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April 30, 2018

GAO finds CMMI has only expanded two out of 37 care delivery and payment models

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    CMS' Center for Medicare and Medicaid Innovation (CMMI) met its 2015 goal to have at least three new payment models maintain or lower costs while improving or maintaining care quality—and so far has recommended two models for expansion, according to a Government and Accountability Office (GAO) report released Wednesday.

    Report details

    CMMI was created in November 2010 under the Affordable Care Act to test new ways to deliver and pay Medicare, Medicaid, and CHIP providers for care. GAO in 2012 conducted its first assessment of CMMI-implemented payment models.

    The latest assessment was conducted at Republicans' request and sought to determine the status of payment and care delivery models CMMI has implemented since November 2010. For the report, GAO reviewed available documents, including fact sheets, internal assessments, evaluation reports, and data for CMMI-implemented models.


    As of Sept. 30, 2016—the last period for which data were available—CMMI had spent $5.6 billion of the $10 billion it was allotted for fiscal years 2011 through 2019. During that time, CMS had implemented 37 alternative payment models, and more recently, has announced two additional payment models.

    Each of the models vary in delivery and payment approaches, provider participation requirements—mandatory versus voluntary—as well as beneficiaries covered. For example, according to GAO, 22 models exclusively covered Medicare beneficiaries, nine models covered both Medicare and Medicaid beneficiaries, seven models covered beneficiaries in Medicare, Medicaid, and CHIP, and one covered beneficiaries in Medicaid and CHIP.

    According to the report, CMS used an internal review process to assess the models' performance in terms of savings generated and care quality. GAO found that CMS has completed 10 such assessments, and has approved two models for expansion:

    • The Pioneer Accountable Care Organization (ACO) program, which ran from 2012 through 2016 and gave participating providers a financial incentive to contract with CMS to meet quality targets and assume new risk when caring for a set population of Medicare beneficiaries; and
    • The Diabetes Prevention Program, which promoted lifestyle changes to lower the risk of Type 2 diabetes.

    According to the report, CMS has since taken action to expand both programs. The agency incorporated the Pioneer ACO program into its Medicare Shared Savings Program, and in April 2018 launched an expanded Medicare Diabetes Prevention Program.

    According to Modern Healthcare, GAO in its report did not explain why CMS did not move to expand the other programs examined. However, GAO said CMS could expand additional programs if they are found to lower Medicare and Medicaid spending while maintaining or improving care quality.

    In addition, the report found CMMI in 2015 met or partially met its three performance goals:

    • Implementing at least three payment models that reduce health care cost growth, while maintaining or improving care quality;
    • Identifying, testing, and improving payment delivery models; and
    • Accelerating the spread of successful models.

    According to HealthPayerIntelligence, CMMI for 2018 expanded its goal from three successful payment models to six. According to GAO, CMMI officials said CMMI "has developed a methodology to estimate a forecasted return on investment for the model portfolio and is in the early stages of refining the methodology and applying it broadly across the portfolio in 2018" (Diamond, "Pulse," Politico, 4/26; Dickson, Modern Healthcare, 4/26; Beaton, HealthPayerIntelligence, 4/26).

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