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May 9, 2022

The Center for Medicare and Medicaid Innovation—Toward Value-Based Care

Author Affiliations
  • 1Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
  • 2The Warren Alpert Medical School, Brown University, Providence, Rhode Island
JAMA. 2022;327(20):1957-1958. doi:10.1001/jama.2022.6927

Before the enactment of the Patient Protection and Affordable Care Act (ACA) in 2010, experimentation with Medicare or Medicaid programs was prolonged, onerous, and often indecisive.1 The requisite congressional approval for each new model test constituted a lengthy and bureaucratic process, the implementation and evaluation of approved model tests lingered for years, and derived results were often out of date by the time they were finally available.1 It is against this backdrop that section 3021 of the ACA established the Center for Medicare and Medicaid Innovation (CMMI), replete with $10 billion in guaranteed federal appropriation for 2010 through 2019.2 Ensconced within the Centers for Medicare & Medicaid Services (CMS), the CMMI was to expand the scope and accelerate the pace of learning with an eye toward hastening the transition from fee-for-service payment models to value-based care. Now in its second decade, the CMMI resolved to review its past and plan its future in a recently unveiled report titled “Innovation Center Strategy Refresh.”3 The objective of this Viewpoint is to review this long-anticipated strategic plan of the CMMI and to explore the key takeaways thereof.

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4 Comments for this article
First Things First
Johnathon Ross, MD MPH | Toledo Lucas County Board of Health
If you want to reform a sickness care non-system, start with creating an actual system. The three things that providers and patients need are universality, simplicity, and affordability. We have the best caregivers and equipment in the world but the most complex and ineffective wasteful system to provide care to all that need it.

There is no evidence that market forces or the profit motive in healthcare has controlled costs or improved care. If it did, we would have the lowest costs and best quality among the rich nations, instead of the opposite (see Mirror, Mirror by the
Commonwealth Fund).

Many of us have come to the conclusion that an improved expanded Medicare for all (see HR 1976-Jayapal) would provide the best USA system: universal, simple, and affordable.

The Congressional Budget Office has now done studies of this type of system reform and they say that the administrative savings from the simplicity allows all payer rates for providers, total choice of provider for patients, and no copayment or deductibles that would cause affordability problems that have resulted in self-rationing of care. Even with these liberal benefits it would cut total national health expenditures by $40 billion annually and the macroeconomic effects would improve the overall economy.

With an actual system in place you would now be able to have comprehensive data that would allow you to target the social determinants and target low value care more easily.

Maybe we should give the private for-profit insurers and caregivers the $40 billion savings if they will just go away and let us have a healthcare system that works for all of us.

Paul Nelson, MS, MD | Family Health Care, PC, retired
The authors have offered a reasoned analysis of Medicare's CMMI progress to date and its current effort to re-invigorate its future efforts. I am reminded of a report by Lawton Burns and Mark Pauly where the write "data suggest a low prevalence of provider risk models and slow movement to new payment and organizational models. Evidence suggests the impact of both on cost and quality is weak." (Burns & Pauly 2018)

While the CMMI planning process unfolds I am reminded that the nation continues to do poorly on measures of maternal mortality, childhood maltreatment, childhood obesity, adolescent
suicide/homicide, substance abuse, midlife deaths from despair, and longevity at birth. They have all continued to worsen every year.


Lawton R. Burns & Mark V. Pauly, 2018. Transformation of the Health Care Industry: Curb Your enthusiasm? MILBANK QUARTERLY, 96(1):57-109, Wiley Periodicals Inc, NY, NY

Medicare and “Valued Care”
Michael Plunkett, MD MBA | Private Practice

If only 6 of 50 tested models brought better value care, that's 12.6% and not ready for broad implementation. 

Medicare and Medicaid are good at low overhead bill-paying but we should leave innovation to the people who do it best, probably Silicon Valley. Not Washington, DC.

The Distractions of Pay For Performance
Amit Desai, DO, MPH | Community Hospital
Pay-for-performance through various programs such as value-based purchasing to improve quality and reduce cost has become a costly distraction in the daily care of patients. Various metrics to measure system performance become an intense focus for organizations who are concerned about reputational damage and loss of revenue. The focus becomes so narrow that we start trying to modify patients 'care to meet the metric. The loss of physician autonomy from heavily bureaucratic processes to measure quality erodes joy in medicine. Lastly, the documentation burden leads to loss of productive time and seems to alter the appearance of quality rather than true quality.