The ACCESS Era: How 2026 Rewrites Growth, Valuation & Contracting in U.S. Health Care

A CEO Briefing by Axis Growth Partners — Commercialization Architecture™

ACCESS Isn’t a Policy Update. It’s the 2026 Market Separation Event.

ACCESS is not a single CMS program. It is the combined economic force of:

• 2024–2026 mental-health parity (MHPAEA) enforcement,

• 2025 CMS Interoperability & Prior Authorization Final Rule,

• 2026–2027 Medicare Advantage (MA) network adequacy modernization, and

• Explosive GLP-1 drug cost pressure now reshaping benefits.

  
  

Together, these changes function as a market separation engine:

ACCESS does not tighten compliance. ACCESS reprices proof.

And in 2026, it becomes the dividing line between platforms that scale — and those that get carved out.

Why ACCESS Exists (And Why It Becomes Binding in 2026)

1. Behavioral Health Access Failures Are Now Quantified

Regulators found that over 70% of reviewed plans failed MHPAEA NQTL standards for behavioral health access and network adequacy.Demand is surging: outpatient BH use in 2025 is 38% above 2019, while 60%+ of patients report difficulty accessing care.

2. Prior Authorization Transparency Is Now Mandatory

The 2025 CMS rule requires:

• PA approvals within 7 calendar days (standard) and 72 hours (urgent),

• Public reporting of denial rates, overturn rates, and turnaround times,

• API interoperability requirements beginning 2026–2027.

3. Medicare Advantage Tightens Behavioral Access & Network Adequacy

MA covers 33M+ beneficiaries in 2025 — nearly half of Medicare. The 2027 rule proposals expand BH provider types and sharpen adequacy standards tied to Star Ratings.

4. GLP-1 & Specialty Drug Costs Are Breaking Trendlines

GLP-1 spending increased 500%+ from 2018 to 2023 ($13.7B → $71.7B). Evernorth projects ~73% higher GLP-1 utilization by YE 2025. Large employers report significant increases in GLP-1 pharmacy spend and growing cost concern.

ACCESS is the system’s response: Every vendor must now prove claims-level cost displacement — not just engagement, access, or intent.

The ACCESS Rubric for 2026

ACCESS reduces evaluation to one equation:

Condition-level cost displacement ≥ administrative + regulatory burden of compliance

If you cannot prove cost movement in 12–18 months, you:

• lose renewals,

• lose rate lift,

• and become a low-value vendor.

  
  

If you can, you:

• achieve delegated adequacy,

• command premium pricing,

• and expand across multi-state payer networks.

ACCESS eliminates narrative economics.Only validated claims deltas survive.

Who Wins (And Why)

1. National Behavioral Health Platforms

Exposure:

• Must meet parity access standards (70% of plans fail today).

• Must maintain supervision + credentialing that pass NCQA delegation.

• Outcome dashboards without medical-cost linkage will not justify renewal.

Winning Requirement:

• Become a governed psychiatric operator — not a tele-BH vendor.

• Demonstrate BH → medical-cost movement in claims.

• Achieve delegated adequacy.

2. Condition-Specific Platforms (Renal, Oncology, HF, Metabolic)

Exposure:

• GLP-1/specialty drug trend dwarfs most chronic-care ROI stories.

• Attribution models must withstand actuarial audit.

• PMPM contracts depend on adjudication-grade cost movement.

Winning Requirement:

• Produce 12–18 month claims-validated cost displacement.

• Demonstrate measurable impact on the categories driving trend.

This is the highest-value retainer segment in the ACCESS economy.

3. GLP-1 & Metabolic Care Ecosystems

Exposure:

• GLP-1 cost growth is unsustainable (>500% in 5 years).

• Employers and plans are rethinking coverage.

• Programs that cannot show discontinuation + off-ramp economics will be cut.

Winning Requirement:

• Demonstrate metabolic stabilization + reduced drug persistence in claims.

• Integrate mental health + metabolic care.

4. Hospitals, IDNs & MA-Aligned Medical Groups

Exposure:

• BH access, LOS, and readmissions impact MA Star Ratings.

• UM is shifting inside the provider via delegation.

• Psychiatry capacity and continuity become financial exposures.

Winning Requirement:

• Build ACCESS-aligned BH access + supervision models.

• Demonstrate leakage control + post-acute stabilization.

5. Blues, Nationals & Medicaid MCOs

Exposure:

• Must defend parity access + PA transparency in 2026.

• Must consolidate vendors into those with real cost impact.

• Must justify renewals with claims data.

Winning Requirement:

• Establish delegated adequacy partners.

• Redesign vendor portfolios around cost displacement.

Who Loses (And Why)

• Horizontal chronic-care apps with flat effect sizes

• BH-only vendors with no medical-cost linkage

• GLP-1 engagement apps without claims evidence

• Virtual-care marketplaces that cannot pass NCQA delegation

• “Engagement-first” models with no economic proof

• Vendors whose outcomes are not measurable against GLP-1/specialty cost trend

ACCESS doesn’t punish anyone. It exposes weak economics.

What ACCESS Actually Demands in 2026

1. Adequacy + access metrics that pass sampling

(MHPAEA enforcement)

2. Prior auth transparency + turnaround reporting

(CMS 2025 Rule)

3. MA-aligned BH adequacy

(2027 MA proposals)

4. NCQA-grade delegation governance

(Credentialing + UM oversight)

5. Claims-linked outcomes that actuaries accept

(GLP-1 + specialty cost trend)

These are not documentation tasks.These are economic thresholds.

The Market Separation Matrix (2026–2028)

High Claims Movement + High Adequacy → Premium delegated partner

High Claims Movement + Low Adequacy → Fixable, high-value

Low Claims Movement + High Adequacy → Commodity

Low Claims Movement + Low Adequacy → Down-rounds & exits

ACCESS is the sorting mechanism.

Where Axis Growth Partners Fits

Axis is not a consulting firm.

Axis is a Commercialization Architecture™ platform built for the ACCESS economy.

We integrate:

• MHPAEA compliance → economic leverage

• Prior auth transparency → contracting power

• MA adequacy → network strategy

• Claims attribution → actuarial defensibility

• GLP-1 / metabolic / renal / oncology economics → PMPM justification

• BH → medical-cost linkage → rate lift

• Evidence stacks → renewal pathways

• CEO/CFO/Board narratives → valuation impact

What we deliver

• Delegated adequacy architecture

• Economic evidence stacks

• Claims-grade attribution models

• PMPM displacement modeling

• ACCESS readiness & multi-state scoring

• Payer negotiation strategy

• Board-level valuation analysis

ACCESS is the largest economic reset since the ACA.

It will separate the market anyway.

Axis helps CEOs ensure that separation works in their favor.

Tom Riley

Founder & Commercialization Architect | Axis Growth Partners

tomriley@axisgrowthpartners.co