CMS has developed and implemented, under the direction of the US Congress, a variety of measures and care models with the purpose of providing financial incentives to providers to improve both the quality and the cost efficiency of care provided to Medicare and Medicaid patients. A variety of measures cover care settings and providers across the spectrum of healthcare delivery.

CMS establishes a voluntary alternate payment program that encourages groups of providers (doctors, hospitals and other providers) to create Accountable Care Organizations (ACOs). An ACO can improve beneficiary outcomes and increase value of care by providing: (1) Better care for individuals; (2) Better health for populations; and (3) Lowering growth in expenditures. The Shared Savings Program rewards ACOs that lower their growth in healthcare costs while meeting specific performance standards on quality of care and putting patients first.

Medicare Part C and D Star Rating Program is a national pay-for-performance program focused on MA plans for Part C (without prescription drug coverage) and Part D (with prescription drug coverage). Ratings of quality and performance are determined on overall performance using information from member satisfaction, providers and plans

HEDIS is a widely used set of performance measures in the managed care industry, developed and maintained by the National Committee for Quality Assurance (NCQA).  HEDIS was designed to allow consumers to compare health plans to national and regional benchmarks.  In 2018, HEDIS approved four care transition process metrics which the committee has endorsed as TOC Standard consensus process measures

Merit-Based Incentive Payment System (MIPS) is a payment program designed to reward value and outcomes in patient care. It is focused on individual eligible clinicians and group practices. The MIPS program combines the Physician Quality Reporting System, EHR Incentive Program, and Value-Based Payment Modifier into one unified program. Please note that the broader Quality Payment Program includes both MIPS and Alternative Payment Models (APMs). This is a new program, which will impact Medicare Fee-for-Service (FFS) provider payments in 2019 (with 2017 as the first performance period). Most of the care transition related measures listed are culled from the Improvement Activities performance category within MIPS, which assesses activities that improve clinical practice.

Systemic review and data analysis of economic evaluations based on 16700 patients.  Readmissions declined but net savings to hospitals were variable.