Our deeply fragmented health system is especially dangerous for older adults, younger people with disabilities, and their families. In an effort to improve their care, the federal Centers for Medicare and Medicaid Services is rolling out several experimental payment models aimed at better coordinating care and, perhaps, saving Medicare money.

The demonstrations, described by a growing cacophony of acronyms, work in two ways: They compensate providers such as doctors and hospitals based on quality rather than volume of care, and they engage and assist family members in the care of their loved ones.

These changes are ambitious and will require major changes in the way doctors, hospital and nursing home administrators, and patients think about care. And because they are experiments, they likely will evolve in coming years, adding complexity to an already hopelessly confusing health care system.

These initiatives apply to original (or traditional) Medicare, which now covers a bit less than half of enrollees. Some also may apply to those receiving both Medicare and Medicaid, called “dual eligibles.”  Medicare Advantage managed care plans are excluded from these reforms.

One concept behind these efforts, broadly described as value-based care, is not new. And CMS has been trying to better coordinate care for decades and took big steps to support family caregivers during the Biden Administration. But CMS has more aggressively embraced these ideas in recent months.

Yet, these initiatives seem inconsistent with other changes at the Department of Health and Human Services, which runs CMS. For example, HHS has hamstrung other important programs to support family caregivers.

Earlier this year, it moved to abolish the Administration for Community Living and fired nearly half its staff. That office manages the Older Americans Act and the RAISE Act, both key federal initiatives aimed at providing social and other supports for older adults and their families.

Government ius confronted with a choice: It can reduce its health care spending, which tops $1.7 trillion and accounts for one-quarter of all federal spending, in three ways. It can limit access to care or cut payments to health care providers, which President Trump and Congress did with last summer’s big budget bill. Or it can take steps to deliver care more efficiently.

Here are some of the ways CMS is trying to do the latter:

TEAM: This mandatory program (Transforming Episode Accountability Mode) makes hospitals responsible for the costs of a patient’s care for 30 days after discharge. It is a five-year demonstration program that begins this week, on January 1, 2026.

Top start, it will cover five surgical procedures, including hip fracture repairs; spinal fusions; and open-heart, major bowel, and orthopedic surgeries such as knee replacements at more than 700 hospitals.

If costs over the 30 days after discharge exceed a government benchmark, the hospital must pay Medicare. If the costs are lower than the target, the hospital (and its partner providers) can keep the savings.

A key consequence to watch: TEAM may limit the use of skilled nursing facilities for rehab and shift some of that post-acute care to patient’s homes. That will not only place new financial pressures on the nursing facilities, it will add to the care burden on families.

ACCESS (Advancing Chronic Care with Effective, Scalable Solutions) is aimed at encouraging doctors and other providers to use technology to prevent and manage chronic diseases. It also intends to improve care coordination between primary care doctors and specialists.

Like the other initiatives, it is based on shifting payment to encourage better quality at lower costs, what this voluntary model calls an “outcome-aligned payment approach.”  Due to begin in July, 2026, ACCESS will cover patients with chronic conditions such as diabetes, obesity, depression, and arthritis.

LEAD: The Long-Term Enhanced ACO Design is a 10-year demonstration that will begin in 2027. Participation will be voluntary. LEAD is the latest iteration of what started years ago as Accountable Care Organizations, or ACOs.

The idea: Doctors that achieve quality goals at low cost receive bonuses, those that don’t must pay penalties.

Many physician practices have abandoned ACOs, or never even enrolled, because the payment arrangements were insufficient, too complicated, or both. The latest version is intended to be more flexible and will give providers a choice between sharing 100% of the risk and gain, or sharing 50%.

CMS also wants to expand the ACO model to include Medicaid.

GUIDE: Created by the Biden Administration, GUIDE pays voluntarily participating providers a monthly fee of $200-$300 to provide care navigation services and other supports for people with dementia and their family caregivers.

Providers began offering services last summer. Along with a 2024 decision to create billing codes for family caregiver training, GUIDE recognized for the first time that Medicare has some responsibility for supporting family caregivers and for non-medical services such as training and care navigation.

All these initiatives will evolve over time. Some may fail. And it is hard to square them with the budget law’s cuts to Medicaid that will limit care for low-income older adults and younger people with disabilities.

But they have the potential to change the way doctors and hospitals think about their role in caring for patients, including older adults. And that’s a positive.