Payment Model Innovation

Fee-for-service payment is fundamentally incompatible with rural healthcare delivery. A hospital with high fixed costs and low patient volume cannot survive on per-service payments that fluctuate with demand. The emergency department must be staffed 24 hours regardless of whether five patients or fifty arrive. The lab technician earns the same salary whether running thirty tests or three hundred. When revenue depends on volume but costs remain constant, financial viability becomes a function of factors largely beyond administrative control.

RHTP applications invoke “value-based payment” with remarkable consistency. Nearly every state proposes transitioning rural providers toward alternative payment models. Yet the applications rarely engage with the evidence base, which reveals that standard value-based care approaches often fail in rural settings. Patient populations are too small for meaningful risk adjustment. Provider panels lack the volume to make shared savings arithmetic work. Quality measurement infrastructure barely exists. States are proposing payment innovation for settings that systematically lack the characteristics associated with payment reform success.

What has changed since those applications were written is the federal government’s own payment innovation landscape. Between December 2025 and February 2026, CMS announced a wave of CMMI models that collectively reshape the payment environment in which RHTP operates. ACCESS, LEAD, MAHA ELEVATE, BALANCE, TEAM, and WISeR create new payment pathways, new accountability structures, and new technology requirements that intersect directly with RHTP transformation investments. States that wrote RHTP applications proposing generic “value-based care readiness” now face specific federal models they can connect those investments to, or fail to connect them to.

The core question for payment reform is no longer whether fee-for-service harms rural hospitals. The question is whether rural providers can navigate a simultaneous explosion of payment model options while operating on margins that leave no room for experimentation that fails.

The Rural Payment Problem

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Why Standard Models Fail

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Accountable care organizations require minimum attributed populations for statistical reliability in quality measurement and cost benchmarking. Many rural counties lack 5,000 total Medicare beneficiaries, let alone 5,000 attributable to a single ACO. Shared savings models assume coordinated care will reduce hospitalizations and emergency visits, generating savings to share. When baseline utilization is already low because patients defer care or travel elsewhere, savings potential diminishes.

Bundled payments assume sufficient procedure volume to absorb variation in individual case costs. A hospital performing twenty joint replacements annually cannot absorb the financial impact of one complex case the way a facility performing two hundred can.

Attribution challenges compound the difficulty. Rural patients receiving primary care locally and specialty care in distant urban centers create split patterns that attribution methodologies handle poorly. The ACO accountable for the patient may have little ability to influence their care.

Quality measurement capacity barely exists at scale. Small rural hospitals often lack the electronic health record capability, quality department staffing, and data analytics infrastructure that performance-based payment demands. A 2025 CMS finding that Shared Savings Program ACOs include over 10,000 FQHCs, RHCs, and CAHs represents growth, but participating rural facilities often depend on larger partners for measurement and reporting.

Payer Mix as Destiny

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Rural populations skew older, making Medicare the dominant payer. Medicare covers 40 to 60 percent of rural hospital revenue, creating both stability (Medicare pays reliably) and vulnerability (Medicare rate changes disproportionately affect rural hospitals). Commercial insurance presence varies dramatically. Agricultural communities may have significant employer-sponsored coverage; retirement destinations may have almost none. Medicaid coverage depends on expansion status and state reimbursement policies.

A rural hospital in expansion-state Minnesota operates in a fundamentally different financial environment than one in non-expansion Texas, regardless of identical RHTP participation. Payment reform that addresses only Medicare leaves half the revenue problem untouched. Payment reform that requires all-payer participation faces the reality that rural hospitals lack bargaining power with commercial insurers and depend on state decisions for Medicaid rates.

The AMA Framework

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The AMA Council on Medical Service’s 2025 report documented the fundamental mismatch between value-based payment designs and rural realities, adopting policy supporting minimum standards for rural alternative payment models: fixed-cost payment on predictable schedules not tied to volume, adequate payment rates covering full cost of care, reasonable patient cost-sharing, and administrative simplicity minimizing reporting burden. These standards implicitly acknowledge that existing value-based models fail to meet rural needs. They describe what payment reform should provide, not what current models deliver.

Evidence: What We Know Works

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Evidence Rating Table

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Global Budget Evidence

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The Pennsylvania Rural Health Model provides the most rigorous evidence on global budgets for rural hospitals. Operating from 2019 through December 2024, PARHM paid eighteen rural hospitals prospective global budgets covering inpatient and outpatient services across all payers.

All eighteen participating hospitals remained open through COVID-19, when fee-for-service dependent facilities faced devastating volume collapses. Hospital executives consistently reported that budget predictability enabled planning and investment impossible under volume-dependent payment. A 2024 Health Affairs Scholar study found early reductions in potentially avoidable utilization.

But rigorous financial evaluation produced mixed results. A July 2025 Health Affairs study using synthetic difference-in-differences methodology found PARHM participation associated with a 4.5 percentage point increase in operating margins in unadjusted models. After adjustment for hospital characteristics and market factors, the improvement shrank to 3.0 percentage points and became statistically nonsignificant. The authors concluded that global budgets alone may be insufficient to reverse rural hospital financial decline without broader community economic development and workforce investment.

Pennsylvania’s experience suggests global budgets can preserve access and provide stability without necessarily transforming financial performance. The model’s value may lie in preventing closure rather than generating profit. This is not a trivial outcome. It is also not the transformative result that justifies the political and administrative cost of implementation.

Maryland’s Total Cost of Care model demonstrates global budgets at scale, operating since the 1970s with all-payer rate-setting authority no other state possesses. Maryland transitioned into the AHEAD model framework beginning January 2026. The transition raises questions about whether federal standardization can accommodate Maryland’s regulatory infrastructure.

ACO Evidence

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A June 2025 JAMA study found ACO formation associated with mean differential reductions of $142 (1.2 percent) in annual per-patient spending over three years and $294 (2.4 percent) over six years. Savings increased over time as ACOs developed care coordination capabilities.

Rural ACO participation has grown but remains limited. CMS reports the Shared Savings Program included 476 ACOs in 2025, with participation from 10,455 FQHCs, RHCs, and Critical Access Hospitals, a 16 percent increase from 2024. The Advance Investment Payment program, providing upfront funding to new ACOs in rural and underserved areas, attracted 28 participating ACOs.

However, ACO REACH failed to enroll its intended population. A 2025 JAMA Health Forum analysis found REACH beneficiaries significantly less likely to be rural (3.9 percent vs. 8.4 percent in Medicare overall), less likely to reside in high-vulnerability areas, and more likely to be White than the broader Medicare population. The model designed to reduce rural health inequities did not reach rural populations at meaningful scale. LEAD replaces it in 2027.

The CMMI Model Wave

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Between December 2025 and February 2026, the CMS Innovation Center announced or finalized a series of models that collectively represent the most significant restructuring of Medicare payment innovation since the ACA. Article 3A introduced these models at the awareness level. This section provides the operational analysis RHTP transformation planners need.

ACCESS: The Chronic Disease Payment Revolution

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The Advancing Chronic Care with Effective, Scalable Solutions model is a 10-year voluntary national model beginning July 5, 2026, testing outcome-aligned payments for technology-enabled chronic disease management. ACCESS represents the most consequential payment innovation for rural RHTP implementation because it creates a Medicare revenue pathway for exactly the infrastructure states are building with transformation funds.

Four clinical tracks organize participation around comorbid condition clusters:

Early Cardio-Kidney-Metabolic (eCKM): Hypertension, dyslipidemia, obesity/overweight with central obesity markers, prediabetes. Annual allowed amount: $360 (initial period), $180 (follow-on). This track targets the prevention population, patients with risk factors before they progress to established disease.

Cardio-Kidney-Metabolic (CKM): Diabetes, chronic kidney disease (Stage 3a/3b), atherosclerotic cardiovascular disease including heart disease. Annual allowed amount: $420 (initial period), $210 (follow-on). The highest-paying track, targeting the established chronic disease population that drives the majority of rural Medicare spending.

Musculoskeletal (MSK): Chronic musculoskeletal pain. Annual allowed amount: $180 (initial period only, no follow-on). A single-year intervention model for conditions that represent substantial rural disability burden.

Behavioral Health (BH): Depression and anxiety. Annual allowed amount: $180 (initial period), $90 (follow-on). Directly aligns with RHTP’s behavioral health integration emphasis.

Payment mechanics matter enormously for rural providers. CMS withholds 50 percent of the Medicare portion of each monthly payment, reconciling after the 12-month care period based on performance. Updated guidance shifted from quarterly to monthly payment disbursement, improving cash flow for participating organizations. But the 50 percent withhold means a provider managing a CKM beneficiary receives approximately $14 per month in cash ($420 x 80 percent Medicare share x 50 percent = $168 annually, or $14/month), with the remaining $14/month contingent on outcomes.

The rural add-on provides a $15 fixed additional payment for beneficiaries in rural areas aligned to eCKM or CKM tracks during the initial period only. This is modest, intended to offset connected device distribution costs rather than to fundamentally alter the payment adequacy question for rural participants.

Outcome thresholds determine whether the withheld payment is earned back. For 2026-2027, at least 50 percent of aligned beneficiaries must meet all required outcome targets for the participant to receive full payment. Measures vary by track but include blood pressure control (systolic below 130 mmHg or 15 mmHg reduction), weight management (BMI below 30 or 5 percent weight loss), HbA1c targets, LDL cholesterol management, validated pain and function scores, and standardized behavioral health symptom measures. CMS will raise minimum thresholds over time.

The FFS exclusion is the critical operational constraint. ACCESS participants and their affiliated entities may not submit Medicare fee-for-service claims for other services furnished to their ACCESS-aligned beneficiaries during an active care period. This means a rural practice that aligns a diabetic patient to the CKM track cannot also bill RPM (99454, 99457), CCM (99490, 99491), or other chronic care management codes for that patient. The ACCESS payment replaces, not supplements, existing FFS chronic care billing.

For rural practices currently billing RPM and CCM codes, the math requires careful analysis. A practice generating $140 to $200 per patient per month from combined RPM/CCM billing would receive $35/month from ACCESS (before the 50 percent withhold), with $17.50/month conditional on outcomes. ACCESS payment is lower than current FFS chronic care management revenue for practices with established programs. The model’s value proposition depends on scale (aligning large numbers of beneficiaries), the ability to use technology efficiently across the aligned population, and the 10-year revenue stability that FFS code survival does not guarantee.

Technology requirements are substantial. Participants must use FHIR-based APIs to report outcomes and share clinical updates electronically with coordinating clinicians. Connected devices (cellular blood pressure monitors, scales, glucose meters) must be distributed to aligned beneficiaries. Electronic care plans must be maintained and shared. These requirements align precisely with RHTP infrastructure investments in interoperability, remote monitoring platforms, and connected device ecosystems. RHTP builds the capacity. ACCESS creates the payment pathway.

Co-management payment for primary care practitioners and referring clinicians: approximately $30 per service (up to once per four months per beneficiary per track), with an additional $10 onboarding modifier available the first time it is billed. No Part B cost-sharing applies. Annual co-management revenue per beneficiary per track: approximately $100. For rural PCPs whose patients are managed by an ACCESS participant, this creates modest but real revenue for coordination activities.

Application timeline: Applications opened January 12, 2026. First cohort deadline April 1, 2026, for July 5, 2026 start. Rolling applications through April 2033. Over 500 organizations submitted interest forms by January 2026.

The Making Care Primary cautionary tale. CMS terminated the Making Care Primary model in March 2025, months after launching a 10-year demonstration. ACCESS carries the same 10-year framing. Rural providers investing in ACCESS participation infrastructure should understand that CMS has demonstrated willingness to terminate long-duration models early when political priorities shift or evaluation results disappoint.

LEAD: The ACO Successor

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The Long-term Enhanced ACO Design model replaces ACO REACH beginning January 1, 2027, with a planned 10-year duration through December 2036. LEAD represents the most significant ACO redesign since the Shared Savings Program’s creation.

Key design features for rural application:

Broad eligibility explicitly includes existing ACOs, new entrants, FQHCs, rural providers, and organizations serving high proportions of dual-eligible beneficiaries. Where ACO REACH failed to reach rural populations, LEAD’s design attempts to correct by lowering beneficiary alignment thresholds and providing rural-specific add-on payments.

Professional and global risk tracks allow organizations to choose accountability levels. Professional risk (lower risk, lower reward) may suit rural organizations entering accountable care for the first time. Global risk (higher stakes, higher potential return) may suit organizations with established population health infrastructure.

Prospective, capitated population-based payments support team-based and downstream value-based care, moving beyond shared savings toward predictable prospective revenue that addresses the AMA’s fixed-cost payment standard.

CMS-Administered Risk Arrangements (CARA) create “shadow bundles” intended to integrate specialty care into ACO models. For rural settings where specialty access is limited, CARA could enable formal accountability arrangements with distant specialists serving rural populations through telehealth or periodic visits.

New beneficiary enhancements include medical nutrition therapy, Part D premium buydowns, and chronic disease prevention incentives. These tools could help LEAD ACOs in rural areas address the social and economic barriers that drive poor outcomes.

The first cohort is expected in September 2026, with formal applications opening mid-2026. Rural organizations considering LEAD participation should be building population health infrastructure now, which is precisely what RHTP funds.

MAHA ELEVATE

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The Make America Healthy Again: Evidence-Based Lifestyle-Medicine and Functional-Medicine Evaluation for Better Value and More Efficient Treatment model tests whether lifestyle and functional medicine interventions can improve outcomes and reduce costs in FFS Medicare. CMS will test approximately 30 evidence-based interventions including nutritional counseling, exercise prescriptions, stress management, sleep optimization, and substance use interventions.

The first cohort begins September 2026. Outcome-aligned payment structure mirrors ACCESS: 50 percent upfront, 50 percent contingent on outcomes.

For rural RHTP implementation, ELEVATE matters because it creates Medicare payment for wellness and prevention activities that RHTP applications frequently propose but that FFS Medicare does not currently reimburse. If a state’s RHTP plan emphasizes community wellness programs, nutrition education, or lifestyle medicine, ELEVATE participation could provide the sustainability pathway those programs need after RHTP funding expires. The model also carries political significance as the administration’s signature health innovation initiative, which may protect it from the early termination risk that afflicts other CMMI models.

BALANCE

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The Better Alignment and Lower Cost for GLP-1 Receptor Agonist Medications model negotiates manufacturer rebates for GLP-1 medications (semaglutide, tirzepatide) in exchange for expanded access. Medicaid access begins May 2026. Part D access begins January 2027.

BALANCE matters for rural RHTP because GLP-1 medications represent potentially transformative treatment for the obesity, diabetes, and cardiovascular disease burden that drives rural health disparities. Current barriers are primarily cost and access. If BALANCE succeeds in reducing GLP-1 costs, rural providers participating in ACCESS or LEAD who can prescribe and monitor GLP-1 therapy gain a powerful clinical tool. If BALANCE fails or produces insufficient price reductions, the cost barrier persists and rural chronic disease management continues relying on behavioral interventions with modest effect sizes.

TEAM: Mandatory Bundled Payment

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The Transforming Episode Accountability Model launched January 1, 2026, as a mandatory episode-based payment model. Hospitals in selected geographic areas bear financial risk for 30-day surgical episodes spanning inpatient or outpatient procedures and post-acute care.

TEAM affects rural hospitals in selected regions regardless of their transformation strategy. Unlike voluntary models where rural providers can assess readiness before participating, TEAM imposes accountability on all hospitals in designated areas. Rural hospitals performing qualifying surgical procedures must manage episode costs or face financial penalties. For low-volume surgical programs where a single complex case can overwhelm the episode budget, mandatory bundled payment creates financial risk that voluntary models allow providers to avoid.

WISeR: Prior Authorization Expansion

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The Widespread Implementation of Smart, Efficient Review model introduces prior authorization to traditional FFS Medicare for specific high-cost services. This is notable because FFS Medicare has historically operated without prior authorization, which was a distinguishing feature compared to Medicare Advantage.

For rural providers, WISeR introduces administrative burden previously associated only with MA plans into the FFS Medicare population. Rural practices already reporting that prior authorization from MA plans consumes substantial staff time and delays care will now face similar requirements from traditional Medicare for targeted services.

AHEAD: The State-Level Model

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The Achieving Healthcare Efficiency through Accountable Design model represents CMS’s approach to state-based payment reform through hospital global budgets and total cost of care accountability. Six states participate: Maryland (Cohort 1, performance began January 2026), Connecticut, Hawaii, and Vermont (Cohort 2, performance begins 2028), Rhode Island and five New York counties (Cohort 3). The model runs through December 2035.

AHEAD requires participating states to meet total cost of care targets across Medicare, Medicaid, and commercial payers. Critical Access Hospitals receive special accommodations: delayed penalties for avoidable utilization, additional time in upside-only arrangements, and a payment floor based on most recent cost reports. September 2025 policy changes extended timelines and added geographic attribution. CMS will offer up to two additional states the opportunity to join in July 2026.

AHEAD’s rural implications remain theoretical. No performance data exists. The model’s structure suggests potential for the kind of predictable, prospective payment that Pennsylvania’s experience showed could preserve access. Whether AHEAD’s federal framework can accommodate the flexibility that makes global budgets work in diverse rural settings remains an open question.

For states not participating in AHEAD, the model offers limited direct relevance. But it establishes a policy precedent: CMS is willing to support state-level payment reform with multi-payer participation requirements. States building RHTP payment reform infrastructure are building capacity that could support future AHEAD participation if the model expands.

The Integration Gap

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Article 3A identifies the structural coordination gap between RHTP and CMMI. This section examines what that gap means operationally for payment model innovation.

RHTP builds capacity. Transformation funds support remote monitoring platforms, connected device ecosystems, telehealth infrastructure, care coordination staffing, data analytics systems, and quality measurement capability. These investments create the organizational infrastructure that CMMI model participation requires.

CMMI models create payment pathways. ACCESS pays for technology-enabled chronic disease management. LEAD pays for population health accountability. ELEVATE pays for wellness and prevention. These models provide ongoing Medicare revenue for activities that RHTP can fund initially but cannot sustain permanently.

No federal coordination mechanism connects them. CMS Innovation Center and the RHTP program office operate independently. CMMI model application timelines do not align with RHTP planning cycles. CMMI model eligibility requirements do not reference RHTP capacity. RHTP scoring criteria do not assess whether state plans facilitate CMMI participation.

States are the integration layer. The federal government designed two complementary strategies and left states to connect them. State RHTP directors who understand CMMI models can sequence investments to build ACCESS, LEAD, or ELEVATE participation capacity. State directors who do not understand these models will build infrastructure that works during the RHTP period but lacks a payment pathway to sustain it afterward.

The Sustainability Equation

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Every RHTP-funded payment innovation investment faces the same question: what pays for this after 2030?

A remote monitoring platform funded by RHTP in Year 1 needs ongoing revenue in Year 6. If the state sequenced that investment toward ACCESS participation, the platform generates ACCESS outcome-aligned payments starting in Year 1 or 2, continuing through the model’s 10-year duration, extending revenue six years beyond RHTP’s sunset. If the state funded the platform without CMMI awareness, it generates RPM/CCM FFS revenue that depends on annual code survival and faces potential displacement if ACCESS grows.

A care coordination team funded by RHTP needs permanent financing. If the state facilitated LEAD participation, LEAD’s prospective capitated payments fund ongoing care coordination. If the state built the team without ACO connectivity, the team disbands when RHTP funding ends unless the state or providers find alternative revenue.

The CMMI models do not guarantee sustainability. Making Care Primary’s termination demonstrates that 10-year model commitments are not binding. But they provide the most plausible payment pathway for sustaining RHTP investments that currently exists. The alternative is hoping that FFS billing codes continue, that state legislatures appropriate replacement funding, or that commercial payers voluntarily adopt value-based arrangements with providers who lack bargaining power. Hope is not a payment model.

RHTP Application Assessment

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What Applications Proposed

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Virtually every RHTP application includes value-based payment language. Texas proposes “alternative payment model readiness” without specifying which models. California plans value-based payment evaluation and rural payment model landscape assessment. North Carolina targets “rural provider transition to value-based payment” with primary care capitation pilots. Ohio references innovation hubs creating “value-based payment arrangements.”

What Applications Lack

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CMMI model awareness. Applications were drafted before ACCESS, LEAD, and ELEVATE announcements. No application could have anticipated the specific models now available. But the applications also lack frameworks for connecting RHTP investments to federal payment innovation generally. Most treat payment reform as an internal state initiative rather than as infrastructure enabling federal model participation.

Realistic timelines. Payment model transitions require years of preparation. Provider contracting, actuarial analysis, quality measurement infrastructure, and care management capacity cannot be built within RHTP’s two-year obligation window. Applications proposing value-based transformation by 2027 underestimate implementation requirements.

The FFS displacement analysis. Applications proposing RPM and CCM as sustainability strategies do not account for the possibility that ACCESS displaces FFS chronic care billing. If ACCESS succeeds and scales, practices aligned to the model cannot simultaneously bill RPM/CCM codes. States that funded RPM infrastructure assuming FFS billing continuity may find that the federal government’s own payment model eliminates the revenue stream those investments were designed to generate.

Promising Elements

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California’s Transformative Payments provide upfront infrastructure funding not tied to service volume, acknowledging that rural facilities need investment capital before they can succeed in performance-based arrangements.

North Carolina’s primary care capitation pilots test prospective payment for rural primary care, conceptually aligned with LEAD’s capitated population-based payment design.

Vermont’s AHEAD participation builds on existing all-payer experience, potentially demonstrating how federal frameworks can accommodate state innovation.

Implementation Guidance

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Sequence Infrastructure Toward CMMI Participation

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States should audit RHTP transformation investments against CMMI model requirements:

If your plan funds remote monitoring platforms and connected devices, those investments create ACCESS participation infrastructure. Ensure platforms meet FHIR API requirements. Ensure connected devices are FDA-cleared or eligible for TEMPO enforcement discretion. Begin population analysis to identify beneficiaries who would qualify for eCKM, CKM, MSK, and BH tracks.

If your plan funds care coordination teams and population health analytics, those investments create LEAD participation infrastructure. Begin building attribution-capable data systems. Develop quality measurement capacity sufficient for ACO reporting. Identify potential ACO partners or assess whether state-facilitated ACO formation is viable.

If your plan funds wellness programs, nutrition education, or lifestyle medicine, those investments create ELEVATE participation infrastructure. Document intervention protocols in formats suitable for CMMI application. Build outcome measurement systems that can demonstrate clinical impact.

Build Infrastructure Before Reform

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Payment transformation requires capacity most rural providers lack. States should invest RHTP resources sequentially: data systems first (EHR upgrades, health information exchange, quality reporting capability), then care coordination staffing (care managers, community health workers, social workers), then administrative capacity (value-based contracting expertise, performance measurement, financial modeling), then provider engagement (relationships and trust enabling collaborative redesign).

Attempting payment reform without this infrastructure produces participation in name only, where providers sign value-based contracts but lack capacity to change care delivery.

Design for Rural Realities

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Adjust attribution methodologies for split care patterns where patients receive primary care locally and specialty care distantly. Aggregate risk pools across multiple small providers because individual rural facilities cannot bear population-based risk alone. Simplify quality measurement by using streamlined measure sets that reduce burden while preserving accountability. Provide upside opportunity before downside risk because rural facilities operating on negative margins cannot absorb losses from failed performance.

Pursue Global Budget Approaches Where Feasible

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The evidence, while mixed, supports global budgets as the payment approach most compatible with rural healthcare economics. Fixed prospective payment addresses the fundamental volume dependence that fee-for-service creates. States should explore AHEAD participation. States not positioned for AHEAD should seek federal demonstration opportunities or develop state-funded global budget pilots using RHTP administrative infrastructure.

Engage Payers Strategically

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Medicare alternative payment models provide a foundation but not a complete solution. Leverage Medicaid managed care contracting authority to require MCO participation in state payment initiatives. Develop business cases for commercial payer participation that demonstrate cost or administrative burden reduction. Coordinate across programs to reduce provider burden from multiple value-based contracts with different requirements.

Plan for Model Termination Risk

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Every CMMI model participation strategy should include contingency planning for early termination. Making Care Primary was cancelled months after launch. If ACCESS, LEAD, or ELEVATE face similar termination, providers who restructured operations around model participation need fallback revenue strategies. Do not eliminate FFS billing capability while transitioning to model-based payment. Maintain the organizational capacity to revert if necessary.

The Medicaid Cut Interaction

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Payment reform assumes stable underlying coverage. Projected $911 billion in Medicaid cuts over ten years would fundamentally alter the financial environment in which payment reform operates. Global budgets calculated on current payer mix become unreliable when Medicaid coverage changes. Value-based arrangements designed for current beneficiary populations require recalibration when populations lose coverage.

Rural areas face disproportionate exposure. Medicaid covers 25 percent of rural residents under 65. Coverage reductions concentrate in states with non-expansion Medicaid and high uninsured rates, which overlap substantially with states having vulnerable rural hospital infrastructure. Payment reform cannot succeed if the underlying coverage infrastructure collapses. A rural hospital participating in LEAD cannot achieve population health goals when the population is losing coverage for the services that population health management coordinates.

ACCESS, LEAD, and ELEVATE serve FFS Medicare populations only. They do not address Medicaid revenue. They do not address commercial payment. They do not address uncompensated care. CMMI models provide a sustainability pathway for one payer. RHTP’s payment innovation challenge requires multi-payer solutions that CMMI models alone cannot provide.

The 2030 Question

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Every payment initiative funded by RHTP must answer: what happens in Year 6?

Durable approaches include state Medicaid plan amendments institutionalizing alternative payment methods, regulatory frameworks enabling all-payer rate-setting, commercial payer contracts with multi-year commitments, and provider capacity investments that persist beyond grant periods.

Temporary approaches include time-limited demonstrations without path to permanent authority, payment pilots dependent on continued federal funding, value-based arrangements that revert to FFS when grants end, and infrastructure investments that cannot be maintained without ongoing subsidy.

The CMMI model timelines offer partial durability. ACCESS runs through 2036. LEAD through 2036. AHEAD through 2035. If these models survive their stated durations, they extend payment innovation six years beyond RHTP’s sunset, providing the continuity that standalone RHTP payment pilots cannot. If they do not survive, the sustainability question returns to state resources and political will. The prudent strategy treats CMMI models as the primary sustainability pathway while building state-level capacity as the backup.

Maryland’s payment system survived fifty years because regulatory infrastructure became embedded in state government. Pennsylvania’s model ended when the federal demonstration concluded. The difference lies not in policy merit but in institutional durability. States that use RHTP to build payment reform into permanent state infrastructure create durability. States that use RHTP to participate in federal demonstrations create dependency.