CMS INNOVATION 

CENTER

Model Implementation 

and Center 

Performance

Report to Congressional Requesters

March 2018

GAO-18-302

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-18-302, a report to 

congressional requesters

March 2018

CMS INNOVATION CENTER

Model Implementation and Center Performance 

What GAO Found

As of March 1, 2018, the Center for Medicare and Medicaid Innovation 

(Innovation Center) had implemented 37 models that test new approaches for 

delivering and paying for health care with the goal of reducing spending and 

improving quality of care. These models varied based on several characteristics, 

including the program covered—Medicare, Medicaid, the Children’s Health 

Insurance Program (CHIP), or some combination of the three—and the nature of 

provider participation—voluntary or mandatory. Going forward, the Innovation 

Center indicated that the center plans to continue focusing on the use of 

voluntary participation models and to develop models in new areas, including 

prescription drugs, Medicare Advantage, mental and behavioral health, and 

program integrity. Through fiscal year 2016, the Innovation Center obligated $5.6

billion of its $10 billion appropriation for fiscal years 2011 through 2019.

The Innovation Center has used evaluations of models (1) to inform the 

development of additional models, (2) to make changes to models as they are 

implemented, and (3) to recommend models for expansion. For example, 

Innovation Center officials noted that, for some instances where evaluations

have shown reduced spending with maintained or improved quality of care, the 

center has developed new models that build upon the approaches of earlier 

models, but with adjustments intended to address reported limitations. In 

addition, the Innovation Center used evaluations to recommend two models to 

the Centers for Medicare & Medicaid Services (CMS) Office of the Actuary for 

certification for expansion. According to CMS officials, a model evaluation and a 

certification for expansion differ in that a model evaluation assesses the impact 

of a delivery and payment approach for model participants only, while a 

certification for expansion assesses the future impact on program spending more 

broadly across all beneficiaries, payers, and providers who would be affected by 

the expanded model. As a result, the Office of the Actuary used the results of the 

evaluation and other information, such as Medicare claims data and published 

studies, to certify the expansion of both models.

To assess the center’s overall performance, the Innovation Center established 

performance goals and related measures and reported meeting its targets for 

some goals in 2015, the latest year for which data were available (see table 

below).

Center for Medicare and Medicaid Innovation Reported Results for 2015 Performance Goals

Performance goal Performance targets met

Reducing the growth of health care costs while promoting better 

health and healthcare quality through delivery system reform Partially met

Identifying, testing, and improving payment and delivery models Met

Accelerating the spread of successful practices and models Partially met

Source: Center for Medicare & Medicaid Services. | GAO-18-302

Innovation Center officials told GAO that the center also recently developed a 

methodology to estimate a forecasted return on investment for its model 

portfolio. The center is in the early stages of refining the methodology and 

applying it broadly across its models.

View GAO-18-302. For more information, 

contact Kathleen M. King at (202) 512-7114 or 

kingk@gao.gov.

Why GAO Did This Study

The Patient Protection and Affordable 

Care Act created the Innovation Center 

within CMS to test new approaches to 

health care delivery and payment—

known as models—for use in 

Medicare, Medicaid, or CHIP. The 

Innovation Center became operational 

in November 2010. In 2012, GAO 

reported on the early implementation of 

the Innovation Center. GAO found that, 

during the first 16 months of 

operations, the Innovation Center 

focused on implementing 17 new 

models and developed preliminary 

plans for evaluating the effects of each 

model and for assessing the center’s 

overall performance.

GAO was asked to update its previous 

work. In this report, GAO: (1) describes 

the status of payment and delivery 

models implemented and the 

resources used; (2) describes the 

center’s use of model evaluations; and 

(3) examines the center’s assessment 

of its own performance. GAO reviewed 

available documentation, such as 

model fact sheets and frequently asked 

questions, and evaluation reports for 

models that have been implemented. 

GAO reviewed obligation data and 

performance information for the time 

period for which complete data or 

information were available. GAO also 

interviewed officials from the 

Innovation Center and CMS’s Office of 

the Actuary. 

The Department of Health and Human 

Services provided technical comments 

on a draft of this report, which GAO 

incorporated as appropriate.
Page i GAO-18-302 CMS Innovation Center

Letter 1

Background 5

The Innovation Center Implemented 37 Models That Test Varying 

Delivery and Payment Approaches, and Obligated over $5.6 

Billion 12

Evaluations Inform the Development of Models and Decisions to 

Certify Certain Models for Expansion 18

The Innovation Center Established Performance Goals and 

Related Performance Measures and Reported Meeting Its 

Targets for Some Goals 22

Agency Comments 26

Appendix I Center for Medicare and Medicaid Innovation’s General Process for 

Implementing Models 28

Appendix II Models Implemented or Announced by the Center for Medicare and 

Medicaid Innovation under Section 1115A 32

Appendix III Models Required by Different Provisions of the Patient Protection and 

Affordable Care Act 45

Appendix IV GAO Contact and Staff Acknowledgments 47

Tables

Table 1: Description of Center for Medicare and Medicaid 

Innovation (Innovation Center) Staffing Groups 8

Table 2: Selected Characteristics of the Center for Medicare and 

Medicaid Innovation Implemented and Announced 

Models, as of March 1, 2018 14

Table 3: Reported Results of the Center for Medicare and

Medicaid Innovation’s Performance Measures for Its Goal 

to Reduce the Growth of Health Care Costs While 

Promoting Better Health and Health Care Quality through 

Delivery System Reform 23

Contents
Page ii GAO-18-302 CMS Innovation Center

Table 4: Reported Results of the Center for Medicare and 

Medicaid Innovation’s Performance Measures for Its Goal 

to Identify, Test, and Improve Payment and Service 

Delivery Models 24

Table 5: Reported Results of the Center for Medicare and 

Medicaid Innovation’s Performance Measures for Its Goal 

to Accelerate the Spread of Successful Practices and 

Models 25

Table 6: Reported Results of Center for Medicare & Medicaid 

Services’ Performance Measures for Its Goal to Shift 

Medicare Health Care Payments from Volume to Value 26

Table 7: Description of the Center for Medicare and Medicaid 

Innovation’s (Innovation Center) General Process for 

Model Implementation 28

Table 8: Number of Section 1115A Center for Medicare and 

Medicaid Innovation Models Implemented and Announced 

by Category, as of March 1, 2018 32

Table 9: Descriptions and Other Information for Center for 

Medicare and Medicaid Innovation (Innovation Center) 

Models Organized under Accountable Care 33

Table 10: Descriptions and Other Information for Center for 

Medicare and Medicaid Innovation (Innovation Center) 

Models Organized under Episode-Based Payment 

Initiatives 35

Table 11: Descriptions and Other Information for the Center for 

Medicare and Medicaid Innovation (Innovation Center) 

Models Organized under Initiatives Focused on MedicareMedicaid Enrollees 37

Table 12: Descriptions and Other Information for the Center for 

Medicare and Medicaid Innovation (Innovation Center) 

Models Organized under Initiatives Focused on the 

Medicaid and Children’s Health Insurance Program 

Population 38

Table 13: Descriptions and Other Information for the Center for 

Medicare and Medicaid Innovation (Innovation Center) 

Models Organized under Initiatives to Accelerate the 

Development and Testing of New Payment and Service 

Delivery Models 39

Table 14: Descriptions and Other Information for the Center for 

Medicare and Medicaid Innovation (Innovation Center) 

Models Organized under Initiatives to Speed the Adoption 

of Best Practices 42
Page iii GAO-18-302 CMS Innovation Center

Table 15: Descriptions and Other Information for the Center for 

Medicare and Medicaid Innovation (Innovation Center) 

Models Organized under Primary Care Transformation 43

Table 16: Models Implemented by the Center for Medicare and 

Medicaid Innovation Required by Different Provisions of 

the Patient Protection and Affordable Care Act 45

Figures

Figure 1: Center for Medicare and Medicaid Innovation Staffing 

Levels, Fiscal Years 2011-2017 7

Figure 2: Center for Medicare and Medicaid Innovation (Innovation 

Center) Process for Model Development and 

Implementation 10

Figure 3: Cumulative Number of Models Implemented by the 

Center for Medicare and Medicaid Innovation, 2011-2018 13

Figure 4: Center for Medicare and Medicaid Innovation Annual 

Obligations, Fiscal years 2011-2016 17
Page iv GAO-18-302 CMS Innovation Center

Abbreviations

ACO Accountable Care Organization

APRN Advanced Practice Registered Nurse

BPCI Bundled Payments for Care Improvement

CHIP Children’s Health Insurance Program

CMS Centers for Medicare & Medicaid Services

CJR Comprehensive Care for Joint Replacement

Diabetes Prevention

Program YMCA of the USA Diabetes Prevention Program

FQHC Federally Qualified Health Center

HHS Department of Health and Human Services

ICIP Innovation Center Investment Proposal

OMB Office of Management and Budget

Innovation Center Center for Medicare and Medicaid Innovation

PPACA Patient Protection and Affordable Care Act

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Page 1 GAO-18-302 CMS Innovation Center

441 G St. N.W.

Washington, DC 20548

March 26, 2018

The Honorable Orrin G. Hatch

Chairman

Committee on Finance

United States Senate

The Honorable Greg Walden

Chairman

Committee on Energy and Commerce

House of Representatives

The Honorable Michael C. Burgess

Chairman

Subcommittee on Health

Committee on Energy and Commerce

House of Representatives

Federal spending on health care in the United States—driven primarily by 

Medicare and Medicaid expenditures—is expected to reach over $1 

trillion in 2018 and to continue increasing and exerting pressure on the 

federal budget.1 At the same time, studies have found that higher levels 

of spending do not reliably lead to enhanced quality of care.2 The Centers 

for Medicare & Medicaid Services (CMS), within the Department of Health 

and Human Services (HHS), has sought to both reduce spending and 

improve quality of care for beneficiaries enrolled in Medicare, Medicaid, 

and the Children’s Health Insurance Program (CHIP) by testing new ways 

 1

Medicare is the federal health insurance program for persons aged 65 or over, certain 

individuals with disabilities, and individuals with end-stage renal disease. Medicaid is a 

joint federal-state health care financing program for certain low-income individuals and 

medically needy individuals.

2

See for example, Sirovich, Brenda E., Daniel J. Gottlieb, H. Gilbert Welch, and Elliott S. 

Fisher. “Regional Variations in Health Care Intensity and Physician Perceptions of Quality 

of Care.” Annals of Internal Medicine, vol. 144, no. 9 (2006); Landrum, M. B., Meara, E. 

R., Chandra, A., Guadagnoli, E., & Keating, N. L. “Is Spending More Always Wasteful? 

The Appropriateness Of Care And Outcomes Among Colorectal Cancer Patients.” Health 

Affairs, vol. 27, no. 1 (2008); Yasaitis, L., Fisher, E. S., Skinner, J. S., & Chandra, A. 

“Hospital Quality And Intensity Of Spending: Is There An Association?” Health Affairs, vol. 

28, no.4, (2009); and Rothberg MB, Cohen J, Lindenauer P, Maselli J, Auerbach A. “Little 

Evidence Of Correlation Between Growth In Health Care Spending And Reduced 

Mortality.” Health Affairs, vol. 29, no.8 (2010).

Letter
Page 2 GAO-18-302 CMS Innovation Center

for delivering and paying for health care services.3 To further such testing, 

the Patient Protection and Affordable Care Act (PPACA) established the 

Center for Medicare and Medicaid Innovation (Innovation Center) within 

CMS under section 1115A of the Social Security Act.

4

In establishing the Innovation Center, the law provided CMS with 

additional authority when testing new health care delivery and payment 

approaches, known as models.5 For example, CMS may expand the 

duration and scope of models tested by the Innovation Center through 

rulemaking instead of needing the enactment of legislation, which was 

required to expand the demonstrations that CMS frequently conducted in 

the past. In addition, the law provided a dedicated appropriation for 

testing models—$10 billion for the Innovation Center’s activities for the 

period of fiscal years 2011 through 2019 and $10 billion per decade 

beginning in fiscal year 2020.

In November 2012, we reported on the early activities of the Innovation 

Center. We found that, during the first 16 months of operations, the 

Innovation Center focused on implementing 17 new models while 

assuming responsibility for 20 demonstrations that CMS began before the 

start of the center. We also reported that the Innovation Center developed 

preliminary plans for evaluating the effects of each model on spending 

and quality of care and assessing the center’s overall performance.6

At the time of our 2012 report, however, it was too early to consider 

certain questions raised by members of Congress about Innovation 

 3

CHIP is a federal-state program that provides health care coverage to children 18 years 

of age and younger living in low-income families whose incomes exceed the eligibility 

requirement for Medicaid.

4

The Innovation Center was established by section 1115A of the Social Security Act, as 

added by section 3021 of PPACA. See Pub. L. No. 111-148, §§ 3021, 10306. 124 Stat. 

119, 389, 939 (Mar. 23, 2010) (codified at 42 U.S.C. § 1315a).

5

Historically, CMS’s efforts to test new approaches to health care delivery and payment 

have been referred to as “demonstrations.” In this report, we will use the term “models” 

when discussing approaches initiated by the Innovation Center, and “demonstrations” 

when discussing approaches that were initiated prior to the establishment of the center.

6

We also found that the Innovation Center had initiated implementation of a process to 

review and eliminate unnecessary duplication in the contracts awarded in one of its 

models. We recommended completing the implementation expeditiously. Implementation 

was completed in August 2013. See GAO, CMS Innovation Center: Early Implementation 

Efforts Suggest Need for Additional Actions to Help Ensure Coordination with Other CMS 

Offices, GAO-13-12 (Washington, D.C.: November 15, 2012).
Page 3 GAO-18-302 CMS Innovation Center

Center operations, including the use of its dedicated funding, the impact 

of the models tested, and the center’s overall performance. Given the 

amount of time that has passed—the Innovation Center has been in 

operation for over 7 years—you asked us to update our previous work to 

provide information on the activities of the center and to report on any 

results of the testing. This report examines

1. the status of the Innovation Center’s testing of models and the 

resources used for such activities;

2. the use of model evaluations; and

3. the Innovation Center’s assessment of its performance.

To determine the status of model testing and the resources used by the 

Innovation Center for such activities, we reviewed Innovation Center 

documentation, including information on models the center was 

implementing or had announced, as well as web pages, model fact 

sheets, and frequently asked questions. We obtained and analyzed 

Innovation Center data on the amounts of the Innovation Center’s 

appropriations obligated. We also interviewed and obtained written 

responses from Innovation Center officials. Our work focused on models 

tested and funded through appropriations under section 1115A of the 

Social Security Act, as enacted by PPACA, which established the center 

and provided its dedicated appropriations. In general, our work covered 

the period during which the Innovation Center first became operational 

(fiscal year 2011) through the most recent time period for which complete 

information was available. For the status of model testing, we considered 

information through March 1, 2018. For the resources used, we analyzed 

data on the amounts of the Innovation Center’s appropriations obligated 

through fiscal year 2016. We assessed the reliability of the obligation data 

by comparing it to publicly reported amounts and discussing the data with 

center officials. We determined these data were sufficiently reliable for the 

purposes of our objectives.

To determine how the Innovation Center used evaluations of models, we 

interviewed officials from the center, CMS’s Office of the Actuary, 

evaluation contractors, and subject matter experts to discuss the use of 
Page 4 GAO-18-302 CMS Innovation Center

evaluations, in general, as well as for five selected models specifically.7

We selected models based on a nonprobability sample that included both 

Medicare and Medicaid models; ongoing and completed models; models 

that fell under the responsibility of different Innovation Center staffing

groups; and one model evaluated for expansion. Because we used a 

nonprobability sample, our results are not generalizable beyond the 

models we reviewed; however, they provide insight into how CMS uses 

the evaluations of its models. We also analyzed publicly available 

evaluation reports and other model documentation publicly available from 

the Innovation Center and the Office of the Actuary.

To describe the Innovation Center’s assessment of its performance, we 

reviewed information reported on the center’s targeted and actual 

performance available in CMS’s Congressional Budget Justifications for 

fiscal years 2012 through 2018. Information on the center’s targets was 

available for performance years 2014 through 2018. Complete 

information on the center’s actual performance was available for 2015. 

Partial information was available for 2014 and 2016, and no information 

was available for 2017 and 2018. We also interviewed Innovation Center 

officials regarding the assessment of performance.

We conducted this performance audit from February 2017 to March 2018 

in accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.

 7

The five models selected were the Bundled Payments for Care Improvement Model 2; 

the Comprehensive Primary Care Initiative; the Health Care Innovation Awards; the 

Pioneer Accountable Care Organization model; and the Strong Start for Mothers and 

Newborns Initiative: Enhanced Prenatal Care model.
Page 5 GAO-18-302 CMS Innovation Center

Section 1115A establishes certain requirements for the Innovation Center 

that relate to the selection of models, use of resources, and evaluation of 

models. These requirements include:

• consulting with representatives of relevant federal agencies, as well 

as clinical and analytical experts in medicine or health care 

management, when carrying out its duties as described in the law;

• ensuring models address deficits in care that have led to poor clinical 

outcomes or potentially avoidable spending;

• making no less than $25 million of the Innovation Center’s dedicated 

funding available for model design, implementation, and evaluation 

each fiscal year starting in 2011;

• evaluating each model to analyze its effects on spending and quality 

of care, and making these evaluations public; and

• modifying or terminating a model any time after testing and evaluation 

has begun unless it determines that the model either improves quality 

of care without increasing spending levels, reduces spending without 

reducing quality, or both.

Under section 1115A, certain requirements applicable to previous CMS 

demonstrations are inapplicable to models tested under the Innovation 

Center. For example, while prior demonstrations generally required 

congressional approval in order to be expanded, section 1115A allows 

CMS to expand Innovation Center models—including on a nationwide 

basis—through the rulemaking process if the following conditions are met: 

(1) the agency determines that the expansion is expected to reduce 

spending without reducing the quality of care, or improve quality without 

increasing spending; (2) CMS’s Office of the Actuary certifies that the 

expansion will reduce or not increase net program spending; and (3) the 

agency determines that the expansion would not deny or limit coverage or 

benefits for beneficiaries.8 In addition, certain requirements previously 

cited by the Medicare Payment Advisory Commission as administrative 

 8

In addition, the law provides that demonstrations conducted under 42 U.S.C. § 1395cc-3, 

Medicare’s Health Care Quality Demonstration Program, may also be expanded under the 

same conditions. 42 U.S.C. § 1315a(c).

Background

Requirements for 

Innovation Center Models 

Implemented under 

Section 1115A
Page 6 GAO-18-302 CMS Innovation Center

barriers to the timely completion of demonstrations are inapplicable.

9

Specifically, section 1115A provides the following:

• HHS cannot require that an Innovation Center model initially be 

budget neutral—that is, designed so that estimated federal 

expenditures under the model are expected to be no more than they 

would have been without the model—prior to approving a model for 

testing.

• Certain CMS actions in testing and expanding Innovation Center 

models cannot be subject to administrative or judicial review.

• The Paperwork Reduction Act—which generally requires agencies to 

submit all proposed information collection efforts to the Office of 

Management and Budget (OMB) for approval and provide a 60-day 

period for public comment when they want to collect data on 10 or 

more individuals—does not apply to Innovation Center models.10

The Innovation Center uses a combination of staff and contractors to test 

models. Since the center became operational in November 2010, the 

number of staff increased steadily through the end of fiscal year 2016.11

(See fig. 1.) As of September 30, 2017, there were 617 staff—a slight

decrease in the number of staff from the end of the prior fiscal year. 

Officials indicated that, in the future, changes in the model portfolio may 

require additional staff to manage and support model development and 

implementation. However, officials do not anticipate needing to increase 

staffing levels at the same pace as they did between fiscal years 2011 

and 2016. Additionally, the Innovation Center uses third-party contactors 

to perform functions related to the implementation of models and to 

perform evaluations of the changes in the quality of care furnished and 

program spending under a model.

 9

See Medicare Payment Advisory Commission, Report to Congress: Aligning Incentives in 

Medicare, (Washington, D.C.: 2010).

1044 U.S.C. §§ 3501-3520. OMB assists the President in overseeing the preparation of the 

federal budget and in supervising its administration in executive branch agencies. OMB 

also oversees and coordinates the administration’s procurement, financial management, 

information, and regulatory policies.

11We previously reported that, as of March 31, 2012, the Innovation had 184 staff. See 

GAO-13-12. Staff are primarily funded through appropriations under section 1115A of the 

Social Security Act.

Innovation Center Staffing 

and Organization
Page 7 GAO-18-302 CMS Innovation Center

Figure 1: Center for Medicare and Medicaid Innovation Staffing Levels, Fiscal Years 

2011-2017

The Innovation Center has organized its 617 staff members primarily into 

eight groups and the Office of the Director. Four of the eight groups are 

responsible for coordinating the development and implementation of 

models.12 Staff in these four groups primarily lead efforts in developing 

model designs and obtaining approval for their models from CMS and 

HHS. Once a model is approved, staff coordinate the remaining 

implementation steps, including soliciting and selecting participants and 

overseeing the model during the testing and evaluation period. The other 

four groups perform key functions that support model development and 

implementation, such as reviewing ideas submitted for consideration as 

possible models, overseeing the evaluations of models, providing 

feedback to model participants about their performance, disseminating 

 12We previously reported that as of March 31, 2012, the groups that implement models 

included the Medicare Demonstration Group, which was responsible for implementing 

models required by authorities other than section 1115A of the Social Security Act and 

CMS demonstrations that existed prior to the establishment of the Innovation Center. See 

GAO-13-12. According to Innovation Center officials, the responsibility for these models 

and demonstrations was reassigned to other model groups.
Page 8 GAO-18-302 CMS Innovation Center

lessons learned across models, and monitoring budget resources.13 The 

Office of the Director, in general, has oversight responsibilities for the 

models led by these groups. Table 1 provides information on the staffing 

groups within the Innovation Center.

Table 1: Description of Center for Medicare and Medicaid Innovation (Innovation Center) Staffing Groups

Group Purpose

Groups that coordinate model development and implementation

Patient Care Models Group Develop and coordinate the implementation of models designed to improve 

care for clinical groups of patients, such as patients needing heart bypass 

surgery

Prevention and Population Health Group Develop and coordinate the implementation of models designed to improve the 

health of different populations of beneficiaries.

Seamless Care Models Group Develop and coordinate the implementation of models designed to improve 

coordination of care for a general patient population across care settings.

State Innovations Group Develop and coordinate the implementation of models designed to use states’ 

policy and regulatory levers to accelerate health care transformation in multipayer environments.

Groups that support model development and implementation

Business Services Group Provide administrative support to the Innovation Center in areas such as 

budgeting, contracting, project management, information technology support 

and maintenance.

Learning and Diffusion Group Facilitate learning within models and disseminate the lessons learned across 

models so that participants can benefit from the experiences of other models.

Policy and Programs Group Manage ideas for consideration as possible models and seek to ensure a 

balanced portfolio of different types of models and manage stakeholder 

engagement for the Innovation Center.a

Research and Rapid Cycle Evaluation Group Coordinate the evaluation of models and provide ongoing feedback to 

participants. 

Source: GAO analysis of Centers for Medicare & Medicaid Services information. | GAO-18-302

Notes: We previously reported that the groups under which the Innovation Center organized staff 

included the Medicare Demonstration Group and the Stakeholder Engagement Group. See 

GAO-13-12. The Medicare Demonstration Group, which previously was responsible for implementing 

 13We previously reported that as of March 31, 2012, the groups that support model 

implementation included the Stakeholder Engagement Group, which conducted outreach 

to potential stakeholders, to gain support and solicit ideas for innovative models, and to 

potential participants—such as physician groups and hospitals—to inform them of the 

opportunity to participate in models. See GAO-13-12. According to Innovation Center 

officials, this group was incorporated into the Policy and Programs Group in 2016. The 

Policy and Programs Group is also responsible for developing and implementing a portion 

of the Quality Payment Program—a new payment framework for Medicare intended to 

reward providers for efficient, high-quality care, instead of a higher volume of services. 

This program includes two tracks: (1) the Merit-based Incentive Payment System and (2) 

Advanced Alternative Payment Models.
Page 9 GAO-18-302 CMS Innovation Center

certain models and demonstrations, was eliminated, and its responsibilities were reassigned to other 

groups. The Stakeholder Engagement Group was incorporated into the Policy and Programs Group.

a

The Policy and Programs Group is also responsible for developing and implementing a portion of the 

Quality Payment Program—a new payment framework for Medicare intended to reward health care 

providers for efficient, high-quality care, instead of a higher volume of services. This program includes 

two tracks: (1) the Merit-based Incentive Payment System and (2) Advanced Alternative Payment 

Models.

The Innovation Center has developed internal agency guidance that 

outlines a general process used by the four model groups for developing 

and implementing models. (See fig. 2.) Appendix I provides additional 

information about the general process for implementing models.

Innovation Center Process 

for Model Development 

and Implementation
Page 10 GAO-18-302 CMS Innovation Center

Figure 2: Center for Medicare and Medicaid Innovation (Innovation Center) Process for Model Development and 

Implementation

The Innovation Center has organized its models into seven categories 

based on delivery and payment approaches tested and program 

beneficiaries covered. The seven categories are as follows:

Innovation Center 

Categories for Models
Page 11 GAO-18-302 CMS Innovation Center

• Accountable Care. This category includes models built around 

accountable care organizations (ACOs)—groups of coordinated 

health care providers who are held responsible for the care of a group 

of patients. The models are designed to encourage ACOs to invest in 

infrastructure and care processes for improving coordination, 

efficiency, and quality of care for Medicare beneficiaries.

• Episode-based payment initiatives. This category includes models 

in which providers are held accountable for the Medicare spending 

and quality of care received by beneficiaries during an “episode of 

care,” which begins with a health care event (e.g., hospitalization) and 

continues for a limited time after.

• Initiatives Focused on Medicare-Medicaid Beneficiaries. This 

category includes models focused on better serving individuals 

eligible for both Medicaid and Medicare in a cost-effective manner.

• Initiatives Focused on Medicaid and CHIP Populations. This 

category includes models administered by participating states to lower 

spending and improve quality of care for Medicaid and CHIP 

beneficiaries.

• Initiatives to Accelerate the Development and Testing of New 

Payment and Service Delivery Models. This category includes 

models where the Innovation Center works with participants to test 

state-based and locally developed models, covering Medicare 

beneficiaries, Medicaid beneficiaries, or both.

• Initiatives to Speed the Adoption of Best Practices. This category 

includes models in which the Innovation Center collaborates with 

health care providers, federal agencies, and other stakeholders to test 

ways of disseminating evidence-based best practices that improve 

Medicare spending and quality of care for beneficiaries.

• Primary Care Transformation. This category includes models that 

use advanced primary care practices—also called “medical homes”—

to emphasize prevention, health information technology, care 

coordination, and shared decision-making among patients and their 

providers.

For certain categories, the Innovation Center assigns primary 

responsibility for developing and implementing models to a single model 

group; for some other categories, the responsibility is shared across 

different groups. For example, the center assigned responsibility for 

models in the ACO and the Primary Care Transformation categories to 

the Seamless Care Model Group, whereas the responsibility for models in 

the Initiatives to Accelerate the Development and Testing of New 
Page 12 GAO-18-302 CMS Innovation Center

Payment and Service Delivery Models categories were assigned across 

all four model groups. Appendix II provides a summary of the number of 

models organized under each category and a description of each model.

As of March 1, 2018, the Innovation Center had implemented 37 models 

under section 1115A of the Social Security Act.14 (See fig. 3.) Of those 37 

models, the testing period has concluded for 10 of them.15 In addition, the 

Innovation Center has announced two models to begin testing in 2018.

 14In addition to these models, we previously reported that the Innovation Center was 

responsible for implementing 6 models required by other provisions of PPACA, as well as 

20 CMS demonstrations that existed prior to the establishment of the Innovation Center. 

See GAO-13-12. The testing periods for 4 of the 6 models required by other provisions of 

PPACA and 19 of 20 demonstrations have ended. See appendix III for more information 

on the 6 models required by other provisions of PPACA. 

15These ten models are the Advance Payment ACO Model, the Bundled Payments for 

Care Improvement Model 1 (Retrospective Acute Care Hospital Stay Only), the 

Comprehensive Primary Care Initiative, the Federally Qualified Health Center Advanced 

Primary Care Practice Demonstration, the Health Care Innovation Awards Round 1, the 

Health Care Innovation Awards Round 2, the Initiative to Reduce Avoidable 

Hospitalizations among Nursing Facility Residents: Phase One, Pioneer ACO, Partnership 

for Patients, and State Innovation Models Initiative: Round One.

The Innovation 

Center Implemented 

37 Models That Test 

Varying Delivery and 

Payment Approaches, 

and Obligated over 

$5.6 Billion

The Innovation Center 

Implemented 37 Models 

and Announced an 

Additional 2; Models 

Varied by Delivery and 

Payment Approaches 

Tested, Beneficiaries 

Covered, and Other 

Characteristics
Page 13 GAO-18-302 CMS Innovation Center

Figure 3: Cumulative Number of Models Implemented by the Center for Medicare 

and Medicaid Innovation, 2011-2018

Note: Models were implemented between January 1, 2011 and March 1, 2018. Of the 37 models, the 

testing period ended in calendar year 2017 or before for 10 models.

Innovation Center models varied based on several characteristics, 

including delivery and payment approaches tested and program(s) 

covered. Delivery and payment approaches varied across all 

implemented and announced models—even models organized by the 

Innovation Center under the same model category. For example, the six 

models that tested an episode-based payment approach varied in terms 

of how episodes were defined, including the clinical and surgical episodes 

to which models applied. In addition, some models included multiple 

approaches for achieving changes in health care delivery or payment. 

Models also differed in terms of the programs covered, with 22 models 

covering Medicare only, 9 models covering Medicare and Medicaid, one 

model covering Medicaid and CHIP, and 7 models covering all three 

programs. Other characteristics by which models varied include the 

nature of model participation for providers (voluntary or mandatory) and 

the source of innovation (i.e., federal, state, or local initiatives). See table 

2 for a breakdown of models across selected characteristics. Appendix II 

provides a full description of all models implemented and announced by 

the Innovation Center.
Page 14 GAO-18-302 CMS Innovation Center

Table 2: Selected Characteristics of the Center for Medicare and Medicaid Innovation Implemented and Announced Models, 

as of March 1, 2018

Model characteristic Description of models implemented or announced

Program covered • Twenty-two models covered Medicare only—one of which specifically focused on 

Medicare Advantage.

• Nine models covered Medicare and Medicaid.

• One model covered Medicaid and the Children’s Health Insurance Program (CHIP).

• Seven models covered Medicare, Medicaid, and CHIP.

Nature of provider participation • Thirty-seven models had voluntary participation.

• One model had a combination of mandatory and voluntary participation.a

• One model had mandatory participation.

Innovation source • Thirty-one models tested a delivery and payment approach designed by the 

Innovation Center.

• Six models tested approaches designed and implemented by or in partnership with 

states.

• Two models tested a variety of delivery and payment approaches designed and 

implemented by individual cooperative agreement awardees. 

Other • Eight models were considered advanced alternative payment models—payment 

approaches that gave incentive payments to provide high-quality and cost-efficient 

care allowing providers to earn more for taking on some risk related to patient 

outcomes.

• Two models tested delivery and payment approaches designed to prevent the 

development of specific diseases in at-risk beneficiaries.

• Two models focused on specialty care services— orthopedic surgeries and 

chemotherapy—to test payment arrangements in which hospitals received additional 

payments or made recoupment payments if total spending for Medicare services 

provided during an “episode of care” was over or under a predetermined target 

price.

Source: GAO analysis of Centers for Medicare & Medicaid Services information. | GAO-18-302

a

On December 1, 2017, a final rule was issued making provider participation in select geographic 

areas voluntary for this model, effective January 1, 2018. Prior to the final rule, provider participation 

was mandatory in all geographic areas included in this model.

In September 2017, the Innovation Center provided some insight into its 

future plans when it issued an informal “request for information” that 

identified guiding principles under which models will be designed going 

forward, described focus areas for new models, and requested feedback 

from stakeholders. One of the guiding principles focused on voluntary 

models—a principle consistent with a final rule published in December 

2017 canceling four mandatory participation models in development and 

making participation in a fifth mandatory model voluntary for some 
Page 15 GAO-18-302 CMS Innovation Center

geographic areas.16 Other guiding principles included promoting 

competition based on quality, outcomes, and costs; empowering 

beneficiaries, their families, and caregivers to take ownership of their 

health; and using data-driven insights to ensure cost-effective care that 

also leads to improvements in beneficiary outcomes. In addition, the 

Innovation Center indicated the following focus areas for new model 

development: additional advanced alternative payment models; 

consumer-directed care and market-based innovation models; physician 

specialty models; prescription drug models; Medicare Advantage 

innovation models; state-based and local innovation, including Medicaidfocused models; mental and behavioral health models; and program 

integrity.

According to Innovation Center documentation, through September 30, 

2016, the center obligated over $5.6 billion of the $10 billion appropriated 

for fiscal years 2011 through 2019 under section 1115A of the Social 

Security Act.17 The obligated amounts for individual models during this 

period ranged from $8.4 million to over $967 million, and varied based on 

model scope and design.18 For example, a model where the Innovation 

Center used its waiver authority to provide additional flexibility to 

participants (rather than additional funding) required only $8.4 million in 

obligations for the evaluation of the model and implementation activities. 

In contrast, a model where the Innovation Center awarded funding to a 

 16See 82 Fed. Reg. 57,066 (Dec. 1, 2017). The final rule canceled the Episode Payment 

Models—the Surgical Hip/Femur Fracture Treatment Model, the Acute Myocardial 

Infarction Model, and the Coronary Artery Bypass Graft Model—and the Cardiac 

Rehabilitation Incentive Payment Model, all of which were scheduled to begin on January 

1, 2018. The Comprehensive Joint Replacement model was implemented in April 2016 in 

67 geographic areas. When implemented, participation was mandatory in all areas. The 

final rule made participation voluntary in 33 of the 67 geographic areas and for all low 

volume and rural hospitals.

17An obligation is a definite commitment that creates a legal liability of the government for 

the payment of goods and services ordered or received, or a legal duty on the part of the 

United States that could mature into a legal liability by virtue of actions on the part of the 

other party beyond the control of the United States. Payment may be made immediately or 

in the future. 

18Obligated amounts for individual models reflect payments made to model participants 

(including health care providers, states, and others) as well as other payments to support 

model development and testing. Amounts do not include Medicare, Medicaid, and CHIP 

payments that health care providers or others receive for services provided to the 

beneficiaries. For models selected by the Innovation Center for development and 

implementation, the center obtains approval from CMS, HHS, and OMB for the amount it 

expects will be required to test and evaluate models. 

The Innovation Center 

Obligated over 55 Percent 

of Its Initial Multiyear 

Appropriation through 

Fiscal Year 2016
Page 16 GAO-18-302 CMS Innovation Center

broad set of partners, including providers, local government, and publicprivate partnerships, to test their own care delivery and payment models 

required more than $870 million in obligations for payments to awardees 

and used over $95 million for contractor evaluations and other activities 

that supported model development and implementation.

Innovation Center spending falls into three categories: model programs, 

innovation support, and administration.

• Model programs include obligations that directly support individual 

models and delivery system reform initiatives.

• Innovation support includes center-wide operational expenses that are 

not directly attributable to a single model.

• Administration includes permanent federal full-time equivalent payroll 

expenses, administrative contracts, administrative interagency 

agreements, and general administrative expenses.

As the Innovation Center implemented additional models each year, total 

annual obligations increased steadily from approximately $95 million in 

fiscal year 2011 to more than $1.3 billion in fiscal year 2015, but 

decreased slightly in fiscal year 2016. (See fig. 4) Most of these total 

obligations were for model programs, which followed a similar pattern, 

increasing from $51 million in 2011 to about $1.1 billion in fiscal year 

2015, with a slight decrease in fiscal year 2016. According to officials, the 

2016 decrease in obligations for model programs was due in part to some 

of the earlier, expensive models ending and to newer models being less 

costly than the older models. Officials noted, for example, that a number 

of newer models incorporated basic program infrastructure used in 

previously implemented models, which allowed for reduced model costs. 

Officials also indicated that the decrease in obligations may be due to 

newer models using payment approaches that are funded by the 

Medicare Trust Fund, rather than funded by the Innovation Center’s 

dedicated appropriation. The center’s obligations for both innovation 

support and administration increased from around $20 million for each 

category in fiscal year 2011 to about $163 million for innovation support 

and $119 million for administration in fiscal year 2016. Officials told us 

that as obligations for model programs grew, so did obligations for 

innovation support and administration, which includes indirect costs and 

contractor assistance.
Page 17 GAO-18-302 CMS Innovation Center

Figure 4: Center for Medicare and Medicaid Innovation Annual Obligations, Fiscal 

years 2011-2016
Page 18 GAO-18-302 CMS Innovation Center

The Innovation Center has used the results from model evaluations to 

generate ideas for new models. For some of the early implemented 

models, evaluation results showed reduced spending and maintained or 

improved quality of care, but also identified model design limitations that 

could affect those results. According to officials, in some of these 

instances, the Innovation Center has developed new models that build 

upon the approaches of earlier models, but include adjustments intended 

to address identified limitations (see text box).

Example of A Model That Tests the Same General Delivery and Payment Approach 

of a Previously Implemented Model While Addressing Limitations

Bundled Payment for Care Improvement (BPCI) Model 2 tested an episode-based 

delivery and payment approach in which the Innovation Center set a benchmark, or 

target, price for all Medicare services a beneficiary might receive during a clinical 

episode—defined by BPCI Model 2 as the initial hospital stay and all services received up 

to 90 days after discharge. If the total spending for Medicare services during an episode 

was lower than the target price, participating hospitals would receive payments in 

addition to the normal fee-for-service payments. If the total spending for Medicare 

services during an episode was higher than the target price, participating hospitals would 

have to reimburse Medicare. Participants could select up to 48 different clinical episodes 

under the model. 

The evaluation of BPCI Model 2 found that orthopedic surgery episodes—of which 

approximately 90 percent were hip and knee joint replacement surgeries—may have 

resulted in reduced program spending and improved quality of care. However, the 

evaluation also identified limitations affecting those results. For example, the target prices 

for hip and knee replacement surgeries did not account for potential differences in 

Medicare spending between elective surgeries and surgeries required after a fracture. As 

a result of this limitation, hospitals could attempt to control spending by limiting the 

number of episodes associated with higher cost beneficiaries (i.e., those requiring 

surgery due to a fracture).

In part to address the design issue identified under BPCI Model 2, Innovation Center 

officials told us they developed the Comprehensive Care for Joint Replacement (CJR) 

model. Implemented in April 2016, the CJR model tests the same general delivery and 

payment approach used in BPCI Model 2, but focuses specifically on hip and knee joint 

replacement surgical episodes and adjusts the target price to account for the higher 

spending related to hip and knee joint replacement surgeries following a fracture. As of 

March 1, 2018, no evaluations of the CJR model have been publicly released.

Source: GAO. | GAO-18-302

Evaluations Inform 

the Development of 

Models and Decisions 

to Certify Certain 

Models for Expansion

The Innovation Center 

Has Used the Results 

from Evaluations to Inform 

the Development of 

Additional Models and to 

Make Changes to 

Implemented Models

Evaluations of Implemented Models

The evaluation of each model is performed by 

a third-party contractor, who generally 

determines the effect of a model on quality of 

care and program spending by comparing 

data for model participants to those of a 

comparison group of providers and 

beneficiaries with characteristics similar to 

model participants. For purposes of the 

evaluation, the Innovation Center has the 

authority to require the collection and 

submission of necessary data by model 

participants. Accordingly, the third-party 

contractor collects both quantitative and 

qualitative data. The quantitative data are 

used to assess program spending and quality 

of care and the qualitative data are used to 

provide the context needed to understand the 

quantitative results. 

Source: GAO | GAO-18-302
Page 19 GAO-18-302 CMS Innovation Center

The Innovation Center has also used the results from evaluations as one 

way to improve the operational and participant support for new models. 

According to officials, evaluations have helped them identify lessons 

learned regarding support systems, such as which types of systems work 

well with which types of models, and then the center incorporated those 

lessons when designing the systems for new models. For example, 

officials noted that the experience with the learning system from the 

Bundled Payments for Care Improvement (BPCI) models informed the 

learning system for the Comprehensive Care for Joint Replacement 

(CJR) model.19 The lessons learned helped the Innovation Center better 

identify where participants would need additional support and the learning 

activities—such as webinars and implementation guides—to provide the 

needed support during the early stages of model implementation. 

Innovation Center officials told us that these lessons from evaluations 

helped ensure that each successive model built upon the collective 

experience of models implemented by the center.20

The Innovation Center also has used evaluation results to make periodic 

changes to models during the testing period. According to officials, these 

changes include adjustments to the delivery and payment approaches 

tested, such as refining the target population, broadening the geographic 

focus, and refinements of spending calculations. Innovation Center 

officials noted that, in general, such changes were limited to minimize 

their effects on the evaluation of program spending and quality of care. 

Officials also identified changes to operational and participant support 

systems, which have included changes to the timing of participant data 

reporting, revisions to how data are collected from participants, and 

changes to the way learning materials are delivered to participants. 

According to officials, these types of changes are generally intended to 

help improve the experience of participants.

 19The Innovation Center uses learning systems to help participants achieve success 

under its models by articulating the aim and drivers of success, providing technical 

assistance and feedback, and facilitating peer-to-peer exchange of ideas, among other 

functions. 

20Another way in which the evaluations inform the development of additional models 

relates specifically to primary care redesign models. The Innovation Center initiated a 

systematic review of the evaluation results for six primary care redesign models 

implemented by the center. The review, in part, identified common themes to consider 

when developing new models. See https://innovation.cms.gov/Files/reports/primarycarefinalevalrpt.pdf (accessed March 7, 2018).
Page 20 GAO-18-302 CMS Innovation Center

According to Innovation Center officials, evaluation results may also be 

used in making a decision to terminate a model prior to the end of its 

planned testing period. However, officials stated that the Innovation 

Center has not terminated any models prior to the conclusion of their 

testing periods, either based on the results of an evaluation or for other 

reasons.21

The Innovation Center used evaluation results in recommending two 

models be certified for expansion. According to Innovation Center 

officials, the evaluation of each model adequately demonstrated that the 

delivery and payment approach tested reduced Medicare spending while 

maintaining or improving quality of care. Based on these results, the 

Innovation Center formally requested that CMS’s Office of the Actuary 

analyze the financial impact of a potential expansion of each model. The 

two models were:

• Pioneer ACO. Pioneer ACO tested an ACO delivery and payment 

approach that gave providers an opportunity to be paid a relatively 

greater share of savings generated, compared to participants in other 

ACO models, in exchange for accepting financial responsibility for any 

losses. In year 3 of the model, ACOs that met certain levels of savings 

in the first two years could elect to receive a portion of their Medicare 

fee-for-service payments in the form of predetermined, per beneficiary 

per month payments.

• YMCA of the USA Diabetes Prevention Program (Diabetes 

Prevention Program). The Diabetes Prevention Program applied a 

lifestyle change program recognized by the Centers for Disease 

Control and Prevention to reduce to the risk of Type 2 diabetes for atrisk Medicare beneficiaries. The Diabetes Prevention Program was a 

part of the Health Care Innovation Awards Round One model.

When assessing the Pioneer ACO and Diabetes Prevention Program 

models for expansion, the officials from the Office of the Actuary 

considered the model evaluation results that were available and 

information from other sources.22 For example, the assessment of 

Pioneer ACO used historical shared savings calculations and beneficiary 

 21Innovation Center officials told us that some models have been canceled prior to the 

start of testing due to lack of interest in participation.

22The Office of the Actuary conducted its assessments prior to the availability of final 

evaluations for both models.

Evaluations Informed 

Innovation Center 

Decisions to Recommend 

Two Models be Certified 

for Expansion
Page 21 GAO-18-302 CMS Innovation Center

attribution data from ACOs in the Medicare Shared Saving Program and 

Pioneer ACO; Medicare claims and enrollment data; and published 

studies. According to CMS officials, a model evaluation and a certification 

for expansion differ in that a model evaluation assesses the historical 

impact of a delivery and payment approach for model participants only, 

while a certification for expansion assesses the future impact on program 

spending across all beneficiaries, payers, and providers who would be 

affected by the expanded model.

Based on its assessments, the Office of the Actuary certified both models 

for expansion and steps have been taken to expand them. In certifying 

Pioneer ACO, the Office of the Actuary concluded that because ACOs, in 

general, have been shown to produce savings relative to Medicare feefor-service, an expansion of Pioneer ACO would generate further savings 

to the Medicare program.23 According to officials, CMS expanded Pioneer 

ACO by incorporating elements of the model—through rulemaking—as 

one of the options that providers may choose under the Medicare Shared 

Savings Program.24 For the Diabetes Prevention Program, the Office of 

the Actuary concluded that certain changes considered as part of the 

expansion would, in the near term, improve upon the original savings 

achieved as part of the Health Care Innovation Awards as well as savings 

achieved in similar diabetes prevention programs. The Innovation Center 

has expanded—through rulemaking—the Diabetes Prevention Program 

under a new, nationwide model to be implemented in April 2018.

In addition, officials from the Innovation Center and the Office of the 

Actuary discussed potentially assessing whether Partnership for Patients 

should be certified for expansion. Partnership for Patients is a model that 

leveraged federal, state, local, and private programs to spread proven 

practices for reducing preventable hospital-acquired conditions and 

readmissions across acute care hospitals. According to officials, the 

Innovation Center shared the results for Partnership for Patients—which 

showed improved quality of care in the form of reduced preventable 

hospital-acquired conditions and readmissions—with the officials from the 

 23In order for the requirements for expansion to be met, the Secretary must also 

determine that expansion is expected to reduce spending without reducing the quality of 

care or improve the quality of care without increasing spending and that expansion would 

not deny or limit the coverage or provisions of benefits.

24The Medicare Shared Savings Program is a permanent Medicare ACO program. The 

program includes different participation options that allow ACOs to assume various levels 

of risk.
Page 22 GAO-18-302 CMS Innovation Center

Office of the Actuary. After discussing these issues, Innovation Center 

officials decided not to request a formal analysis for certification of 

expansion.25

To assess is own performance, the Innovation Center established three 

center-wide performance goals and related measures.26

Goal 1: Reduce the growth of healthcare costs while promoting 

better health and health care quality through delivery system reform.

This goal has three performance measures that focus on ACOs. As 

shown in table 3, the Innovation Center has reported mixed results in 

achieving the targets set. According to agency reported data, the 

Innovation Center met the targets for 2 of its 3 Goal 1 performance 

measures for 2015. For the remaining measure—the percentage of ACOs 

that shared in savings—the center did not meet its target during either of 

the two years for which data were available. According to officials, when 

results fall short of targets, they examine the causes and make 

appropriate adjustments to the program. Officials stated that the missed 

target was driven by the high growth in the number of ACOs that were 

new—and therefore would not yet be expected to achieve a level of 

savings in which they could share—and not by ACO performance deficits. 

As a result, officials decided that no adjustments were required to the 

Medicare Shared Savings Program or other ACO Models to help improve 

performance. However, as shown in table 3, the Innovation Center set a 

target for 2016 that was lower than the 2015 target. For 2017, the 

Innovation Center lowered the expectation for growth compared to 

previous years, setting a target that was 1 percent higher than the 2016 

target. Moving forward, CMS believes that as more ACOs gain 

experience, more will share in savings. Additionally, the agency expects 

that with additional performance years, the targets for the measure will 

become more refined.

 25According to Innovation Center officials, the evidence of improvements under the model 

was sufficient for the model approach to be incorporated in the Quality Improvement 

Organization program—a program under which CMS contracts with organizations to 

improve quality of care of Medicare beneficiaries in nursing homes and other settings.

26We previously reported that the Innovation Center’s initial plans for evaluating its own 

performance included aggregating data on cost and quality measures developed for 

individual models, in conjunction with its third-party contractors. See GAO-13-12. 

According to center officials these measures could not be aggregated because of 

differences in the target populations and participating providers across models.

The Innovation 

Center Established 

Performance Goals 

and Related 

Performance 

Measures and 

Reported Meeting Its 

Targets for Some 

Goals
Page 23 GAO-18-302 CMS Innovation Center

Table 3: Reported Results of the Center for Medicare and Medicaid Innovation’s Performance Measures for Its Goal to Reduce 

the Growth of Health Care Costs While Promoting Better Health and Health Care Quality through Delivery System Reform

Legend: ✔– met or exceeded performance target; ✘– did not meet performance target; n/a – data not available

Source: Centers for Medicare & Medicaid Services (CMS). | GAO-18-302

a

CMS has not released performance data for 2016 through 2018 for this performance measure.

Goal 2: Identify, test, and improve payment and service delivery 

models. This goal has one performance measure, which identifies the 

number of models that currently indicate (1) cost savings while 

maintaining or improving quality or (2) improving quality while maintaining 

or reducing cost. As of September 30, 2016, the Innovation Center 

reported that four section 1115A model tests have met these criteria (see 

table 4). 27

 27The four models that have met the criteria of the Innovation Center’s goal 2 are: Pioneer 

ACO, the Diabetes Prevention Program, the Initiative to Prevent Avoidable 

Hospitalizations among Nursing Facilities Residents Phase 1, and lower-extremity joint 

replacement under the BPCI.

Performance 

measure

Performance year

2014 2015 2016a 2017a 2018a

Increase the 

number of Medicare 

beneficiaries who 

have been aligned 

with accountable 

care organizations 

(ACOs)

✔

(Target: 5,425,000)

(Actual: 5,954,342)

✔

(Target: 7,090,000)

(Actual: 7,731,655)

n/a

(Target: 8,710,000)

(Actual: n/a)

n/a

(Target: 9,920,000)

(Actual: n/a)

n/a

(Target: 

11,245,000)

(Actual: n/a)

Increase the 

number of 

physicians 

participating in an 

ACOs

✘

(Target: 150,000)

(Actual: 132,148)

✔

(Target: 178,000)

(Actual: 195,212)

n/a

(Target: 266,600)

(Actual: n/a)

n/a

(Target: 275,200)

(Actual: n/a)

n/a

(Target: 331,200)

(Actual: n/a)

Increase the 

percentage of 

ACOs that share in 

savings

✘

(Target: 35 percent)

(Actual: 34 percent)

✘

(Target: 37 percent)

(Actual: 34 percent)

n/a

(Target: 36 percent)

(Actual: n/a)

n/a

(Target: 37 percent)

(Actual: n/a)

n/a

(Target: n/a)

(Actual: n/a)
Page 24 GAO-18-302 CMS Innovation Center

Table 4: Reported Results of the Center for Medicare and Medicaid Innovation’s Performance Measures for Its Goal to 

Identify, Test, and Improve Payment and Service Delivery Models

Legend: ✔– met or exceeded performance target; ✘– did not meet performance target; n/a – data not available

Source: Centers for Medicare & Medicaid Services (CMS). | GAO-18-302

Note: The goal and related performance measure were established in 2014. A target for performance 

was established in 2015.

a

CMS has not released performance data for fiscal year 2017 or 2018 for this performance measure.

Goal 3: Accelerate the spread of successful practices and models.

For this goal, the first performance measure focuses on the number of 

states developing and implementing a health system transformation and 

payment reform plan.28 The second measure focuses on increasing the 

percentage of active model participants who are involved in Innovation 

Center or related learning activities. As shown in table 5, the Innovation 

Center reported meeting its target for the first measure for both fiscal 

years 2015 and 2016, but not meeting its target for the second measure. 

For the second measure, the Innovation Center noted in its report to 

Congress that although the results for fiscal year 2016 showed a slight 

decrease in overall participation in Innovation Center or related learning 

activities, the majority of models performed higher than their individual 

targets. Several models underperformed, however, bringing down the 

overall percentage rate.

 28The Innovation Center provides funding and technical assistance to states to design or 

to test new payment and service delivery models that have the potential to reduce health 

care costs in Medicare, Medicaid, and CHIP.

Performance measure Performance year

2014 2015 2016 2017a 2018a

Increase the number of model 

tests that currently indicate (1) 

cost savings while maintaining 

or improving quality, and/or (2) 

improving quality while 

maintaining or reducing cost

n/a ✔

(Target: 3 models)

(Actual: 3 models)

✔

(Target: 4 models)

(Actual: 4 models)

n/a

(Target: 5 models)

(Actual: n/a)

n/a

(Target: 6 models)

(Actual: n/a)
Page 25 GAO-18-302 CMS Innovation Center

Table 5: Reported Results of the Center for Medicare and Medicaid Innovation’s Performance Measures for Its Goal to 

Accelerate the Spread of Successful Practices and Models

Legend: ✔– met or exceeded performance target; ✘– did not meet performance target; n/a – data not available

Source: Centers for Medicare & Medicaid Services (CMS). | GAO-18-302

Note: The goal and related performance measure were established in 2014. A target for performance 

was established in 2015.

a

CMS has not released performance data for fiscal year 2017 or 2018 for this performance measure.

In addition to the Goal 3 performance measures, the Innovation Center 

identifies two related contextual indicators—which according to officials 

are measures that provide supporting information to help understand 

trends or other information related to the goal. The first contextual 

indicator provides a snapshot of Medicare beneficiary participation at a 

given point in time for all models operational for more than 6 months. In 

fiscal year 2016, CMS reported that over 3.6 million Medicare fee-forservice beneficiaries participated in models, representing approximately 9 

percent of Medicare fee-for-service beneficiaries. The second contextual 

indicator provides information to help understand the level of interest and 

participation among providers in the Innovation Center’s model portfolio. 

In fiscal year 2016, the Center estimates that 103,291 providers 

participated in Innovation Center payment and service delivery models.

In addition to the three goals established by the Innovation Center, CMS 

has established an agency-wide goal related to the center’s performance. 

In 2015, CMS announced goals to help drive Medicare, and the health 

care system at large, toward rewarding the quality of care instead of the 

quantity of care provided to beneficiaries. One of these goals was to shift 

Medicare health care payments from volume to value using alternative 

payment models established under the Innovation Center. This agencywide goal has one performance measure, which is to increase the 

Performance measure Performance year

2014 2015 2016 2017a 2018a

Number of States developing 

and implementing a health 

system transformation and 

payment reform plan

n/a ✔

(Target: 38 states)

(Actual: 38 states)

✔

(Target: 38 states)

(Actual: 38 states)

n/a

(Target: 17 states)

(Actual: n/a)

n/a

(Target: 12 states)

(Actual: n/a)

Increase the percentage of 

active model participants who 

are engaged in Innovation 

Center or related learning 

activities

n/a ✘

(Target: 61 

percent)

(Actual: 58.6 

percent)

✘

(Target: 64.5 

percent)

(Actual: 56.9 

percent)

n/a

(Target: 59.7 

percent)

(Actual: n/a)

n/a

(Target: 60 

percent)

(Actual: n/a)
Page 26 GAO-18-302 CMS Innovation Center

percentage of Medicare fee-for-service payments tied to alternative 

payment models, such as ACOs or bundled payment arrangements. As 

shown in table 6, CMS reported meeting its target for 2015 and 2016.

Table 6: Reported Results of Center for Medicare & Medicaid Services’ Performance Measures for Its Goal to Shift Medicare 

Health Care Payments from Volume to Value

Legend: ✔ – met or exceeded performance target; ✘– did not meet performance target; n/a – data not available

Source: Centers for Medicare & Medicaid Services (CMS). | GAO-18-302

Note: The goal and related performance measure were established in 2014. A target for performance 

was established in 2015.

a

CMS has not released performance data for 2017 or 2018 for this performance measure.

Looking forward, officials told us that the Innovation Center 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. As part 

of the development efforts, the Innovation Center expects to utilize 

standard investment measures used in the public and private sectors.

We provided a draft of this report to HHS for comment. The Department 

provided technical comments, which we incorporated as appropriate.

As agreed with your offices, unless you publicly announce the contents of 

this report earlier, we plan no further distribution until 30 days from the 

report date. At that time, we will send copies to the Secretary of Health 

and Human Services. In addition, the report will be available at no charge 

on the GAO website at http://www.gao.gov.

Performance measure Performance year

2014 2015 2016 2017a 2018a

Increase the percentage of 

Medicare Fee-for-Service 

Payments Tied to Alternative 

Payment Models

n/a ✔

(Target: 26 

percent)

(Actual: 26 

percent)

✔

(Target: 30 

percent)

(Actual: 30 

percent)

n/a

(Target: 40 

percent)

(Actual: n/a)

n/a

(Target: 50 

percent)

(Actual: n/a)

Agency Comments
Page 27 GAO-18-302 CMS Innovation Center

If you or your staff have any questions about this report, please contact 

me at (202) 512-7114 or kingk@gao.gov. Contact points for our Offices of 

Congressional Relations and Public Affairs may be found on the last page 

of this report. GAO staff who made key contributions to this report are 

listed in appendix IV.

Kathleen M. King

Director, Health Care
Appendix I: Center for Medicare and Medicaid 

Innovation’s General Process for Implementing 

Models

Page 28 GAO-18-302 CMS Innovation Center

Table 7: Description of the Center for Medicare and Medicaid Innovation’s (Innovation Center) General Process for Model 

Implementation 

Idea & concept

Identify ideas for new models • Internally, the Innovation Center receives ideas for different payment and 

care delivery approaches from the administration and leadership of the 

Centers for Medicare & Medicaid Services (CMS) and the Department of 

Health and Human Services (HHS).

• Externally, the Innovation Center solicits and receives ideas for different 

payment and care delivery approaches through listening sessions, its webbased idea-submission tool, informal requests for information inviting the 

public to provide information to CMS for information and planning purposes, 

and other mechanisms.a

• As part of this step, the Innovation Center considers model types suggested 

in its authorizing law, and seeks input from across CMS; HHS; other federal 

partners, including the Physician-Focused Payment Model Technical 

Advisory Committee (PTAC); and an array of external stakeholders.b

Develop promising ideas into concepts for new 

models

• The Innovation Center reviews details of the ideas that have been 

submitted—such as the health care services addressed; providers, 

beneficiaries, and stakeholders involved; and the resources needed— to 

assess the potential for developing the idea into a working model.

• A small collaboration team is formed from across the Innovation Center to 

further develop promising model concepts. A model concept includes 

preliminary model design, evaluation plans, budget information, and 

estimates of potential savings to be achieved.

• The Innovation Center evaluates concepts in the context of the current 

portfolio of models, administration priorities, and other criteria such as the 

potential impact on Medicare and Medicaid beneficiaries, the concept’s 

ability to improve how care is delivered nationally, and the degree to which 

the concept would meet the needs of the most vulnerable beneficiaries.

Planning & design

Develop an Innovation Center Investment 

Proposal (ICIP)

• Once the Innovation Center decides to move forward with a concept, it 

develops an ICIP, which typically includes

• a proposed design for the model, including the size and scope 

of testing, the population and programs involved, and duration;

• a summary of prior evidence and supporting research;

• a preliminary evaluation plan, including research questions, 

proposed measures related to spending and quality, and 

discussion of the model’s expected impact; and

• an implementation plan, including the application and selection 

process, an analysis of whether the model overlaps or 

complements other initiatives, and an analysis of the potential 

for expansion of the model.

• The Innovation Center prepares separate documents for approval that are 

related to funding requests and solicitations associated with the model.

Appendix I: Center for Medicare and 

Medicaid Innovation’s General Process for 

Implementing Models
Appendix I: Center for Medicare and Medicaid 

Innovation’s General Process for Implementing 

Models

Page 29 GAO-18-302 CMS Innovation Center

Obtain approval from CMS, HHS, and the Office of 

Management and Budget (OMB) and announce 

model

• The Innovation Center seeks approval for the model. This includes separate 

approval processes for the ICIP, model funding, and any solicitations that 

would be issued to potential participants.

• The approval process includes a sequence of reviews within CMS, within 

HHS, and finally within OMB. During these reviews, revisions may be made 

on the basis of input from individuals in other CMS centers and offices, in 

other related HHS programs, and from OMB.

• Once the ICIP is approved, the Innovation Center issues an announcement 

and other information about the model to the public.

Solicit & build

Solicit and select contractors for evaluating and 

implementing model

• The Innovation Center solicits and hires contractors to evaluate the model. 

Applicants are asked to propose specific evaluation approaches to the 

preliminary evaluation plans that the Innovation Center has identified. 

Contractors are selected through a competitive process. Once a contractor is 

selected, it works with the Innovation Center to complete a design phase and 

reach agreement on the final evaluation plan for the model.

• The Innovation Center also engages contractors for other purposes that are 

part of implementation, such as data collection and provider recruitment.

Solicit, select, and establish agreements with 

participants

• The Innovation Center issues information about how to apply for participation 

in the model, including information about which types of providers or 

organizations are eligible to participate, the process for submitting 

applications, and the selection process. The Innovation Center may also 

organize webinars or learning sessions open to the public and interested 

participants to share information and answer questions.

• Innovation Center models vary by the type of participant that is involved—for 

example, physician group practices, health plans, and state Medicaid 

programs.

• Models also vary in terms of the type of agreement that is established with 

participants—for example, whether it is a grant, a cooperative agreement, a 

contract, or a provider agreement.

• The selection process for participants is generally competitive. The criteria 

used in the selection process may vary by model. For example, selection 

criteria may include such factors as organizational capabilities and plans for 

ensuring quality of care. In other cases, eligible participants may be selected 

in order to achieve a mix and balance of certain characteristics for evaluation 

purposes, for example geographic location (urban, rural) and whether the 

participant uses electronic health records
Appendix I: Center for Medicare and Medicaid 

Innovation’s General Process for Implementing 

Models

Page 30 GAO-18-302 CMS Innovation Center

Build operational and participant support • The Innovation Center and contractors create systems or plans that support 

the implementation of each model, including:

• information technology systems that collect, maintain, and 

provide access to data;

• a learning system that consists of a combination of educational 

approaches that focus on collaboration and group-based 

activities, as well as known improvement strategies that 

support participants in achieving the goals of the model’s 

learning activities;

• a communication plan that establishes communication 

channels between participants and the Innovation Center, as 

well as for information released to the general public;

• a monitoring system that establishes requirements for 

participant reporting and, if applicable, corrective action plans; 

and

• an operational plan that establishes steps—including training—

to help ensure the Innovation Center and participants 

understand how the model will operate once it is implemented.

Run, evaluate, & expand

Run model implementation • The innovations that models are testing—changes to health care delivery or 

payment—are put into effect by CMS and by participants.

• The testing period for Innovation Center models is typically set for 3 to 5 

years. However, monitoring may indicate that the model should be modified, 

terminated, or expanded before this period ends (see below). The Innovation 

Center may choose to shorten the test period for a model for such reasons.

Conduct evaluation of model to assess its impact 

on cost and quality

• Data are collected for cost and quality measures. Using a variety of statistical 

techniques, these data are generally compared to data for a comparison 

group representing patients or providers that are not participating in the 

model to determine the model’s impact on cost and quality. When 

comparison groups are not possible, data for model participants are 

compared to “baseline” data that represent a period prior to the test period. 

Qualitative information on the different strategies participants may use to 

deliver care under each model is also collected and analyzed.

• During the testing period information collected is shared on a regular basis 

with participants. The purpose of this “rapid cycle” feedback is to provide 

timely information so that participants can make improvements during the 

testing period.
Appendix I: Center for Medicare and Medicaid 

Innovation’s General Process for Implementing 

Models

Page 31 GAO-18-302 CMS Innovation Center

Determine whether to terminate, modify, or 

recommend expanding model

• The Innovation Center regularly reviews each model’s impact on the quality 

and cost of care to determine whether the payment or delivery approach is 

successful and should be recommended for expansion.

• The Secretary is required to terminate or modify the design and 

implementation of a model unless the Secretary determines (and the Chief 

Actuary certifies with respect to program spending), after testing has begun, 

that the model is expected to improve the quality of care without increasing 

spending, reduce spending without reducing the quality of care, or improve 

the quality of care and reduce spending.

• The Secretary may expand the duration and scope of a model if (1) the CMS 

Chief Actuary certifies that expansion would reduce or not result in any 

increase in net program spending, (2) the Secretary determines that 

expansion is expected to reduce spending without reducing the quality of 

care or improve the quality of patient care without increasing spending, and 

(3) the Secretary determines that expansion would not deny or limit the 

coverage or provision of benefits.

Closing

Participant, contract, and administrative closeout • The Innovation Center makes final payments to participants and contractors, 

final evaluations are completed and publicly released, lessons learned are 

documented and, if applicable, continuity of model operations is coordinated 

with CMS. 

Source: Centers for Medicare & Medicaid Services. | GAO-18-302

a

An agency may issue a request for information for planning purposes.

b

PTAC was chartered by the Secretary of HHS in January 2016. PTAC evaluates stakeholder 

proposals for physician-focused payment models, and submits comments and makes 

recommendations on the models to the Secretary of HHS, who is required to respond to PTAC’s 

recommendations.
Appendix II: Models Implemented or 

Announced by the Center for Medicare and 

Medicaid Innovation under Section 1115A

Page 32 GAO-18-302 CMS Innovation Center

As of March 1, 2018, the Center for Medicare and Medicaid Innovation 

(Innovation Center) organized its models into seven categories based on 

delivery and payment approaches tested and program beneficiaries 

covered. Table 8 provides the number of models implemented and 

announced, organized under each category.

Table 8: Number of Section 1115A Center for Medicare and Medicaid Innovation Models Implemented and Announced by 

Category, as of March 1, 2018

Model category Models implemented Models announced Total

Accountable Care 7 0 7

Episode-based Payment Initiatives 6 1 7

Initiatives Focused on Medicare-Medicaid Enrollees 3 0 3

Initiatives Focused on the Medicaid and Children’s 

Health Insurance Program Population

1 0 1

Initiatives to Accelerate the Development and Testing of 

New Payment and Service Delivery Models 

14 0 14

Initiatives to Speed the Adoption of Best Practices 2 1 3

Primary Care Transformation 4 0 4

Total 37 2 39

Source: GAO analysis of Centers for Medicare & Medicaid Services information. | GAO-18-302

Appendix II: Models Implemented or 

Announced by the Center for Medicare and 

Medicaid Innovation under Section 1115A
Appendix II: Models Implemented or 

Announced by the Center for Medicare and 

Medicaid Innovation under Section 1115A

Page 33 GAO-18-302 CMS Innovation Center

The Innovation Center organized seven of its models under the 

Accountable Care category. (See table 9.)

Table 9: Descriptions and Other Information for Center for Medicare and Medicaid Innovation (Innovation Center) Models 

Organized under Accountable Care

Model Description Status

(Years tested)

Participants Obligations funded 

under section 1115Aa

and titles XVIII and XIXb

of the Social Security 

Act

Advance Payment Accountable Care 

Organization (ACO) Model – Tested the 

effectiveness of providing physician-based and 

rural Medicare Shared Savings Program ACOs 

with upfront and monthly payments that they 

could use to invest in care coordination 

activities.c

Implemented - testing 

period ended

(2012-2015)

35 ACOs $73.8 million

($110.1 million)

Pioneer ACO – Tested the effectiveness of 

allowing experienced ACOs to take on greater 

financial risk than ACOs that participated in the 

Medicare Shared Savings Program.d In 

exchange, participating ACOs are eligible for a 

greater percentage of any savings achieved. In 

year 3 of the model, providers that met certain 

levels of savings in the first two years were 

eligible to receive prospective per beneficiary 

per month payments.

Implemented - testing 

period ended

(2012-2016)

Began with 32 ACOs and 

concluded with eight.

$96.9 million

($244.3 million)

Comprehensive End-Stage Renal Disease 

Care Model – Tests the effectiveness of an 

ACO delivery and payment approach for 

providing care to end-stage renal disease 

beneficiaries.

Implemented

(2015-2020)

37 end-stage renal disease 

seamless care 

organizations

$56.5 million

(n/a)

ACO Investment Model – Tests the 

effectiveness of pre-paid shared savings in 

encouraging new Medicare Shared Savings 

Program ACOs to form in rural and underserved 

areas and in encouraging current Medicare 

Shared Savings Program ACOs to transition to 

arrangements with greater financial risk.d

Implemented

(2016-tbd)

45 ACOs $62.0 million

($10.9 million)

Next Generation ACO Model – Tests the 

impact of strong financial incentives for ACOs, 

coupled with tools to support better patient 

engagement and care management. ACOs 

participating in the Next Generation ACO Model 

must assume greater risk and can earn greater 

rewards than in other Centers for Medicare & 

Medicaid Services’ (CMS) ACO initiatives. 

Implemented

(2016-2020)

44 ACOs $44.5 million

($11.8 million)
Appendix II: Models Implemented or 

Announced by the Center for Medicare and 

Medicaid Innovation under Section 1115A

Page 34 GAO-18-302 CMS Innovation Center

Model Description Status

(Years tested)

Participants Obligations funded 

under section 1115Aa

and titles XVIII and XIXb

of the Social Security 

Act

Vermont All-Payer ACO Model – Tests a 

model in which Medicare, Medicaid, and 

commercial health care payers in Vermont will 

coordinate to have similar design requirements 

for ACOs. Under the arrangement, Vermont 

commits to meeting statewide quality of care 

and financial targets. CMS will also provide 

funding to Vermont to support care coordination 

and improve collaboration between providers.

Implemented

(2017-2022)

1 state n/a

(n/a)

ACO Track 1 Plus – Tests the effectiveness of 

offering an advanced alternative payment 

model with a more limited risk track than 

currently available in the Medicare Shared 

Savings Program to encourage more Medicare 

Shared Savings Program ACOs, especially 

ACOs composed solely of small physician 

practices and small rural hospitals, to take on 

financial risk.

Implementede

(2018-tbd)

n/a n/a

(n/a)

Legend: n/a – not applicable; tbd – to be determined

Source: Centers for Medicare & Medicaid Services. | GAO-18-302

Note: Information in this table is as of December 1, 2017 with the exception of the status for ACO 

Track 1 Plus, which was updated as of March 1, 2018.

a

Obligations funded under section 1115A reflect payments to participants in the testing of models, 

such as health care providers of services, states, conveners, and others. These payments may 

include care management fees and cooperative agreement awards and are paid through Innovation 

Center funds as appropriated under section 1115A of the Social Security Act. Amounts reflect 

obligations made for fiscal years 2012 through 2016.

b

Obligations funded under Titles XVIII or XIX reflect payments, such as shared savings payments, 

made from the Medicare Trust Funds, as well as any other payments made under Titles XVIII or XIX 

for model-related services on behalf of beneficiaries. This column does not include Medicare, 

Medicaid, and Children’s Health Insurance Program payments to health care providers or others for 

services provided to beneficiaries. Amounts reported reflect obligations through fiscal year 2016.

c

An ACO refers to a group of providers and suppliers of services, such as hospitals and physicians, 

that work together to coordinate care for the patients they serve.

d

The Medicare Shared Savings Program is an ACO program enacted as an ongoing part of the 

Medicare program and not an Innovation Center model. See 42 U.S.C. § 1395jjj. The program 

includes different participation options that allowed ACOs to assume various levels of risk.

e

ACO Track 1 Plus was implemented on January 1, 2018.

The Innovation Center organized seven of its models under the EpisodeBased Payment Initiatives category. (See table 10.)
Appendix II: Models Implemented or 

Announced by the Center for Medicare and 

Medicaid Innovation under Section 1115A

Page 35 GAO-18-302 CMS Innovation Center

Table 10: Descriptions and Other Information for Center for Medicare and Medicaid Innovation (Innovation Center) Models 

Organized under Episode-Based Payment Initiatives

Model Description Status

(Years tested)

Participants Obligations funded under 

section 1115Aa and titles 

XVIII and XIXb of the 

Social Security Act

Bundled Payments for Care Improvement 

(BPCI) Model 1, Retrospective Acute Care 

Hospital Stay Only – Tested the effectiveness of 

a payment arrangement in which hospitals 

received discounted payments for Medicare 

services provided during an inpatient hospital stay 

and in which physicians who provided services 

during the inpatient stay were paid their standard 

rates under the physician fee schedule. Hospitals 

were able to share cost-savings they generated 

under the model with physicians as a means of 

encouraging them to participate in redesigning the 

care process to become more efficient. Hospitals 

were also held financially responsible for the cost 

of all Medicare services provided 30 days after 

discharge that exceeded historical trends.

Implemented – testing 

period ended

(2013-2016)

Began with 24 hospitals 

and concluded with nine.

$75.7 million, 

includes BPCI Models 1-4

(n/a)

BPCI Model 2, Retrospective Acute & PostAcute Care Episode – Tests the effectiveness of 

a payment arrangement in which acute care 

hospitals and physician group practices receive 

additional payments or make recoupment 

payments if the total costs for Medicare services 

provided during an inpatient hospital stay and up 

to 90 days after discharge are over or under a predetermined target price.

Implemented

(2013-2018)

335 hospitals and 204 

physician group 

practices

See BPCI Model 1

BPCI Model 3, Retrospective Post-Acute Care 

Only – Tests the effectiveness of a payment 

arrangement in which post-acute care providers—

such as a skilled nursing facility, inpatient 

rehabilitation facility, long-term care hospital or 

home health agency—or physician group 

practices receive payments or make recoupment 

payments if total costs for certain Medicare 

services are over or under a predetermined target 

price. These services are those provided during a 

clinical episode that begins with post-acute care 

services and include all services up to 90 days 

after the hospital discharge that preceded the 

post-acute care services. 

Implemented

(2013-2018)

620 skilled nursing 

facilities, 81 home health 

agencies, 9 inpatient 

rehab facilities, and 48 

physician group 

practices

See BPCI Model 1
Appendix II: Models Implemented or 

Announced by the Center for Medicare and 

Medicaid Innovation under Section 1115A

Page 36 GAO-18-302 CMS Innovation Center

Model Description Status

(Years tested)

Participants Obligations funded under 

section 1115Aa and titles 

XVIII and XIXb of the 

Social Security Act

BPCI Model 4, Prospective Acute Care 

Hospital Stay Only – Tests the effectiveness of 

making a single, predetermined payment in 

advance for all Medicare services furnished by a 

hospital, physicians, and other practitioners during 

an inpatient stay in an acute care hospital. 

Physicians and other practitioners submit “no-pay” 

claims to Medicare and are paid by the hospital 

out of the advance, bundled payment.

Implemented

(2013-2018)

2 hospitals See BPCI Model 1

Comprehensive Care for Joint Replacement 

Model – Tests the effectiveness of a payment 

arrangement in which acute care hospitals receive 

additional payments or make recoupment 

payments if the total costs for certain Medicare 

services are over or under a predetermined target 

price. These services are those provided during a 

clinical episode that includes an inpatient hospital 

stay related to a hip or knee replacement surgery 

and all services up to 90 days after discharge.

Implemented

(2016-2020) 

Participation required for 

about 800 hospitals in 

67 randomly selected 

geographic areasc

$25.7 million

(n/a)

Oncology Care Model – Tests the effectiveness 

of a payment arrangement in which providers 

receive a monthly payment for each Medicare 

beneficiary during a 6-month episode of care 

following the administration of chemotherapy and 

can earn additional performance-based payments 

if the total costs for Medicare services provided 

during the episode are under a predetermined 

target price. Starting in 2017, practices could 

receive higher performance-based payments by 

taking on risk for costs that exceed the target 

price.

Implemented

(2016-2021)

192 practices and 14 

payers

$58.3 million

(n/a)

BPCI Advancedd – Will test the effectiveness of a 

payment arrangement in which acute care 

hospitals and physician group practices receive 

additional payments if the total costs for Medicare 

services provided are under a pre-determined 

target price and performance is maintained or 

improved on specific quality measures. Services 

are those to be provided during a clinical episode 

that will include either an inpatient hospital stay or 

outpatient procedure and all services for 90 days 

after discharge or the procedure. This model will 

qualify as an advanced alternative payment 

model.

Announced

(2018-2023)

tbd n/a

(n/a)

Legend: n/a – not applicable; tbd – to be determined

Source: Centers for Medicare & Medicaid Services. | GAO-18-302

Note: Information in this table is as of December 1, 2017 with the exception of information for BPCI 

Advanced, which was updated as of March 1, 2018.
Appendix II: Models Implemented or 

Announced by the Center for Medicare and 

Medicaid Innovation under Section 1115A

Page 37 GAO-18-302 CMS Innovation Center

a

Obligations funded under section 1115A reflect payments to participants in the testing of models, 

such as health care providers of services, states, conveners, and others. These payments may 

include care management fees and cooperative agreement awards and are paid through Innovation 

Center funds as appropriated under section 1115A of the Social Security Act. Amounts reflect 

obligations made for fiscal years 2012 through 2016.

b

Obligations funded under Titles XVIII or XIX reflect payments, such as shared savings payments, 

made from the Medicare Trust Funds, as well as any other payments made under Titles XVIII or XIX 

for model-related services on behalf of beneficiaries. This column does not include Medicare, 

Medicaid, and Children’s Health Insurance Program payments to health care providers or others for 

services provided to beneficiaries. Amounts reflect obligations made through fiscal year 2016.

c

On December 1, 2017, a final rule was issued making provider participation in 33 geographic areas 

voluntary for this model, effective January 1, 2018. Participation will remain mandatory for 34 

geographic areas.

d

BPCI Advanced was announced on January 9, 2018.

The Innovation Center organized three of its models under the Initiatives 

Focused on Medicare-Medicaid Enrollees category. (See table 11.)

Table 11: Descriptions and Other Information for the Center for Medicare and Medicaid Innovation (Innovation Center) Models 

Organized under Initiatives Focused on Medicare-Medicaid Enrollees

Model Description Status

(Years tested)

Participants Obligations funded under 

section 1115Aa and titles 

XVIII and XIXb of the Social 

Security Act

Initiative to Reduce Avoidable Hospitalizations 

Among Nursing Facility Residents: Phase One

– Tested effectiveness of partnerships between 

independent organizations and long-term care 

facilities to enhance on-site services to reduce 

hospitalizations for Medicare-Medicaid 

beneficiaries.

Implemented – testing 

period ended

(2012-2016)

Seven Enhanced Care 

and Coordination 

Provider organizations 

and 143 long-term care 

facilities

$124.7 million

(n/a)

Financial Alignment Initiative for MedicareMedicaid Enrollees – Tests two models to 

integrate primary, acute, behavioral health and 

long-term services and supports for MedicareMedicaid enrollees and better aligns the financing 

of the Medicare and Medicaid programs.

Implemented

(2013-2020)

Model tests are operating 

in 13 states, with two 

demonstrations operating 

in New York.

$234.2 million

($7.2 million)

Initiative to Reduce Avoidable Hospitalizations 

Among Nursing Facility Residents: Phase Two

– Tests whether a new payment model for a new 

set of long-term care facilities, as well as longterm care facilities that participated in the initial 

phase of the model and continue to offer 

enhanced on-site services, will improve quality of 

care by reducing avoidable hospitalizations, while 

also lowering combined Medicare and Medicaid 

spending.

Implemented

(2016-2020)

Six Enhanced Care and 

Coordination Provider 

organizations

$18.8 million

(n/a)

Legend: n/a – not applicable

Source: Centers for Medicare & Medicaid Services. | GAO-18-302
Appendix II: Models Implemented or 

Announced by the Center for Medicare and 

Medicaid Innovation under Section 1115A

Page 38 GAO-18-302 CMS Innovation Center

Note: Information in this table is as of December 1, 2017.

a

Obligations funded under section 1115A reflect payments to participants in the testing of models, 

such as health care providers of services, states, conveners, and others. These payments may 

include care management fees and cooperative agreement awards and are paid through Innovation 

Center funds as appropriated under section 1115A of the Social Security Act. Amounts reflect 

obligations made for fiscal years 2012 through 2016.

b

Obligations funded under Titles XVIII or XIX reflect payments, such as shared savings payments, 

made from the Medicare Trust Funds, as well as any other payments made under Titles XVIII or XIX 

for model-related services on behalf of beneficiaries. This column does not include Medicare, 

Medicaid, and Children’s Health Insurance Program payments to health care providers or others for 

services provided to beneficiaries. Amounts reflect obligations made through fiscal year 2016.

The Innovation Center organized one of its models under the category, 

Initiatives Focused on the Medicaid and Children’s Health Insurance 

Program Population. (See table 12.)

Table 12: Descriptions and Other Information for the Center for Medicare and Medicaid Innovation (Innovation Center) Models 

Organized under Initiatives Focused on the Medicaid and Children’s Health Insurance Program Population

Model Description Status

(Years tested)

Participants Obligations funded under 

section 1115Aa and titles 

XVIII and XIXb of the 

Social Security Act

Strong Start for Mothers and Newborns 

Initiative: Enhanced Prenatal Care Models -

Tests three approaches to enhance the current 

care delivery and address the medical, 

behavioral and psychosocial factors that may be 

present during pregnancy and contribute to 

preterm-related poor birth outcomes.

Implemented

(2013-2018)

27 awardees with more 

than 200 sites including 

hospitals, health plans, 

community-based 

providers, Federally 

Qualified Health Centers, 

nationally-certified birth 

centers, Indian Health 

services clinics, local 

health departments, and 

physician groups

$96.2 million

(n/a)

Legend: n/a – not applicable

Source: Centers for Medicare & Medicaid Services. | GAO-18-302

Note: Information in this table is as of December 1, 2017.

a

Obligations funded under section 1115A reflect payments to participants in the testing of models, 

such as health care providers of services, states, conveners, and others. These payments may 

include care management fees and cooperative agreement awards and are paid through Innovation 

Center funds as appropriated under section 1115A of the Social Security Act. Amounts reflect 

obligations made for fiscal years 2012 through 2016.

b

Obligations funded under Titles XVIII or XIX reflect payments, such as shared savings payments, 

made from the Medicare Trust Funds, as well as any other payments made under Titles XVIII or XIX 

for model-related services on behalf of beneficiaries. This column does not include Medicare, 

Medicaid, and Children’s Health Insurance Program payments to health care providers or others for 

services provided to beneficiaries. Amounts reflect obligations made through fiscal year 2016.
Appendix II: Models Implemented or 

Announced by the Center for Medicare and 

Medicaid Innovation under Section 1115A

Page 39 GAO-18-302 CMS Innovation Center

The Innovation Center organized 14 of its models under the category, 

Initiatives to Accelerate the Development and Testing of New Payment 

and Service Delivery Models. (See table 13.)

Table 13: Descriptions and Other Information for the Center for Medicare and Medicaid Innovation (Innovation Center) Models 

Organized under Initiatives to Accelerate the Development and Testing of New Payment and Service Delivery Models

Model Description Status

(Years tested)

Participants Obligations funded under 

section 1115Aa and titles 

XVIII and XIXb of the 

Social Security Act

Partnership for Patients – Tested whether a 

coordinated, goal-directed, national collaborative 

approach for systematically spreading known best 

practices in patient safety could make acute care 

hospitals safer, more reliable, and less costly by 

reducing hospital acquired conditions and 

readmissions.

Implemented – testing 

period ended

(2011-2016)

3,700 short stay acute care 

hospitals

$559.4 million

(n/a)

Health Care Innovation Awards Round One –

Tested the effectiveness of providing funding to a 

broad set of partners, including providers, local 

government, and public-private partnerships, to 

test new care delivery and payment models for 

beneficiaries enrolled in Medicare, Medicaid, or 

the Children’s Health Insurance Program (CHIP).

Implemented – testing 

period ended

(2012-2015)

108 awardees including 

academic medical centers, 

not-for-profit organizations, 

provider organizations, 

managed care 

organizations, integrated 

health systems, health 

clinics, hospitals, and local 

and state agencies.

$967.4 million

(n/a)

State Innovation Models Initiative: Round One

– Tested the effectiveness of financial, technical, 

and other support to states that were either 

prepared to test or were committed to design and 

test new payment and service delivery models for 

beneficiaries enrolled in Medicare, Medicaid, or 

CHIP.

Implemented – testing 

period ended

(2013-2016)

Six test states, 16 design 

states

$326.7 million

(n/a)

Health Care Innovation Awards Round Two –

Tested the effectiveness of providing funding to 

awardees to test new care delivery and payment 

models for beneficiaries enrolled in Medicare, 

Medicaid, or CHIP.

Implemented – testing 

period ended

(2014-2017)

39 awardees including 

academic medical centers,

not-for-profit organizations, 

provider organizations, 

managed care 

organizations, integrated 

health systems, health 

clinics, hospitals, and local 

and state agencies.

$397.7 million

(n/a)

Maryland All-Payer Model – Tests the 

effectiveness of an all-payer system for hospital 

payment on quality of care and cost.

Implemented

(2014-2019)

One state $12.6 million

(n/a)

Repetitive Scheduled Non-Emergent 

Ambulance Transport Model (Prior 

Authorization) – Tests the effectiveness of prior 

authorization of repetitive scheduled nonemergent ambulance transport.

Implemented

(2014-2018)

Nine states $28.9 million

(n/a)
Appendix II: Models Implemented or 

Announced by the Center for Medicare and 

Medicaid Innovation under Section 1115A

Page 40 GAO-18-302 CMS Innovation Center

Model Description Status

(Years tested)

Participants Obligations funded under 

section 1115Aa and titles 

XVIII and XIXb of the 

Social Security Act

State Innovation Models Initiative: Round Two

– Tests the effectiveness of financial, technical, 

and other support to states that are either 

prepared to test or are committed to designing 

and testing new payment and service delivery 

models for beneficiaries enrolled in Medicare, 

Medicaid, or CHIP.

Implemented

(2015-2018)

11 test states, 17 design 

states, plus America 

Samoa, District of 

Columbia, Commonwealth 

of the Northern Mariana 

Island, and Puerto Rico

$373.7 million

(n/a)

Hyperbaric Oxygen Therapy Model (Prior 

Authorization) – Tests the effectiveness of prior 

authorization of non-emergent hyperbaric oxygen 

therapy.

Implemented

(2015-2018)

Three states $5.7 million

(n/a)

Home Health Value-Based Purchasing Model –

Tests the effectiveness of tying payments for 

Medicare-certified home health agencies to the 

quality of care provided.

Implemented

(2016-2022)

Nine states $18.0 million

(n/a)

Medicare Care Choices Model – Tests the 

effectiveness of providing Medicare, Medicaid, or 

dual-eligible beneficiaries the option to receive 

hospice-like support services from certain hospice 

providers while concurrently receiving curative 

services.

Implemented

(2016-2020 )

141 hospices $16.5 million

(n/a)

Part D Enhanced Medication Therapy 

Management Model – Tests the effectiveness of 

providing basic, stand-alone prescription drug 

plans with the regulatory flexibility to design and 

implement innovative medication therapy 

management programs with the goal of optimizing 

medication use.

Implemented

(2017-2021)

Six Part D sponsors $10.7 million

(n/a)

Pennsylvania Rural Health Model – Tests 

whether multi-payer global budgets will enable 

participating rural hospitals to invest in quality and 

preventive care and to tailor the services they 

deliver to better meet the needs of their local 

communities.

Implemented

(2017-2023)

One state n/a

(n/a)

Medicare Advantage Value-Based Insurance 

Design Model – Tests the effectiveness of 

offering Medicare Advantage plans the flexibility to 

design and offer reduced cost-sharing and/or 

additional supplemental benefits to enrollees with 

chronic conditions with the goal of incentivizing 

beneficiaries to use high-value services. Eligible 

Medicare Advantage plans in seven states, upon 

approval from the Centers for Medicare & 

Medicaid Services (CMS), can offer varied plan 

benefit designs for enrollees who fall into certain 

clinical categories identified and defined by CMS.

Implemented

(2017-2021)

11 Medicare Advantage 

and Medicare Advantage 

prescription drug plansc

$8.4 million

(n/a)
Appendix II: Models Implemented or 

Announced by the Center for Medicare and 

Medicaid Innovation under Section 1115A

Page 41 GAO-18-302 CMS Innovation Center

Model Description Status

(Years tested)

Participants Obligations funded under 

section 1115Aa and titles 

XVIII and XIXb of the 

Social Security Act

Accountable Health Communities Model –

Tests the effectiveness of systematically 

identifying and addressing the health-related 

social needs of beneficiaries through improved 

clinical-community linkages.

Implemented

(2017-2022)

32 organizations including 

hospitals, university health 

systems, and local health 

departments

n/a

(n/a)

Legend: n/a – not applicable

Source: Centers for Medicare & Medicaid Services. | GAO-18-302

Note: Information in this table is as of December 1, 2017.

a

Obligations funded under section 1115A reflect payments to participants in the testing of models, 

such as health care providers of services, states, conveners, and others. These payments may 

include care management fees and cooperative agreement awards and are paid through Innovation 

Center funds as appropriated under section 1115A of the Social Security Act. Amounts reflect 

obligations made for fiscal years 2012 through 2016.

b

Obligations funded under Titles XVIII or XIX reflect payments, such as shared savings payments, 

made from the Medicare Trust Funds, as well as any other payments made under Titles XVIII or XIX 

for model-related services on behalf of beneficiaries. This column does not include Medicare, 

Medicaid, and Children’s Health Insurance Program payments to health care providers or others for 

services provided to beneficiaries. Amounts reflect obligations made through fiscal year 2016.

c

In 2017, participation was limited to eligible plans in 7 states. CMS expanded the model into 3

additional states in 2018 and will expand into 15 more in 2019. The Bipartisan Budget Act of 2018 

requires that the model covers all states effective no later than January 1, 2020.

The Innovation Center organized three of its models under the category, 

Initiatives to Speed the Adoption of Best Practices. (See table 14.)
Appendix II: Models Implemented or 

Announced by the Center for Medicare and 

Medicaid Innovation under Section 1115A

Page 42 GAO-18-302 CMS Innovation Center

Table 14: Descriptions and Other Information for the Center for Medicare and Medicaid Innovation (Innovation Center) Models 

Organized under Initiatives to Speed the Adoption of Best Practices

Model Description Status

(Years tested)

Participants Obligations funded under 

section 1115Aa and titles 

XVIII and XIXb of the 

Social Security Act

Health Care Payment Learning and Action 

Network – Facilitates the national learning 

collaborative to accelerate the adoption of 

advanced payment models that include private 

payers, purchasers, health care providers, 

consumers, and states.

Implemented

(2015-tbd)

Over 600 organizations $11.7 million

(n/a)

Million Hearts®: Cardiovascular Disease Risk 

Reduction Model – Tests the effectiveness of 

providing financial incentives for health care 

providers to reduce the patients’ risk of heart 

attack and stroke on outcomes and accountability 

for costs among Medicare beneficiaries.

Implemented

(2017-2022)

516 organizations $13.8 million

(n/a)

Medicare Diabetes Prevention Program 

Expanded Model – Will test the effectiveness of 

an evidence-based intervention targeted to 

prevent the onset of type 2 diabetes among 

Medicare beneficiaries with an indication of 

prediabetes.

Announced

(2018-tbd)

tbd n/a

(n/a)

Legend: n/a – not applicable; tbd – to be determined

Source: Centers for Medicare & Medicaid Services (CMS). | GAO-18-302

Note: Information in this table is as of December 1, 2017 with one exception. We excluded the Direct 

Decision Support model, which was cancelled by the Innovation Center on February 2, 2018, as of 

March 1, 2018.

a

Obligations funded under section 1115A reflect payments to participants in the testing of models, 

such as health care providers of services, states, conveners, and others. These payments may 

include care management fees and cooperative agreement awards and are paid through Innovation 

Center funds as appropriated under section 1115A of the Social Security. Amounts reflect obligations 

made for fiscal years 2012 through 2016.

b

Obligations funded under Titles XVIII or XIX reflect payments, such as shared savings payments, 

made from the Medicare Trust Funds, as well as any other payments made under Titles XVIII or XIX 

for model-related services on behalf of beneficiaries. This column does not include Medicare, 

Medicaid, and Children’s Health Insurance Program payments to health care providers or others for 

services provided to beneficiaries. Amounts reflect obligations made through fiscal year 2016.

The Innovation Center organized four of its models under the category, 

Primary Care Transformation. (See table 15.)
Appendix II: Models Implemented or 

Announced by the Center for Medicare and 

Medicaid Innovation under Section 1115A

Page 43 GAO-18-302 CMS Innovation Center

Table 15: Descriptions and Other Information for the Center for Medicare and Medicaid Innovation (Innovation Center) Models 

Organized under Primary Care Transformation

Model Description Status

(Years tested)

Participants Obligations funded under 

section 1115Aa and titles 

XVIII and XIXb of the Social 

Security Act

Federally Qualified Health Center (FQHC) 

Advanced Primary Care Practice 

Demonstration – Tested the effectiveness of the 

advanced primary care practice model—referred 

to as a patient-centered medical home—for health 

centers that have received a FQHC designation 

from the Centers for Medicare & Medicaid 

Services. FQHCs provide comprehensive 

community-based primary and preventive care 

services in medically underserved areas or to 

medically underserved populations. As part of the 

model, FQHCs were paid a monthly care 

management fee for each eligible Medicare 

beneficiary receiving primary care services.

Implemented – testing 

period ended

(2011-2014)

434 FQHC sites $64.2 million

(n/a)

Comprehensive Primary Care Initiative –

Tested the impact of enhanced primary care 

services, including care coordination, prevention, 

and 24-hour access for Medicare and Medicaid 

beneficiaries. The initiative included multiple 

payers and participating providers received a 

monthly care management fee and an opportunity 

to share in any net savings to the Medicare 

program.

Implemented – testing 

period ended

(2012-2016)

442 primary care 

practices

$397.0 million

($0.6 million)

Comprehensive Primary Care Plus – Tests the 

impact of multi-payer enhanced primary care 

services for Medicare and Medicaid beneficiaries, 

including care coordination, prevention, and 24-

hour access for Medicare and Medicaid 

beneficiaries. This model includes greater 

financial resources and flexibility to make 

appropriate investments to improve quality and 

efficiency of care. The initiative included multiple 

payers and participating providers received a 

monthly care management fee, performancebased incentive payments, and payments under 

the Medicare physician fee schedule.

Implemented

(2017-2022)

2,816 primary care 

practices

$66.7 million

(n/a)

Transforming Clinical Practice Initiative – Tests 

the effectiveness of providing support to outpatient 

clinical practices to move from volume to valuebased delivery systems within the Quality 

Payment Program by sharing, adapting, and 

developing comprehensive quality improvement 

strategies to facilitate large-scale practice 

transformation.

Implemented

(2015-2019)

29 practice 

transformation networks 

and 12 support and 

alignment networks

$328.7 million

(n/a)

Legend: n/a – not applicable

Source: Centers for Medicare & Medicaid Services. | GAO-18-302
Appendix II: Models Implemented or 

Announced by the Center for Medicare and 

Medicaid Innovation under Section 1115A

Page 44 GAO-18-302 CMS Innovation Center

Note: Information in this table is as of December 1, 2017.

a

Obligations funded under section 1115A reflect payments to participants in the testing of models, 

such as health care providers of services, states, conveners, and others. These payments may 

include care management fees and cooperative agreement awards and are paid through Innovation 

Center funds as appropriated under section 1115A of the Social Security Act. Amounts reflect 

obligations made for fiscal years 2012 through 2016.

b

Obligations funded under Titles XVIII or XIX reflect payments, such as shared savings payments, 

made from the Medicare Trust Funds, as well as any other payments made under Titles XVIII or XIX 

for model-related services on behalf of beneficiaries. This column does not include Medicare, 

Medicaid, and Children’s Health Insurance Program payments to health care providers or others for 

services provided to beneficiaries. Amounts reflect obligations made through fiscal year 2016.
Appendix III: Models Required by Different 

Provisions of the Patient Protection and 

Affordable Care Act

Page 45 GAO-18-302 CMS Innovation Center

In addition to models required by section 1115A of the Social Security 

Act, as added by the section 3021 of Patient Protection and Affordable 

Care Act, the Center for Medicare and Medicaid Innovation implemented 

six models under different provisions of the Patient Protection and 

Affordable Care Act. (See table 16.)

Table 16: Models Implemented by the Center for Medicare and Medicaid Innovation Required by Different Provisions of the 

Patient Protection and Affordable Care Act

Model Description Status

(Years tested)

Participants Obligations through 

September 30, 2016

Incentives for Prevention of Chronic 

Diseases in Medicaid – Tested the impact of 

providing incentives to Medicaid beneficiaries 

to participate in prevention programs such as 

those that address tobacco cessation, 

controlling or reducing weight, lowering 

cholesterol, lowering blood pressure, and 

managing or avoiding the onset of diabetes. 

The final evaluation was unable to directly 

measure whether the programs prevented 

chronic diseases, but found programs focusing 

on tobacco cessation increased cessation 

rates.

Implemented – testing 

period ended

(2011-2015)

10 states $71.1 million

Medicaid Emergency Psychiatric 

Demonstration – Tested the extent to which 

reimbursing private psychiatric hospitals for 

inpatient services needed to stabilize 

psychiatric emergency medical conditions in 

adult Medicaid beneficiaries ages 21 to 64 

(which is generally prohibited under Medicaid) 

improved access to and quality of care for 

these beneficiaries and reduced overall 

Medicaid spending and utilization. The final 

evaluation was unable to make definitive 

conclusions about whether the demonstration 

improved access to and quality of care while 

reducing spending and utilization.

Implemented – testing 

period ended

(2012-2015)

27 private psychiatric 

hospitals in 11 states and 

the District of Columbia

$74.2 Million

Medicare Independence at Home 

Demonstration – Tests the effectiveness of 

delivering an expanded scope of primary care 

services in a home setting on improving care 

for Medicare beneficiaries with multiple chronic 

conditions.

Implemented

(2012-2019)

14 primary care practices 

and consortia

$16.1 million

Appendix III: Models Required by Different 

Provisions of the Patient Protection and 

Affordable Care Act
Appendix III: Models Required by Different 

Provisions of the Patient Protection and 

Affordable Care Act

Page 46 GAO-18-302 CMS Innovation Center

Model Description Status

(Years tested)

Participants Obligations through 

September 30, 2016

Community Based Care Transitions 

Program – Tested approaches to reduce 

unnecessary hospital readmissions by 

improving the transition of Medicare 

beneficiaries from the inpatient hospital setting 

to home or other care settings. The final 

evaluation was unable to make definitive 

conclusions on the impact of the model, but 

found some evidence that suggested the 

potential for the program to reduce hospital 

readmissions.

Implemented – testing 

period ended

(2012-2017)

Began with 101 

community-based 

organizations and 

concluded with 44.

$291.5 million

Certain Complex Diagnostic Lab Tests –

Tested the effect of making separate payments 

for certain complex diagnostic laboratory tests 

on access to care, quality of care, health 

outcomes, and expenditures. The final 

evaluation found that the Demonstration did not 

have a significant impact on the care received, 

health outcomes, or expenditures among the 

Medicare beneficiary population as a whole.

Implemented – testing 

period ended

(2012-2014)

Not applicable $400,000

Graduate Nurse Education – Tests the effect 

of offsetting the costs of clinical training for 

Advanced Practice Registered Nurses (APRN) 

on the availability of graduate nursing students 

enrolled in APRN training programs. The final 

evaluation found that the model had a positive 

impact on APRN student growth, and helped 

transform clinical education within participating 

schools of nursing.

Implemented

(2012-2018)

5 hospitals partnering with 

19 schools of nursing

$153 million

Source: Centers for Medicare & Medicaid Services. | GAO-18-302
Appendix IV: GAO Contact and Staff 

Acknowledgments

Page 47 GAO-18-302 CMS Innovation Center

Kathleen M. King, (202) 512-7114, kingk@gao.gov

In addition to the contact named above, Greg Giusto (Assistant Director), 

Aaron Holling (Analyst-in-Charge), Ashley Dixon, and Rachel Rhodes 

made key contributions to this report. Also contributing to the report were 

Sam Amrhein, Muriel Brown, and Emily Wilson.

Appendix IV: GAO Contact and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments

(101673)
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