When CMS signals where drug payment is headed, Medicare leaders lean in. The Medicare Product & Pharmacy Strategy Summit kicked off in Seattle on June 11, 2026 with an opening keynote from Abigale Sanft who delivered the signal. Payment is moving from volume to value, and your plan needs the capabilities to keep pace.
CMMI’s moves land on your desk
Here is why this hits home. The CMS Innovation Center, CMMI, is the engine testing how Medicare and Medicaid pay for drugs. When CMMI moves, your reimbursement, your formulary, and your member experience move with the change. Sanft put a fresh slate of drug-focused models on the table, including GLOBE, GUARD, BALANCE, and ACCESS.
The models all point the same way
Different names, one direction. Across the slate, the goals line up: pay for value, improve patient outcomes, and widen drug affordability and access. Driving all of this is a wave of pharmaceutical innovation, including therapies priced in the millions. Paying for volume falls apart when a single therapy costs more than a home.
Sanft framed CMS’s 2025 direction around one idea: empower people to reach their health goals. In practice, you connect members to their health data, support informed decisions with providers, and widen access to information and tools.
Value-based purchasing is growing up
Value-based purchasing is leaving the pilot phase and moving toward real scale. Expect more weight on outcomes measurement, real-world evidence, and tracking patients over time. Evidence generation is becoming part of coverage decisions, especially for breakthrough therapies. Plans fluent in real-world evidence and analytics will pull ahead.
One warning landed hard. The earlier VBP model ended because costs hit Medicare in a way the program would not allow. So any future road to $0 Part D cost sharing has to pencil out as budget-neutral for Medicare.
Affordability is now a performance metric
Affordability moved from talking point to scorecard, viewed through the beneficiary’s eyes. A brilliant therapy means little when a patient struggles to fill or stay on treatment. So the question shifts from is the drug covered to will the patient get and keep their therapy. CMS is weighing out-of-pocket burden, adherence, and access barriers head on.
Watch the tension. Affordability tools like generic substitution and step therapy pull one way. Access to needed specialty drugs pulls the other. Sanft pointed toward broadly designed support for expensive therapies, plus a close eye on Medicaid, where state budgets and policy make access even harder.
Big therapies need new financial models
Cell and gene therapies break the old math. Huge upfront costs, benefits spread over years, and budgets built for neither. Sanft pointed plans toward risk-sharing and reinsurance, longitudinal data, and a real plan for member churn across payers. And stop reading drug spend on its own. A therapy worth paying for shows up as fewer hospital stays, fewer ER visits, and a patient living better.
Where AI fits, and where people still win
AI got an honest review. Behind the scenes, machine learning is doing real work: predictive analytics, pricing, defining populations, risk adjustment, formulary work, and utilization management. On the front end, AI tools answer beneficiary questions on the spot, point to alternatives, and flag the right members for outreach.
But the limit is the headline. Members still want a human when they are sorting out their benefits. Pile on too much automated outreach and you create abrasion. The play? Let AI carry the heavy lifting up front, then put people on the conversations where trust is built.
Key takeaways
- CMMI is testing how Medicare pays for drugs through models like GLOBE, GUARD, BALANCE, and ACCESS. Watch all of them.
- Payment is shifting from volume to value. Build the outcomes data and analytics now.
- The earlier VBP model ended over impermissible costs. Any future $0 cost-sharing path has to be budget-neutral.
- Affordability is a performance metric. Track out-of-pocket burden, adherence, and access barriers.
- Cell and gene therapies need risk-sharing, reinsurance, and a churn plan across payers.
- Stop reading drug spend alone. Count the hospital stays and ER visits a therapy prevents.
- AI belongs behind the scenes and in population work. Members still want a human for their benefits.
Questions to bring to your team
- Which CMMI models touch your book of business, and are you ready for them?
- Where is your real-world evidence today, and where does it need to be?
- How do you measure affordability for your members, not for your spreadsheet?
- What is your operational plan for cell and gene therapy costs across payers?
- Where does AI help your team, and where do members still need a person?
Continue the conversation at an upcoming RISE event.