Purpose of CMS Innovation Center Models
The CMS Center for Medicare and Medicaid Innovation (the Innovation Center) was established for the purpose of testing “innovative payment and service delivery models to reduce program expenditures ... while preserving or enhancing the quality of care” for individuals with Medicare, Medicaid and/or the Children’s Health Insurance Program (CHIP).
The Innovation Center designs and tests pilot programs called Alternative Payment Models (APMs), which reward health care providers for delivering high-quality, coordinated care and fall into at least one of the following categories (see category and stage descriptions):
- Accountable Care Models
- Disease-Specific and Episode-Based Models
- Health Plan Models
- Prescription Drug Models
- State & Community-Based Models
- Statutory Models
A full list of Innovation Center models can be found on our Innovation Models page.
Model participants receive tools and resources (for example, prospective payments, access to data, infrastructure support and/or flexibilities in care delivery) to help them implement models and achieve the models’ goals.
Innovation Center models are integral to accelerating the move toward a health care system designed to focus on quality of care, provider performance and patient outcomes, commonly referred to as value-based care.
Note: APMs are not clinical trials.
Formulating Model Ideas
As an early step, the Innovation Center draws from internal and external sources to identify problems in the health care system and determine whether they can be addressed by a model. Model ideas are informed by:
- Health care research and outside experts
- Public health needs
- CMS’ and the Administration’s strategic priorities
- Input from interested parties
Ideas are not developed in a vacuum. CMS consults with experts across the health care field, including providers, clinicians and hospital systems; patients and patient advocates; policy analysts; other Federal agencies and state governments; members of the Physician-Focused Payment Model Technical Advisory Committee (PTAC); and others who have an expertise in health care management, payment and delivery. These consultations are conducted in a variety of ways, including through listening sessions, Requests for Information and proposed payment rules.
In some cases, models may be Congressionally mandated.
Note: Model ideas are not developed around a specific technology and they are not clinical trials. Instead, the Innovation Center provides general guidance to model participants, and they decide what technology and care design will work best for improving care in the model.
Vetting and Selecting Model Ideas for Development
After an idea is initially formulated, the Innovation Center performs detailed research and evidence gathering to determine whether the model idea holds promise for improving quality of care and reducing expenditures, and whether it meets other statutory requirements for the selection of models under section 1115A of the Social Security Act. The Innovation Center also applies several criteria to determine which model ideas are most viable for testing, which includes alignment, impact, feasibility and diversity.
Alignment
Models selected for testing align to and advance one or more of the CMS Innovation Center’s five strategic objectives:
- Drive accountable care
- Advance health equity
- Support innovation
- Address affordability
- Partner to achieve system transformation
Additionally, the Innovation Center considers how an idea aligns with its previous work. For example, the Innovation Center looks at existing, relevant data; considers previous Innovation Center models and other pertinent experience; and determines if the idea advances other CMS initiatives.
The Innovation Center also considers whether the idea overlaps with existing or previous CMS programs and other anticipated models to ensure the proposed intervention is “innovative.”
Impact
Along with ensuring a model will help advance the Innovation Center’s strategic objectives, the potential impact of a model is measured by its:
- anticipated reach (the projected number of participants, as well as the breadth and volume of providers and people touched by the model)
- potential for health system transformation (would the model meaningfully enhance health care delivery; reduce Medicare, Medicaid and/or CHIP costs/spending; and improve quality of care)
As part of its statutory focus on quality improvement, the Innovation Center considers whether the model would result in greater care coordination, improved clinical outcomes and a better patient experience. The Innovation Center also assesses whether the model would help advance health equity and reduce disparities in health care quality experienced by vulnerable populations.
The Innovation Center ensures that models maintain the health care coverage and benefits people receive under Medicare, Medicaid and/or CHIP.
Feasibility
Feasibility accounts for any operational or other limitations related to the Innovation Center implementing a model, and whether CMS would need to waive any program requirements for purposes of testing a model. The Innovation Center conducts an extensive model development and clearance process.
Feasibility also takes into consideration the likelihood a model will be successful. Specifically, CMS weighs:
- Operational feasibility: the ability of model participants to build the infrastructure needed to implement the model, as well as the likely costs for implementation
- Evaluative feasibility: if CMS will be able to collect data and analyze results to make reasonable conclusions about the model’s performance (see “Implementing and Evaluating Models” below)
- Scalability: if CMS will be able to effectively expand the model (if successful)
Diversity
Model ideas often push innovation in a specific area of health care, provider type, patient population or mechanism of transformation. Proposed models consider demographic, clinical and geographic diversity.
The Innovation Center engages diverse patient and practitioner populations that have yet to participate in other models as part of our efforts to address health equity and improve outcomes related to specific health disparities. This includes populations and geographic regions with previously low participation in Innovation Center models. For example, the Innovation Center has focused on bringing more safety net providers who have historically worked in underserved communities into models and offered onramps and incentives to help get new providers acclimated with value-based care.
Building Models
After a model idea is formulated and vetted, it enters the building phase, during which the model’s components are created. Model participants, contractors, IT and learning systems, and other aspects of the model are planned out. APMs generally take around 18 to 36 months to design and undergo rigorous review before launching, but the length of time varies depending on the model.
Models may take longer to develop if they:
- Include new and significant health system changes, especially when CMS has limited experience in that specific area
- Require a new data registry or other infrastructure
- Involve other payers; CMS may need to enter into a legal agreement or Memoranda of Understanding with commercial payers or states, or provide additional time to prepare for participation and connect with affected health care providers
- Are mandatory, which involves going through the notice and comment rulemaking process
Models may take less time to develop if they:
- Are built upon previous models and can leverage some of the established design and best practices
- Use existing infrastructure and data for collecting quality measures
Learn more about How an Idea Becomes a CMS Innovation Center Model (PDF)
Implementing and Evaluating Models
Models are usually tested for 5 to 10 years, potentially longer, depending on the model.
Every model tested by the Innovation Center is required, by statute, to be evaluated and must include an analysis of its impact on quality of care (including patient-level outcomes and patient-centeredness) and changes in spending. This evaluation helps to determine whether the model meets criteria for possible expansion. Innovation Center models also are evaluated in relation to an established set of performance requirements (for example, health equity, reporting and beneficiary attribution). Participants have some flexibility in how they achieve these goals.
The exact evaluation methodology is tailored based on the model design. Methodologies reflect what quantitative and qualitative data will be available and necessary to assess a model’s success. The Innovation Center also has created learning collaboratives so that model participants can quickly and broadly share evidence and best practices that have the potential to deliver higher quality care to patients.
The results of model testing help guide CMS decisions about potential changes in policies and also may help inform future model ideas.
The Innovation Center’s evaluation reports are available on our Data and Reports page.
Additional Model Resources
For more information and to learn more about the work being done by the Innovation Center, visit our Connect With Us webpage and sign up for the CMS Innovation Center listserv. The listserv provides regular updates about the Innovation Center, including opportunities to engage with, provide input on and potentially participate in models.
The following resources offer additional information about APMs and the Innovation Center:
CMS Innovation Center Strategic Direction – Learn more about the Innovation Center’s vision for a health care system that achieves equitable outcomes through high-quality, affordable, person-centered care. This page includes a one-year strategy update and more information on the progress on our strategy.
CMS Innovation Center Data & Reports webpage – Search, access and review Innovation Center model evaluation reports, and learn more about the details of Innovation Center initiatives and activities in the Center’s Reports to Congress.
Completed Models Fact Sheet (PDF) – Learn more about how models continue to have a meaningful impact on the Innovation Center’s work and long-term goals even after they have concluded.
Health Care Payment Learning & Action Network (LAN) – Learn more about the LAN, a group of public and private health care leaders dedicated to providing thought leadership, strategic direction, and ongoing support to accelerate our health care system’s adoption of APMs.
Medicare Shared Savings Program (MSSP) – Access program resources and learn more about how MSSP is committed to achieving better health for individuals, better population health and lowering growth in expenditures.
Quality Payment Program (QPP) and QPP Resource Library – Learn more about QPP and its two tracks, the Merit-based Incentive Payment System (MIPS) and Advanced APMs, established by Congress through the Medicare Access and CHIP Reauthorization Act of 2015. The Innovation Center is responsible for overseeing aspects of QPP related to APMs.
Originally posted on: September 22, 2023 | Reviewed and revised on: October 5, 2023