Healthcare Snapshot - January 2026

It was a busy Q4 at CMS as they released several new models that will be going live soon. PSW, as always, will review all models and share education with our network as needed. Below is a brief overview of the various models that have been released or gone live recently.

Wasteful and Inappropriate Services Reduction Model (WISeR) – Live as of January 1, 2026

• Implements Prior Authorization for certain services under Original Medicare, following Local Coverage Determination guidelines.
• PSW continues monitoring for advocacy and compiling educational resources for Washington providers.
• Virtix Health has been selected by CMS to manage these Prior Authorizations in Washington.

Advancing Chronic Care with Effective, Scalable Solutions (ACCESS) – Launching July 1, 2026

• Voluntary model for outcome aligned payments for treatment of chronic conditions.
• Aligns payments with outcomes and funds technology-supported care (wearables, remote, monitoring).
• Applications due April 1, 2026 - PSW will review and prepare as needed. Participants must be Medicare-enrolled TINs.

Long-term Enhanced ACO Design (LEAD) – Coming January 1, 2027

• Features Total Cost of Care with options for capitated payments.
• PSW will conduct actuarial analysis and apply on behalf of networks if participation is beneficial.
• If adopted, provider transfers to LEAD would begin in 2027.

Ambulatory Specialty Model (ASM) – Mandatory starting January 1, 2027

• Focuses on low back pain and heart failure.
• Similar to MIPS in performance measurement (Quality, Cost, Improvement Activities, Promoting Interoperability).
• CMS announced selected areas in Washington, Oregon, and Idaho.

GLOBE and GUARD Models

• GLOBE (Global Benchmark for Efficient Drug Pricing) goes live October 1, 2026.
• GUARD (Guarding U.S. Medicare Against Rising Drug Costs) launches January 1, 2027.
• Both aim to improve drug affordability and accessibility for Medicare patients.
• Manufacturers will participate in these models.
• Public comments due February 23, 2026 - PSW will review details and seek feedback for input.

One of the most meaningful roles of our Care Management team is helping families navigate the challenging transitions that come with aging and increased care needs. These moments can be overwhelming—especially when adult children are managing their own health and responsibilities while caring for an aging parent. Our team steps in to provide guidance, resources, and reassurance during these stressful times.

Our nurse care manager recently connected with an 83-year-old patient following her hospital discharge. During the discharge process, residential care was recommended due to her need for assistance with daily activities such as toileting, dressing, and grooming. However, the patient's daughter hoped to bring her mother home instead.

The nurse care manager discovered that a home health order for therapy services had not been placed. Acting quickly, she coordinated with the primary care provider to ensure the referral was completed. She then followed up with the daughter, offering education on safe caregiving practices to prevent complications like pressure ulcers.

As the daughter expressed concerns about her ability to manage her mother’s growing needs—weakness, agitation, and signs of dementia—the nurse care manager provided guidance on home safety and discussed options for residential care or home care services. Most importantly, she reassured the daughter that ongoing support would be available for as long as needed.

Transitions in care can be difficult, but families don’t have to face them alone. Our Care Management team is here to provide expertise, compassion, and a helping hand every step of the way.