AREA OF FOCUS

Controlling Health Care Costs

APRIL 28, 2022

EVIDENCE FROM A DECADE OF INNOVATION

The Impact of the Payment and Delivery System

Reforms of the Affordable Care Act
AUTHORS

Corinne Lewis, Melinda K. Abrams, Shanoor Seervai, Celli Horstman, David Blumenthal

The U.S. health care system has long been marked by high spending, comparatively poor
health outcomes, inequities, waste, and inefficiency. To address these issues, the
Affordable Care Act (ACA) includes several provisions to reform how the nation
organizes, structures, and pays for its health care. The law instituted several mandatory
national payment reforms through the Medicare program and created the Center for
Medicare and Medicaid Innovation (CMMI), which was funded with $10 billion every
10 years to develop, test, and promote innovative payment and delivery models. Below
is a summary of evidence from some of the major innovations tested by CMMI since its
inception.

Overall, these initiatives transformed health care delivery and payment across the United
States, and many have reduced costs and improved quality of care. The results were often
mixed, however, and the magnitude of impact was modest in many instances. In these
first 10 years, six of the 50 models launched by CMMI yielded statistically significant
savings. Furthermore, many models were not designed explicitly to address health
disparities, and the evaluations rarely investigated how models impacted beneficiaries
across demographics.

In 2021, CMMI published its vision of innovation over the next 10 years, which includes
a renewed focus on creating value and accountability in health care, addressing
affordability, advancing equity, and leveraging data to monitor and support care
transformation. To achieve meaningful, sustainable gains, future models of payment and
delivery system reform will need to be redesigned in light of the lessons learned from the
past 10-plus years of innovation.

SECTIONS
01 Mandatory National Payment Reform Initiatives

02 Accountable Care Organizations

03 Episode-Based Payment Initiatives

04 Primary Care Transformation

05 Innovation in Medicaid and the Children’s Health Insurance Program (CHIP)

06 Improving Care for Dually Eligible Beneficiaries

07 Accelerating the Development, Testing, and Adoption of New Payment and Delivery Models

Mandatory National Payment Reform Initiatives

The Affordable Care Act introduced compulsory value-based payment initiatives
through Medicare to reduce hospital readmissions and hospital-acquired conditions and
to improve the overall quality of care that hospitals deliver. Studies evaluating these
programs have produced mixed results and have not shown significant improvements
in outcomes. Some evidence suggests that one of the models may have increased
mortality, and that these models disproportionately penalize minority- and low-
income-serving hospitals.
 Description Status Impact to Date

Hospital Readmission 2012–present Some studies in

Reduction Program In 2020, 2,545 eligible readmissions fel
(HRRP) hospitals, or 83%, were implementation.
penalized. Other studies fo
Financially penalizes decline in
hospitals with the highest readmissions wa
relative rates of unplanned significant and re
readmissions within 30 days from factors othe
of discharge for Medicare HRRP.
beneficiaries with six clinical Evidence is mixe
conditions. whether HRRP re
in increased mo

Hospital-Acquired 2014–present There was avera

Conditions Reduction annual reduction
Program (HACRP) 4.5% in HACs fro
2010 to 2017.
To reduce medical errors However, drop in
and prevent HACs, the ACA predated ACA an
imposed a 1% financial program does no
penalty for hospitals in the appear to incent
top quartile for preventable improvement, wi
HACs. most penalized
hospitals consis
being in top qua
each year.

Hospital Value-Based 2013–present Studies found no

Purchasing Program significant differe
(HVBPP) quality of care or
mortality betwee
Adjusts Medicare payments participating hos
to hospitals in line with their and controls.
performance on measures
of clinical outcomes, patient
and community
engagement, safety, and
efficiency.

Accountable Care Organizations (ACOs)

ACOs are networks of physicians, hospitals, and other providers that voluntarily come
together to be held accountable for the cost and quality of care for attributed patients.
Participants in ACOs can accept either upside-only risk, whereby they can share in
savings to Medicare, or two-sided (upside and downside) risk, whereby they can share in
savings or pay a penalty, depending on the specific model, on performance on quality
metrics, and on spending relative to benchmarks. As of 2022, there were 483 ACOs
operating under Medicare. Overall, they appear to produce net savings for Medicare
while improving or maintaining quality of care, with ACOs in the Medicare Shared
Savings Program showing the greatest promise. Physician-led ACOs tend to perform
better than hospital-led ACOs, and ACO performance appears to improve over time.
Description Status Impact to Date

Pioneer ACO 2012–2016 Net savings to

32 participated in Medicare of $134
Providers with 2012; dropped to 9 million in 2012 and
experience in by December 2016 $99 million in 2013.
coordinating care (many transitioned Improvement in
across multiple care to MSSP). quality scores over
settings took on higher time.
upside and downside Reductions in
financial risk than in emergency
MSSP model (see department (ED)
below). Pioneer ACOs visits, particularly
that achieved sufficient for conditions
savings in first two years treatable in
were able to move to outpatient settings.
population-based Program certified
payments in year 3. by the U.S.
Secretary of Health
and Human
Services as cost-
effective and worth
promoting.

Medicare Shared 2012–present Net savings to

Savings Program 477 participating, Medicare of $1.9
(MSSP) covering 10.7 billion in 2020.
million Medicare Better performance
Providers meeting beneficiaries as of on savings over
specific quality 2021.. time.
standards and achieving MSSP ACOs led by
savings by spending physicians are
less than targets evenly more likely to
split the amount of produce savings
savings with Medicare. than those led by
Multiple variants exist. In hospitals.
2018, CMS announced Greater likelihood
significant changes to of those taking on
MSSP model, requiring downside risk to
that providers take on receive bonuses
some downside risk and generate
after two years. savings compared
to those taking on
upside risk only.
Scored as well or
better on measures
of quality including
 of quality, including
receipt of
preventive
services, declines
in hospital
readmissions, and
patient/caregiver
experience, than
FFS Medicare
providers.
Less than 1% failing
to meet quality
performance
standards.
Worse
performance and
quality outcomes
for ACOs with
higher minority
populations.

Next Generation ACO 2016–2021 Significantly

(“Next Gen”) 35 participating as reduced total
of 2020. Medicare spending
Allowed experienced for beneficiaries
ACOs to take on greater relative to
levels of upside risk in comparison group,
exchange for greater by $348.6 million
downside risk. Both fee- from 2016 to 2018,
for-service (FFS) and but when factoring
population-based in shared savings
payments were made to payments, non-
practices. Model significantly
participants were also increased net
allowed to waive some Medicare spending
Medicare requirements by $117.5 million.
and enhance certain No significant
benefits like telehealth impacts on number
and post-discharge of hospitalizations
home visits. or unplanned
readmissions, but
significant
increases in the
receipt of annual
wellness visits.

Advance Payment 2012–2015 Performed similarly

ACOs 35 participated to FFS Medicare
ACOs 35 participated. to FFS Medicare
beneficiaries not in
Provided advanced an ACO on
prepaid shared savings spending and
payments, serving as claims-based
start-up capital, to quality measures.
encourage physician-led Two-thirds
and rural organizations continued to
to participate in ACO operate as an ACO
program. after model ended.

ACO Investment 2016–2020 Reduced total

Model (AIM) 14 of the initial 47 Medicare spending
ACOs remained in and utilization
Building on the Advance the program as of compared to
Payment Model, AIM 2020. similar Medicare
provided prepaid shared $96.2 million in AIM FFS beneficiaries in
savings to small and/or payments made first two years of
rural MSSPs to and approximately program.
encourage formation 54% of payments Greater savings
and participation and to recouped by CMS than similar non-
prepare them to move as of 2018. AIM ACOs while
toward high-risk models. 20 AIM ACOS fully maintaining quality
repaid their funds. of care.
63% report they
would not have
participated in ACO
program without
AIM funding.
Only two of 47
dropped out during
the program.

Comprehensive End 2015–2021 Over the four

Stage Renal Disease 33 Seamless Care performance years,
(ESRD) Care Model Organizations were the model reduced
(CEC) participating in the Medicare spending
model, as of 2021. by $151 million, but
Building on other CMMI produced net
ACO models, CEC losses of $46
brought together million.
dialysis clinics, The model
nephrologists, and other decreased all-
providers to coordinate cause
care for Medicare hospitalizations
beneficiaries with ESRD. and ESRD-related
hospitalizations for
ESRD beneficiaries
 ESRD beneficiaries.

Kidney Care Choices 2022–present Results not yet

(KCC) Model 85 participants as available.
of 2022
Similar to CEC, KCC
promotes managed care
f M di
Episode-Based Payment Initiatives
Episode-based payment programs test whether providing a single payment for a defined
episode of care can produce savings while maintaining quality of treatment. Under these
models, providers keep savings if spending is below targets, and lose money if spending
exceeds targets. While on the whole these models have not yielded significant savings for
Medicare, episode-based payments that are mandatory and those for surgical, rather
than medical, conditions show the most promise for lowering costs without reducing
quality.
Description Status Impact to Date

Bundled Payments for 2013–2016 Model 1 only: No

Care Improvement (BPCI) 24 hospitals consistent statis
Model 1: Acute Care participated. significant positi
Hospital Stay Only negative impact
Medicare payme
Hospitals were paid a per episode or h
predetermined, discounted, outcomes.
episode-based payment for BPCI appears to
inpatient stays in the acute less successful f
care hospital for all medical than for
Medicare Severity Diagnosis surgical conditio
Related Groups (MS-DRGs). hospital participa
for common med
conditions was n
associated with
reductions in Me
payments, ED us
readmissions, or
mortality.

BPCI Model 2: 2013–2018 Models 2–4:

Retrospective Acute & 422 hospitals and 277 Significantly redu
Post-Acute Care Episode physician group Medicare per-ep
practices participated. payments and no
Hospitals and physician reduction in qua
group practices were paid compared to non
single payment for inpatient participating hos
stay in an acute care reduced paymen
hospital and all post-acute not translate to n
care and physician services savings for Medi
during the episode. when accounting
Participants chose length of reconciliation
the episode, either 30, 60, payments.
or 90 days after hospital BPCI appears to
discharge, and chose which less successful f
of up to 48 clinical medical than for
conditions they would surgical conditio
receive episode-based hospital participa
payments for. for common med
conditions was n
associated with
reductions in Me
payments, ED us
readmissions, or
mortality
 mortality.

BPCI Model 3: 2013–2018 Models 2–4:

Retrospective Post-Acute 873 skilled nursing Significantly redu
Care Only facilities, 116 home Medicare per-ep
health agencies, 9 payments and no
Model 3 was similar to inpatient rehab reduction in qua
Model 2 except that the facilities, 1 long-term compared to non
episode-based payment did care hospital, and 144 participating hos
not include the inpatient physician group reduced paymen
stay itself, but rather the practices participated. not translate to n
post-acute services after savings for Medi
hospital discharge only. when accounting
reconciliation
payments.
BPCI appears to
less successful f
medical than for
surgical conditio
hospital participa
for common med
conditions was n
associated with
reductions in Me
payments, ED us
readmissions, or
mortality.

BPCI Model 4: 2013–2018 Models 2–4:

Prospective Acute Care 23 hospitals Significantly redu
Hospital Stay Only participated. Medicare per-ep
payments and no
Hospitals were paid a single reduction in qua
payment that covered all compared to non
services provided by the participating hos
hospital, physicians, and reduced paymen
other providers during not translate to n
inpatient stay and related savings for Medi
readmissions for 30 days when accounting
post-discharge. Participants reconciliation
could select up to 48 MS- payments.
DRG conditions to be BPCI appears to
included. less successful f
medical than for
surgical conditio
hospital participa
for common med
conditions was n
 conditions was n
associated with
reductions in Me
payments, ED us
readmissions, or
mortality.

BPCI Advanced 2018–present Medicare has los

More than 1200 estimated $159 m
Building on Models 1 hospitals and physician under this mode
through 4, BPCI Advanced group practices were Quality of care is
provides single, participating as of unchanged unde
retrospective bundled 2021. model.
payment for 90-day clinical While dropout am
episodes. CMS narrowed participants was
options for clinical episodes the first 6 month
from up to 48 MS-DRGs to model expanded
up to 31 inpatient and 4 between years tw
outpatient clinical episodes. three.
In addition, not only can
practices receive additional
payment if they spend below
target price set at the
beginning of each year, they
can also receive
adjustments to those
payments based on
performance on a set of
quality measures.

Comprehensive Care for 2016–present Statistically sign

Joint Replacement Implemented in 67 reductions in gro
metropolitan statistical Medicare payme
Hospitals in designated areas (MSAs) with 432 $1,511 per episod
areas received a single, hospitals as of 2021. (5.2% reduction)
retrospective payment for 2016 to 2019.
hip and knee replacements, Across the entire
which included inpatient model, savings r
hospitalization as well as were mixed, and
post-acute care and other whether Medica
physician services. As with realized net savi
BPCI, participants received inconclusive.
payments if total spending Savings accrued
was below predetermined primarily from sh
target prices.CJR was post-acute care
mandatory for all providers institutions to ot
in specific geographic areas settings like the
in the first two years but Unplanned
in the first two years, but Unplanned
was later made voluntary by readmission rate
CMS for some providers and improved; ED vis
areas. CMS recently issued mortality were
a final rule to extend a maintained.
slightly revised version of The model targe
the model for three years. conditions where
disparities exist,
was not designe
account for thes
disparities. Anot
study found that
model increased
disparities amon
Black patients.

Oncology Care Model 2016–present Medicare cance

(OCM) 126 practices episode paymen
participating as of have increased a
Provides an episode-based 2021. all beneficiaries
payment for care have increased $
surrounding chemotherapy less among mod
administration over six- participants.
month periods to improve Symptom
care coordination and management,
access for cancer patients. emergency
Practices receive enhanced department visit
per-member, per-month hospitalizations
payment and can receive been stable with
performance-based model.
payments as an additional
incentive. Commercial
payers are participating in
the program.

ESRD Treatment Choices 2021–present Results not yet

(ETC) Model. Aims to available.
encourage the use of home
dialysis and kidney
transplants over in-center
hemodialysis for ESRD
Medicare beneficiaries by
adjusting payments to ESRD
facilities. The model will
explicitly address health
equity by incentivizing
outcome improvement
among low-income
 among low income
beneficiaries.

Radiation Oncology Expected to begin in Program not star

Model 2023.

Provides prospective
payments to participants to
promote simplified and
predictable payments, while
improving the quality of care
for cancer patients.
Payments to participants will
be tied to quality outcomes.
Participants include
physician groups, hospital
outpatient departments, and
radiation therapy centers.

Primary Care Transformation

Several federal payment and delivery system innovations have aimed to increase access
to and quality of primary care. These programs typically employ the evidence-based
patient-centered medical home (PCMH) model, which emphasizes care coordination,
teams, patient engagement, and population health management. Evaluations of these
efforts show largely mixed results, with few programs demonstrating meaningful
increases in the availability of primary care, reductions in costly forms of utilization, or
improvements in quality. Perhaps the most successful model has been Independence at
Home, indicating that home-based care can be effective for high-need patients.
Description Status Impact to Date

Medicare Primary 2011–2015 No effect on

Care Bonus Payment Participating patient visits,
providers received quality of primary
Authorized a 10% bonus average additional care, or labor
payment for primary payment of $3,938 supply for primary
care services under in 2012. care services.
Medicare for qualifying Slight effect (1%–
physicians, nurse 2%) on new
practitioners, and Medicare patient
physician assistants. visits at
independent
practices.

Medicaid Fee Bump 2013–2014 One study found

19 states continued significant increase
Required that states the fee bump after in primary care
raise Medicaid it expired, self- appointment
reimbursement for funding the availability but no
primary care services to extension. difference in
Medicare levels. 73% increase in appointment wait
Increased Medicaid payments times.
reimbursement was for primary care Two other studies
funded by federal during bump. found no effect on
government. appointment
availability or
primary care
physicians
accepting new
Medicaid patients.

Comprehensive 2012–2016 Enhanced access

Primary Care (CPC) 442 practices to care, better care
across 14 regions coordination for
Multi-payer advanced served more than patients, and
medical home model in 2.7 million patients. slightly slower
which participating growth in ED visits
practices received a compared to
non-visit-based care comparison
management fee ($20 practices
per member, per month) No effect on quality,
and had option to share patient or physician
in savings to Medicare. satisfaction, or
Practices received Medicare spending
incentives and data when considering
about practice care management
performance and fees paid to
technical assistance in practices.
exchange for meeting
care delivery
requirements.

Comprehensive 2017–2021 Improvements in

Primary Care Plus 2,675 practices and service use and
(CPC+) 60 payers were quality-of-care
participating in 18 measures.
Built on lessons learned regions at the end No net savings;
from CPC, CPC+ of 2019. practices reduced
maintained care delivery growth rate in
requirements of CPC but overall Medicare
changed payment expenditures for
structure from practices beneficiaries but
being able to share in decreases were not
savings to practices enough to offset
receiving performance- care management
based incentive fees.
payments. In Track 2, Practices in
practices can opt out of underserved and
FFS payments in economically
exchange for a larger disadvantaged
quarterly lump-sum areas were less
payment. likely to join the
model.

Independence at 2012–present Significant

Home (IAH) 12 sites decrease in ED
Demonstration participating as of visits but not
2020. hospitalizations.
Practices provide home- Improved
based primary care for beneficiary and
chronically ill Medicare caregiver
beneficiaries using satisfaction.
teams of providers. While Medicare
Practices that achieve expenditures
cost reductions while decreased over five
maintaining or improving years, results were
quality share in savings not significant.
to Medicare. Compared to other
CMMI population-
based ACOs, IAH
has produced the
most net savings
 per beneficiary per
year.

Multi-payer Advanced 2011–2016 One study found

Primary Care Practice 8 states and Medicare
(MAPCP) Program approximately expenditures were
1,200 medical $227 million lower
State-sponsored, multi- homes served than for
payer program that 900,000 Medicare comparable
offered monthly per- beneficiaries. beneficiaries
member, per-month receiving care in
care management fees medical homes
to practices providing after accounting for
primary care aligned payments made to
with medical home practices, due
model. Fee was primarily to
intended to cover reductions in acute
services to support care utilization.
chronically ill Other studies
beneficiaries, including found little to no
care coordination and effect on
patient education. expenditures or
utilization and no
reduction in
Medicaid
expenditures
among states.
Some states
showed
improvements in
access, quality, and
health outcomes,
while others did
not.
There were some
significant
unfavorable
associations of
participation and
avoidable
hospitalizations.

Federally Qualified 2011–2014 Improvements in

Health Center (FQHC) 434 practices utilization,
Advanced Primary served 195,000 spending, and
Care Practice Program Medicare satisfaction
beneficiaries. compared to those
R i d FQHC db h
 Required FQHCs to served by other
achieve Level 3 PCMH practices.
recognition by the NCQA medical
National Committee for home recognition,
Quality Assurance not the
(NCQA). To assist demonstration
practices in making overall, drove
changes to care delivery, improvement.
they were offered
technical assistance
and paid a monthly care
management fee for
each eligible Medicare
beneficiary served.

Medicaid Health Home 2011–present Few states had

State Plan Option 19 states and resources to
Washington, D.C., conduct
States create health participated as of evaluations.
homes in exchange for 2022. Compared to
an enhanced, two-year baseline, early
federal match of 90% results from some
for eligible Medicaid states found
beneficiaries with reductions in ED
h i di i dh i l i i
Innovation in Medicaid and the Children’s Health Insurance
Program (CHIP)
The Center for Medicare and Medicaid Innovation tested several innovative payment
and delivery models through Medicaid and CHIP. These programs aimed to tackle
growing issues in the Medicaid and CHIP populations by preventing chronic disease,
improving birth outcomes, and increasing access to behavioral health care. Two of these
models — the Medicaid Incentives for the Prevention of Chronic Disease and Strong
Start for Mothers and Newborns — improved outcomes for Medicaid and CHIP
beneficiaries, although improvements were not always significant. These two programs
are currently inactive.
Description Status Impact to Date

Medicaid Innovation 2014–2020 Participants repo

Accelerator Program (IAP) All states and D.C. have gaining new know
participated in at least from program an
Provided technical one Medicaid IAP. responding to
assistance to states to technical assista
support their payment and developing refor
delivery system reform state policy and
efforts in four content areas: practice (e.g., ch
high-need, high-cost managed care
Medicaid beneficiaries; payments and
substance use disorders; submitting Secti
community integration to waivers for
support long-term services demonstration
and supports; and physical projects).
and behavioral health One-on-one coa
integration. resulted in increa
state action mor
virtual or group
assistance.

Medicaid Incentives for 2011–2016 Few significant

Prevention of Chronic 10 states participated. changes in Medi
Diseases expenditures be
incentive payme
Provided grants to states to Significantly incr
design evidence-based receipt of preven
incentive programs that services compar
encouraged healthy controls.
behaviors (e.g., tobacco Non-significant
cessation, controlling or improvements in
reducing weight, lowering outcomes includ
cholesterol) among weight loss, lowe
Medicaid beneficiaries. blood pressure,
improved self-re
health status, an
smoking cessati
Monetary value o
incentives signif
predicted progra
satisfaction and
of incentives.
One state, Califo
focused outreac
efforts specifica
addressing dispa
 addressing dispa
affecting ethnic
minorities and le
gay, bisexual, an
transgender peo

Strong Start for Mothers 2013–2017 Lower costs than

and Newborns 182 sites participated. comparable Med
beneficiaries.
Public–private partnership Better birth outc
that raised awareness of including lower r
early elective deliveries and preterm birth, c-
tested effectiveness of sections, and low
three enhanced prenatal weight.
approaches to reduce Rates of preterm
premature births among and cesarean se
Medicaid and CHIP birth were lower
beneficiaries: group Black women in
prenatal care, birth centers, program than the
and maternity care homes. national average
The program
decreased rates
preterm birth, low
weight, and cesa
delivery among B
and Hispanic wo
but the rates rem
higher than thos
among white wo

Medicaid Emergency 2012–2015 There were no

Psychiatric 11 states and D.C. significant reduc
Demonstration participated. in Medicaid or
Medicare spend
Tested whether waiving the inpatient stays, o
institutions for mental emergency
disease (IMD) exclusion, department visit
thereby allowing Medicaid
to reimburse certain
services at psychiatric
hospitals, could lead to
better access, higher quality,
and lower costs through
reductions in other forms of
mental health services. Over
three years, the
demonstration provided $75
million in federal matching
 million in federal matching
funds for treatment of
psychiatric emergencies.

Maternal Opioid Misuse 2021–present Results not yet

(MOM) Model 8 participants. available.

Aims to address the opioid

epidemic by increasing
access to coordinated and
integrated opioid use
disorder (OUD) treatment for
pregnant women through
states' Medicaid flexibilities
and partnerships with
practitioners to coordinate
care.

Integrated Care for Kids 2020–present Results not yet

(InCK) 7 participants. available.

Through state-specific
alternative payment models,
participants will seek to
identify and treat children's
health needs early and
provide coordinated care to
health and social need
providers.

Improving Care for Dually Eligible Beneficiaries

To improve care delivery and coordination across payers, the Center for Medicare and
Medicaid Innovation tested models that aligned financial incentives for people enrolled
in both Medicare and Medicaid. The evidence from these initiatives, though mixed,
indicates that targeting dually eligible beneficiaries can yield savings and decrease
hospitalizations.
Description Status Impact to Date

Financial Alignment 2013–present Some state FAI

Initiative (FAI) for 11 states programs have
Medicare-Medicaid participating as of achieved
Enrollees 2022. significant
Medicare savings
Tests two models to and reductions in
better align financial inpatient care
incentives across compared to a
Medicare and Medicaid matched
with the goal of reducing comparison group,
fragmentation of care while others have
for those dually enrolled: not. Evaluations
(1) a capitated model in have typically
which health plans analyzed impact on
receive a prospective, Medicare
blended payment to expenditures only,
provide coordinated so impact on
care for duals; and (2) a Medicaid
managed FFS model in expenditures is
which states could unknown.
benefit from savings
produced by the
initiative. In both
models, CMS, states,
and health plans enter a
three-way contract to
integrate primary, acute,
and behavioral health
care, and long-term
services and supports.

Initiative to Reduce Phase 1: 2012–2016 Phase 1:

Avoidable Phase 2: 2016– Reductions in
Hospitalizations 2020 probability of
Among Nursing 143 LTC facilities all-cause
Facility Residents: participated in hospitalization
Phases 1 and 2 Phase 1. 247 LTC and potentially
facilities were avoidable
Supports organizations participating in hospitalization
in adopting clinical and Phase 2 as of 2019. rates relative
educational evidence- to comparison
based interventions for groups.
dually eligible Reduced
beneficiaries in long- average
term care (LTC) facilities Medicare
 term care (LTC) facilities Medicare
to prevent expenditures
hospitalizations. per resident.
Building on Phase One, Consistent
Phase Two added a clinical care
payment reform provided by
component. Model registered
reduces financial nurses or
incentive for nurse
hospitalization by practitioners
providing funding for associated
LTC facilities and with success.
practitioners to directly Phase 2:
provide higher-intensity No further
services should a reductions in
beneficiary require hospital-
acute care while in the related
facility. utilization or
costs than
those
achieved in

Accelerating the Development, Testing, and Adoption of New

Payment and Delivery Models
Several initiatives of the Center for Medicare and Medicaid Innovation provided funding
to support health care systems, states, and communities in developing, testing, and
spreading innovative, evidence-based ways of delivering and paying for care. Evaluations
of these programs have often found cost savings and lower rates of costly forms of
utilization like hospitalizations, but variation exists.
Description Status Impact to Date

State Innovation Models 2013–present Several states ha

(SIMs) 34 states had received improved quality
SIM awards as of 2018. care and reduce
Provide federal funding and costly forms of
technical assistance to utilization, and s
states to help them plan, have resulted in
design, and/or implement Medicaid saving
multi-payer partnerships SIM states have
aimed at transforming care successfully
delivery. Most popular implemented
alternative payment models evidence-based
(APMs) adopted and tested models of care a
have been PCMH, ACO, and created multi-pa
episode-of-care models. partnerships to
States applying for the encourage the s
second round of funding are from FFS to value
required to include based payments
interventions that address Overall, states ha
health disparities and increased provid
achieve health equity in their value-based pay
plan for improving (VBP) participatio
population health. Six states have w
to improve linkag
between provide
social service
providers.

Health Care Innovation Round 1: 2012–2015 | Round 1: A mix o

Awards: Round 1 and Round 2: 2014–2017 positive and neg
Round 2 Over 100 organizations effects from awa
received awards in Few produced
Provided approximately $2 Round 1 and 38 awards significant cost s
billion in funding to were made in Round 2 and most interve
providers, payers, local across 27 states and did not impact
government, public-private D.C. hospitalizations
partnerships, and multi- visits. Researche
payer collaboratives to test found some feat
and implement innovative associated with
programs to improve care success: implem
and reduce costs. Awards at a single site, g
focused on one of several staff training, and
priority areas: identifying robust implemen
new models of workforce planning.
development and Round 2: About h
deployment; improving care awardees met at
deployment; improving care awardees met at
for high-need populations; 90 percent of th
testing provider-specific enrollment targe
approaches to transforming two-thirds effect
financial and clinical models implemented de
of care; and improving the model. Evidence
health of geographically awardees succe
defined populations. sustaining progr
was mixed and, i
few models rigor
evaluated, there
little evidence of
reductions, qual
improvement, or
utilization.
Both Rounds 1 a
had study design
issues ranging fr
small sample siz
selection bias.

Medicare Diabetes 2018–present Savings to Medic

Prevention Program 196 suppliers of in- $278 per membe
(MDPP) Expanded Model person services have quarter and sign
reached 2,248 reductions in ED
A national, structured beneficiaries. and inpatient sta
intervention for behavior among participa
change aimed at preventing versus a compar
the onset of type 2 diabetes group.
among Medicare Studies of DPP
beneficiaries with indication programs genera
of prediabetes. MDPP have found simil
suppliers are given promising result
performance-based health outcomes
payments that depend on cost-effectivene
participants' weight loss and One of two mode
attendance. certified by the
Secretary of Hea
and Human Serv
as meeting the
threshold for spr
In the first year,
beneficiaries
experienced wei
loss and increas
physical activity.

Community-based Care Significantly lowe

Community-based Care Significantly lowe
Transitions Program 2012–2017 day readmission
(CCTP) (1.82% lower) and
Over the course of the Medicare Part A
To reduce readmissions expenditures ($6
program, 18 sites
among high-risk Medicare lower per partici
participated.
beneficiaries, provided during course of
federal funding to program) compa
community-based similar nonpartic
organizations for improving
transitions from hospital to
home or other care setting.

Home Health Value-Based 2016–present Modest reductio

Purchasing (HHVBP) 1,931 home health annual Medicare
Model agencies participating spending and
in 9 states as of 2019. improvements in
Home health providers in Expanded model will function among
participating states take on include all 50 states. receiving home c
increasing upside and/or HHVBP states
downside risk to test compared to non
whether value-based HVBPP states.
payment can improve home Lower rates of
care quality and efficiency. unplanned
hospitalizations
skilled nursing fa
use.
Slightly higher
increases in ED
and no differenc
patient satisfact

Accountable Health Initial reductions

Communities (AHC) 2017–present visits.
Model The majority of e
beneficiaries acc
28 community bridge
Addresses health-related organizations navigation to
social needs, such as food participating as of community servi
insecurity and unstable most reported m
2021.
housing, of beneficiaries by than one need.
linking clinical care and The model has b
community services. Model identified as a
funds "community bridge promising appro
organizations" to engage promoting health
clinical sites in social needs equity.
screening and connect
high-need beneficiaries to
community services
 community services.

Community Health Expected to begin in Results not yet

Access and Rural 2022. available.
Transformation (CHART) 4 participating entities.
Model

Supports the financial

stability of providers in rural
communities through
capitated payments and
Medicare waivers.

Emergency Triage, Treat, 2021–present Results not yet

and Transport (ET3) Model 184 participants. available.

Ambulances and providers

who respond to 911 calls by
Medicare FFS beneficiaries
will be able to offer
alternatives to hospital care.
The model aims to increase
the efficiency of emergency
services and provide
person-centered care.

PUBLICATION DETAILS

DATE

April 28, 2022

CONTACT

Celli Horstman, Senior Research Associate, Delivery System Reform, The Commonwealth Fund

[email protected]

CITATION

Corinne Lewis et al., “Evidence from a Decade of Innovation: The Impact of the Payment and Delivery System Reforms of the
Affordable Care Act,” Commonwealth Fund, Apr. 2020. https://doi.org/10.26099/5rj7-9319

AREA OF FOCUS

Controlling Health Care Costs

TOPICS
Affordable Care Act at 10,
Affordable Care Act,
Quality of Care,
Payment Reform

Fuente: https://www.commonwealthfund.org/publications/explainer/2023/feb/value-based-care-what-it-is-why-its-needed