Why It Matters
The discussion highlights a fundamental debate about how best to control healthcare costs while preserving quality and clinician autonomy. By proposing a real‑world comparison between fee‑for‑service and value‑based models, the episode challenges policymakers to consider simplicity as a viable path to sustainable reform, making the conversation timely for providers, insurers, and patients alike.
The Simple Model
My thoughts on the CMS ACCESS model: it’s too damn complicated.
In fairness, the same could be said for just about every CMS/CMMI VBC model. I suppose this is a function of trying to close every loophole, account for every failure point, and prevent widespread gaming. It’s a fool’s errand. No incentive structure is unexploitable.
Administrative complexity is a constant feature (and common complaint) about these models. Despite a litany of programs and multiple attempts, that complexity has failed to produce lasting, meaningful, reproducible, generalizable results. Yet here we go again.
I’d love to see CMS switch things up a bit and develop a different kind of model. Think of it as a parallel track to ACCESS, TEAM, ASM, LEAD, and all the rest — an A/B test in innovator speak.
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We’ll call it The Simple Model. No acronyms needed, the name says it all.
The core focus of the Simple Model will make it as easy as possible for doctors to take care of patients and patients to access care. No laundry list of metrics, no PROMs collection thresholds, no reporting gymnastics, no forced care coordination, no withholds or tiered risk categories. No prior auth, no UM, no peer-to-peer calls. No forced documentation of clinically irrelevant information for billing purposes. Caps on medical malpractice claims.
Straightforward fee-for-service. Physician payments benchmarked and inflation-adjusted just like hospital payments. (Hint: they’d be 30-40% higher than where they are today). No capitation, reconciliation periods, risk-adjusted payments, forced accountability, or muddy attribution. If budget neutrality is required, there are plenty of ways to get it. They may be politically thorny, but they exist — site neutral payments, Medicare Advantage, and meaningful crackdowns on fraud, waste, and abuse (including cases involving physicians).
Let doctors enter or leave the model each year as they see fit. Let patients choose to whether or not to get care through Simple practices.
Run The Simple Model in parallel to TEAM, ACCESS, ASM, LEAD, Medicare Advantage, Traditional Medicare, etc. and compare total cost of care on population and condition levels. Two metrics only: patient satisfaction (% who would return to a Simple practice) and physician participation (net growth or attrition). Let technology prove its value organically.
The Simple Model might be a spectacular failure. At the very least, it would validate that CMS/CMMI are on the right track. It would prove that lack of constraint, volume incentives, and overutilization are the main drivers of rising healthcare costs. Let’s pit FFS against VBC in a showdown for the ages.
There’s also the possibility The Simple Model would be a smashing success. We have plenty of evidence prior VBC attempts produce underwhelming results — clinically and financially. Now ACCESS is doubling down on complexity while adding in tech-enabled care. (If the Peterson Heath Technology Institute is to be believed, the ROI there is mixed at best.) Given reimbursement levels, ACCESS almost makes doctor-out-of-the loop a condition for success.
We’ve had years of making healthcare more administratively complex, legislatively burdensome, technologically backwards, and financially unsustainable for those delivering care. Every year, CMS becomes a little less friendly towards physicians and costs go up.
Let’s address the elephant in the room — current FFS is not a true control arm. The playing field is tilted by regulatory capture. Unfavorable reimbursement trends distort economics. Administrative burden drives up overhead costs. Forced implementation of sub-par technology impedes care delivery.
Yes, regional variation in healthcare spending exists, but subsequent research has complicated the original Dartmouth Atlas conclusions. Too often in healthcare overinterpretation of results leads to overcorrection of approach. The road to reform is littered with unintended consequences.
We keep testing slightly different versions of the same convoluted hypothesis. Healthcare is complicated enough without adding additional layers of complexity. Maybe it’s time for some simplicity.
Ben Schwartz, MD, MBA
Editor-in-Chief
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