipline. That includes in Medicare Advantage (MA), the main target of the BALANCE model. Further, the Part D retail drug program’s financial stability has been eroded via a politically motivated and unwise change during the Biden years that massively reduced cost-sharing without funding. This moved costs to MA plans and freestanding Part D (PDP) plan sponsors. It has fundamentally eroded the PDP financial model.
BALANCE was unable to attract sufficient participation in Medicare to move forward right now. CMS has delayed the 2027 launch in Medicare (it will continue in Medicaid) and instead will extend the temporary BRIDGE program through at least the end of 2027 before determining whether to go back out for participants. The BRIDGE extension, which has the federal government directly paying most of the cost of GLP-1s on behalf of enrollees, could provide important data as to the risk of individuals who receive the GLP-1 expansion and overall costs.
The model may yet have life. UnitedHealthcare recently said it hopes to participate in BALANCE. While I understand the financial plight of insurers (again a good portion of it self-inflicted), I would hope that plans take a chance on the model in the future – balancing the potential for short-term costs and long-term benefits. With people living longer now, GLP-1s could very well hold at least part of the secret to long life at reduced cost in Medicare.
Conclusion
In the end, it is hard to blame the administration for trying to be aggressive in its model approach. It has precious little time to put its indelible mark on healthcare. While I disagree with some of the coverage erosion, Trump’s pushes to transform healthcare with technology, pursue more aggressive VBC models, and address drug prices are admirable. But stepping back just a little — both in terms of sheer number of pilots and aggressive timelines — might be in order to synthesize proposals with a financial environment that is challenging and a still antiquated approach to care delivery. Focus on the core principles of technology and VBC adoption as well as novel coverage such as GLP-1s.
#cms #innovation #weightlossdrugs #vbc
— Marc S. Ryan
