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. 1.) 2.) Initiatives Focused on Medicare-Medicaid Beneficiaries. 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

As of March 1, 2018, the Innovation Center had implemented 37 models  under section 1115A of the Social Security Act. 3.) The Innovation Center Obligated over 55 Percent of Its Initial Multiyear Appropriation through Fiscal Year 2016

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. 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

The Innovation Center has used the results from model evaluations to  generate ideas for new models. 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). 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. 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. 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. The Innovation Center Established Performance Goals and Related Performance Measures and Reported Meeting Its Targets for Some Goals

To assess is own performance, the Innovation Center established three  center-wide performance goals and related measures. 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. 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. Agency Comments

We provided a draft of this report to HHS for comment. The Department  provided technical comments, which we incorporated as appropriate. At that time, we will send copies to the Secretary of Health  and Human Services. Appendix II: Models Implemented or Announced by the Center for Medicare and Medicaid Innovation under Section 1115A

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. 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 16.)
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.

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).
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.