Healthcare Financing and Delivery Innovation

Program of All-Inclusive Care for the Elderly (PACE) is a capitated health plan that provides comprehensive Medicare and Medicaid covered services to frail, older adults in the community who are eligible for nursing home care. New research from ATI explores the latest enrollment trends and highlights latest opportunities for PACE growth.

LEAD gives MSSP ACOs and health systems with deep value-based care experience a way to serve High Needs beneficiaries on payment terms that align with their acuity and changing care needs. Its benchmarks, risk adjustment, and monthly capitation features respond to structural challenges that established organizations have encountered in other models, aiming to generate lower utilization and total cost of care for High Needs beneficiaries while improving outcomes.

Nearly six years after Medicare Advantage opened up to people with end-stage renal disease, enrollment has climbed to nearly 280,000 beneficiaries, more than half of all Medicare beneficiaries with ESRD, and almost double what CMS originally projected. ATI Advisory's analysis of six years of Medicare data shows Medicare Advantage has become the primary way ESRD care gets paid for. Nephrologists, dialysis providers, and MA organizations are now negotiating payment rates, building provider networks, and navigating utilization management for a population that used to be financed almost entirely through fee-for-service.

Beginning January 2028, CMS will launch a nationwide, mandatory bundled payments model for the first time. The Comprehensive Care for Joint Replacement Expanded (CJR-X) Model, an expansion of the recently concluded Comprehensive Care for Joint Replacement (CJR) Model, will hold more than 2,000 acute care hospitals nationwide accountable for the cost and quality of inpatient and outpatient lower extremity joint replacement (LEJR) episodes. Episodes will span the initial LEJR procedure and all Medicare spending in the 90 days following the procedure, including post-acute care.

Aging services and senior living organizations are designed to keep frail older adults with complex, chronic needs healthier, more independent, and out of the hospital and emergency room. This work generates economic value by lowering the total cost of caring for the populations served. A robust value-based payment strategy turns that value into revenue the organization keeps.

Earlier this month, CMS launched the Advancing Chronic Care with Effective, Scalable Solutions (ACCESS) Model, prompting renewed discussion across the digital-native health, AI-forward coaching, and accountable care sectors. ACCESS is part of a broader industry shift toward value-based, technology-enabled chronic care management. The model is distinctive in that it supports services like AI-enabled chat and coaching deployed at scale, which will be subject to the same regulatory scrutiny applied to any other covered clinical service. This combination of features merits sustained attention from technology-enabled healthcare solutions operating in adjacent markets.