A new assessment of 18 Center for Medicare and Medicaid Innovation models reaffirms recent criticism of the agency’s aggregate cost savings—or more accurately, losses—while highlighting several individual payment models that appear effective in cutting down federal spending and improving care quality.

The white paper published Wednesday by healthcare consulting and advisory firm Avalere Health looked at newer quality metrics for outcomes than prior CMMI model analyses, and also dug into whether the agency had been transparent and provided opportunities for feedback when designing the models.

The findings come in the wake of a damning late 2023 Congressional Budget Office assessment of the agency’s work, which found CMMI increased indirect spending by $5.4 billion between 2011 and 2020 (0.1% of net Medicare spending during that time) and spurred sharp scrutiny from cost-conscious lawmakers.

It also lands about a month after the new administration announced it would end participation in several payment models by the end of the year—some as scheduled, and some prematurely. CMMI said it made those determinations following a “data-driven review” and touted $750 million in savings, and promised to release a new strategy down the line.

CMMI models are borne out of the Affordable Care Act and test new payment approaches to tackle rising costs and improve quality of care through Medicare, Medicaid and the Children’s Health Insurance Program (CHIP). There are 23 models currently listed as active on the center’s website.

Avalere Health’s analysis (PDF), which was commissioned by the Healthcare Leadership Council, found the 18 reviewed models brought $6.4 billion in net model losses and $1.3 billion in model-specific operational costs. A third of the models brought “substantial” savings for the government, a third even greater losses and the remainder had “nominal financial impacts.”

The greatest savings came from the Maryland All-Payer model (about $975 million) and the Maryland Total Cost of Care (about $689 million).

On the other end, the Primary Care First Model lost the government about $847 million in net model losses and operational costs, the Comprehensive Primary Car Plus model lost more than $2.8 billion in net model losses and operational costs and the Medicare Advantage Value-Based Insurance Design Model lost over $4.5 billion largely from net model losses. These three models with the highest losses are among those the administration has slated for premature termination at the end of the year. 

“These results suggest that CMMI has had better success in reducing expenditures through state and community-based models,” Avalere wrote. The group also highlighted the net savings “through certain accountable care and disease-specific models, suggesting careful design and population selection may help drive improved performance.” 

On quality measures, four of the 18 models showed performance improvement, three showed “nominal” performance improvement, four had no significant impact on performance and seven had “mixed results.”

Broadly, the models were most successful in reducing utilization and addressing specific patient-centered outcomes of interest, such as chronic disease management. Measures of patient experience and patient demographic outcomes, when available, were minimal or mixed across the models.

Avalere also noted that there were limited opportunities for the public to weigh in on models’ design, or to review the participant-level performance results of a model during its performance period. None of the models had received an endorsement from the Physician-Focused Payment Model Technical Advisory Committee, an independent body that has seen none of its recommended payment models evaluated by CMMI.

The Healthcare Leadership Council, whose CEO members span different corners of the healthcare industry, said it hopes that the government taps the private sector for feedback on refining value-based care strategies. It shared Avalere’s analysis of the models “with leaders on Capitol Hill, as well as relevant officials inside the Administration,” it said.

"While some CMMI models faced challenges, others demonstrated clear success in advancing value-based care,” Maria Ghazal, the group’s president and CEO, said in a release. “As the Trump Administration guides the Center into a new era, this report provides actionable insights for future program design."