The Center for Medicare and Medicaid Innovation, created by the new health reform law, has a mandate to develop innovative payment models to improve health care delivery. To achieve higher quality and slower cost growth, the new center should be prepared to try a variety of approaches that will encourage and reward more integrated care across the health care continuum and work with other public programs and private payers and purchasers to provide consistent incentives for providers and patients. This paper addresses several issues related to facilitating the process of identifying, developing, implementing, and monitoring new initiatives, while recognizing the need to maintain the fiscal integrity of the Medicare program and to focus on new initiatives that show promise to improve quality and control costs.