Equal pay for equal results
Medicare now pays technology firms for results, and a smart-ring maker will promote one of them to its members. Primary care deserves the same deal, or Medicare will pay twice for fragmented care.
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read by an AI voiceOn September 29 investors are due to put a price on Oura, the maker of a smart ring with 5 million paying members. At the top of its range the offering would value the company at $14.1 billion, and it has drawn about four times as many orders as there are shares. Oura's prospectus describes a market that "begins with wearables and extends into preventative healthcare," and part of that extension runs through Medicare. On September 17 Counsel Health, which calls itself "the AI-native primary care company," said it was taking part in ACCESS, a Medicare program that pays for measurable results in chronic disease. From early next year its doctors, working with its AI, will treat high blood pressure, obesity, high cholesterol and prediabetes at no out-of-pocket cost to eligible patients. Oura will promote the service in its app, and its chief medical officer says the program will let the company "study that model at scale."
The Counsel deal is small beside Oura's listing, but it belongs to a pattern. Whoop and Withings, two other makers of consumer health devices, have physician groups on Medicare's list of accepted participants, alongside WeightWatchers, Noom and Alphabet's Verily; about 160 organizations are taking part, and health plans covering 165 million Americans have pledged to pay in a similar way. A second front door to chronic care is being built, and it opens on a phone. Medicare pays the firms behind it for results and keeps paying the patient's own primary care practice by the visit. Paying for results is the right idea, but paying only newcomers for them will fragment care, add to spending and leave primary care with the patients hardest to help. Medicare should offer practices the same terms.
ACCESS, which began in July, pays a fixed yearly fee for each patient, in monthly installments, and holds back half of Medicare's share until the year's results are in. In Counsel's track the fee is $360 for a patient's first year. To be paid in full, at least half of a firm's patients must finish the year and meet their targets, such as a systolic pressure below 130 or a drop of 15 points. Firms may waive the part of the fee that patients normally owe, which lets them offer care at no out-of-pocket cost. Patients sign up by phone or online, without a referral; their doctor gets an update once care begins.
Medicare assures primary care doctors that the firms "do not replace your role as the patient's primary clinician." It pays that role far less. A doctor who reviews a firm's update and acts on it may bill $30, up to three times a year, which, with a small one-time fee for helping a patient get set up, comes to little more than a quarter of the firm's first-year fee. The visits at which she checks the same blood pressure are still paid one by one, from a fee schedule whose basic rate Medicare has proposed to lower next year. And the firm's fee shrinks if too many of its patients get listed services for the same condition from other clinicians, so care that another clinician starts, the family doctor included, can count as duplication.
A practice could in principle join ACCESS itself, since almost any organization enrolled in Medicare's Part B may apply. But a participant, and any practice affiliated with it, may not bill Medicare's ordinary fees for its enrolled patients during their year of care, and claims systems will block such bills automatically. The rule suits a firm with no clinic. A practice that sees the same patients in person would have to give up their visit fees to collect the outcome payment. Aledade, whose network is made up of primary care practices and health centers, has two entities on the list. Still, the design favors the firm that reaches a patient's phone over the doctor who knows her history.
Dr. Mehmet Oz, who runs Medicare and Medicaid, has been frank about how payment shapes what technology does. "Short term, AI is going to be inflationary because it's going to turbocharge the ability of the current billing systems to work more effectively," he told an Oracle conference in September. The Blue Cross Blue Shield Association says hospitals' AI coding added $942 million to its plans' costs over two years with no matching change in care, which hospitals dispute; Hartford HealthCare says autonomous coding, piloted with ambient documentation, raised its primary care revenue by 17 percent, and complaints rose with patients' bills. At an event for ACCESS on September 15, Dr. Oz said Medicare was paying "for outcomes, not for effort or process or some surrogate," and that "the most expensive health care is bad quality care."
He is right on both counts, which makes the design of ACCESS odd. In practice it hands the outcome contract to newcomers and leaves the practices that already manage these diseases on the fee-for-service billing he expects AI to inflate. It even reaches into his preferred remedy, the accountable care organization, which is rewarded when its patients' total costs fall. From 2028 the firms' fees will count in the benchmarks and spending by which such organizations are judged, and analysts at Milliman, an actuarial firm, call that a risk for them unless the firms' patients end up costing less.
Whether the firms earn their fees depends on what they do. The Peterson Health Technology Institute, an independent evaluator, found that hypertension programs that manage patients' medication lower blood pressure quickly and meaningfully, better than usual care, and should save money in the long run; programs that only transmit readings or coach behavior do not, and all of them raise spending at first. In its review, digital diabetes tools showed no meaningful clinical benefit and higher net spending. The evidence Counsel offered with its announcement was about satisfaction: members who saw its doctors rated their care 4.6 out of 5. Satisfaction matters, but Medicare is paying for blood pressure.
History suggests that convenient care is more often added to other care than substituted for it. When RAND studied direct-to-consumer telehealth for respiratory infections, only about one visit in eight replaced a visit elsewhere, and spending rose. Enrollment in Medicare's remote patient monitoring grew more than tenfold in three years, often without all the parts of the service. The Congressional Budget Office found that Medicare's innovation center, which runs ACCESS, raised federal spending by $5.4 billion in its first decade instead of cutting it. On the evidence, ACCESS money is well spent when a firm adjusts the drugs of patients whose disease is out of control, and wasted on monitoring, coaching and convenience for patients who were doing well.
Paying for results has its own trap: it rewards whoever enrolls the patients easiest to improve. The companies say a fifth of Oura's members aged 65 and over are obese; among all Americans aged 60 and over, the CDC counts nearly two in five. People who buy a smart ring and pay for a membership are not typical of Medicare's patients, and a firm that recruits them will hit its targets more easily than a practice that treats everyone, including the patient with five diseases and no smartphone. Yet ACCESS asks the same share of patients to reach their targets whoever a participant enrolls. Unless that changes, Medicare will be paying a bonus for selection.
The strongest objection is that primary care has had its chance: only about one American adult in four with high blood pressure has it under control. If a firm with a ring, an app and doctors on call does better, patients gain. Eighteen clinical and patient societies have backed Medicare's push for technology-supported chronic care, and the American Medical Association's chief executive called ACCESS "an important step." That is a case for paying for results wherever they are achieved. A payment that makes a firm control blood pressure can make a practice do so too, and the practice already has the patient's history, medication list and trust. Primary care gets about 3.4 percent of Medicare's spending; paying others for its most measurable work will not raise that.
Medicare should let practices earn the same outcome payment for their own patients while still billing for their visits. It should adjust targets for the patients each participant enrolls, and show in the directory of results it plans to publish how each participant's patients were recruited. It should require firms to tell a patient's clinician before taking over her blood pressure, and pay enough for acting on their updates to cover the work. Before the fees count against accountable care organizations, it should publish an independent count of what ACCESS adds to total spending. Counsel and Oura should say whether and how Oura is paid for promoting a Medicare service; their announcement did not. And doctors whose patients enroll should read the updates, bill for acting on them and remain the clinician who sees the whole patient.
Dr. Oz has asked why Medicare should have doctors "check boxes" when it could ask whether they found a problem, treated it and made it better. Under ACCESS a firm that met its patient through a ring will be asked that question and paid for the answer. The doctor who found the problem in the first place will still be checking the boxes.
- Counsel Health, which describes itself as the AI-native primary care company, announced on September 17 its participation in the ACCESS model's early cardio-kidney-metabolic (eCKM) track. Starting in early 2027 it will deliver care for hypertension, obesity, hyperlipidemia and/or prediabetes at no out-of-pocket cost to eligible Medicare beneficiaries across nearly all U.S. states. "As a technology and marketing partner, the Oura App will promote Counsel's ACCESS program to Oura Members and connect interested Members with Counsel," the release said; the companies have been partners since May, and members who saw a physician rated their care experience 4.6 out of 5. The release says 20 percent of Oura members aged 65 and over have a BMI of 30 or higher; the CDC's national survey for August 2021 to August 2023 found obesity in 38.9 percent of adults aged 60 and older. Fierce Healthcare reported that Oura has 5 million paid members. Counsel Medical Group, P.A. is on CMS's list of accepted ACCESS applicants. The announcement did not describe financial terms between the companies.
- Oura and selling shareholders are offering 50 million shares at $40 to $44 each, to trade on the Nasdaq Global Select Market under the symbol OURA; the IPO is set to price on September 29. At the top of the range the company would have a market value of $14.1 billion and a fully diluted valuation of about $15 billion, and the offering would raise as much as $2.2 billion; it has drawn about four times as many orders as there are shares available, Bloomberg reported September 25. The S-1 registration statement, filed September 3 and amended September 21, reports 5.0 million paid members at June 30, 2026, and revenue of $1,214.5 million in the nine months to June 30, up 74 percent from $697.6 million a year earlier; membership revenue was $240.5 million, against $108.8 million. It describes "a large and expanding market opportunity that begins with wearables and extends into preventative healthcare" and refers to "our current marketing of certain of our products and product features as general wellness products that we believe are not actively subject to the medical device regulatory requirements" of the FDA. The filings mention Counsel Health. Fierce Healthcare reported that Oura's 2024 partnership with Essence Healthcare gives some Medicare Advantage plan members an Oura Ring and its app at no cost.
- CMS's payment amounts for July 5, 2026 to December 31, 2027 set annual allowed amounts per beneficiary of $360 for the initial period and $180 for follow-on periods in the eCKM track (hypertension, dyslipidemia, obesity, prediabetes); $420 and $210 in the cardio-kidney-metabolic track; $180 in the musculoskeletal track; and $180 and $90 in the behavioral health track, with a $15 rural add-on in the eCKM and CKM initial periods. Allowed amounts include the beneficiary's 20 percent coinsurance, which participants may waive under a uniform policy. The sum of monthly payments may not exceed 50 percent of the Medicare portion; the rest is withheld and reconciled after the 12-month care period. Full payment requires at least 50 percent of aligned beneficiaries, for every participant, to complete the care period and meet all targets (for hypertension, a final systolic pressure below 130 mm Hg or a 15 mm Hg reduction). Payments are reduced, on a prorated basis, when fewer than 90 percent of aligned beneficiaries are free of listed substitute services for the same condition from other Medicare providers. CMS will maintain a directory of participating organizations and their risk-adjusted outcomes.
- CMS says the co-management payment is $30 per service, subject to geographic adjustment and sequestration, billable up to three times per 12-month care period per patient per ACCESS track by a practitioner who reviews a documented ACCESS care update and performs at least one related care-coordination activity, with a one-time $10 add-on for help with onboarding and initial setup and no beneficiary cost-sharing. Patients can enroll directly with an ACCESS participant by phone or online; participants must send the primary care provider structured updates at care initiation, on clinical escalation and at the end of each care period. ACCESS participants and their affiliated entities may not submit Medicare fee-for-service claims for aligned beneficiaries during active care periods, and claims systems will suppress such billing automatically. CMS anticipates no impact from ACCESS payments on Shared Savings Program and ACO REACH benchmark and performance year calculations in 2026 and 2027; beginning in 2028, those expenditures will be included. Milliman called ACCESS costs a risk for ACOs "insofar as they are not offset by reduced utilization and expenditures from those beneficiaries." CMS's proposed 2027 physician fee schedule would lower the conversion factor by 1.19 percent for qualifying APM participants and 1.68 percent for others.
- CMS said on September 15 that 160 organizations were participating in ACCESS at launch, that three out of four people with Medicare qualify for at least one track, that heart failure, COPD, substance use disorder and tobacco cessation tracks start in spring 2027, that 18 clinical and patient societies have expressed support for its efforts on technology-supported care for chronic conditions, and that major health payers representing 165 million Americans with Medicare Advantage, Medicaid and private plans have pledged to adopt an outcomes-based payment structure aligned to ACCESS. CMS's list of accepted applicants includes WHOOP Physician Services, Withings Medical Group, Weight Watchers, Noom, Verily Health (which Healthcare Dive describes as Alphabet-owned), Doctronic, Headspace and two Aledade Care Solutions entities. Dr. John Whyte, the AMA's chief executive, called ACCESS "an important step toward bringing new, effective digital health tools into everyday care for Medicare patients."
- "Short term, AI is going to be inflationary because it's going to turbocharge the ability of the current billing systems to work more effectively," CMS Administrator Dr. Mehmet Oz said at Oracle's health and life sciences summit in Orlando, Healthcare Dive reported September 24; he pointed to accountable care organizations, which are paid on outcomes, as the way to reward AI for clinical efficiency rather than billing. At the ACCESS event on September 15 he said Medicare was "paying for outcomes, not for effort or process or some surrogate" (Healthcare Dive) and, in a conversation with John Doerr, chairman of Kleiner Perkins, that "the most expensive health care is bad quality care" (Medical Economics). The Blue Cross Blue Shield Association estimated $942 million in additional inpatient costs for its member plans over 2024 and 2025, against a 2023 baseline, from hospital AI coding with no matching change in care, $653 million of it from secondary diagnoses that moved more than 55,000 cases into higher-paying groups; the American Hospital Association has said inpatients are older and sicker. Hartford HealthCare said piloting autonomous coding with ambient documentation raised its primary care revenue 17 percent, and that complaints rose as patients' charges did.
- The Peterson Health Technology Institute found that digital hypertension solutions focused on medication management "deliver rapid and clinically meaningful improvements in blood pressure that outperform usual care" and are expected to produce long-term net savings, while solutions focused on monitoring or behavior change alone "do not provide clinically meaningful improvements"; all of them increase spending in the short term (released October 28, 2024, updated June 8, 2026). Its assessment of digital diabetes management tools (released March 21, 2024, updated July 20, 2026) found that they do not deliver meaningful clinical benefits and increase net health care spending. The CDC reports that about one in four U.S. adults with high blood pressure (22.5 percent) has it under control (NHANES 2017 to March 2020).
- In a RAND study of direct-to-consumer telehealth for acute respiratory illness among about 300,000 CalPERS enrollees from 2011 to 2013, 12 percent of telehealth visits replaced visits to other providers and 88 percent were new use, raising net spending by $45 per telehealth user. The HHS Office of Inspector General found that Medicare remote patient monitoring enrollees rose from about 55,000 in 2019 to about 570,000 in 2022 and that 43 percent did not receive all three components of the service. The Congressional Budget Office estimated that the CMS Innovation Center increased federal direct spending by $5.4 billion from 2011 to 2020, about 0.1 percent of net Medicare spending. Primary care accounts for about 4.6 percent of all U.S. health spending and 3.4 percent of Medicare spending, according to the Primary Care Collaborative's summary of the Milbank Memorial Fund's 2025 scorecard.