Almost 5 years ago, John McDonough, a professor at Harvard who worked actively as a senior Kennedy aide for the passage of Obamacare, penned an article titled "A New Cost Control Idea-Paying for Outcomes" (McDonough, 2011). Since then, it is clear that paying for better outcomes has taken off from both policy and implementation points of view (Berenson et al., 2013; Berwick, 2013). Policy makers and academics have encouraged a focus on outcomes. States and private insurers alike have encouraged the movement with implementation of various aspects of paying for better outcomes. I've heard the Medicaid Commissioners of both New York and Texas (last I heard these states are run by governors of rather different political persuasions) publicly state that they are moving to paying for better outcomes. Similarly, the federal Centers for Medicare & Medicaid Services has encouraged paying for better outcomes while keeping many process measures in play.

This issue of the Journal focuses on the theme of paying for outcomes from several points of view. With a large number of responses, Averill and colleagues lay out the philosophy as expressed in proposed federal legislation. Fuller and Goldfield, followed by 2 commentaries, next analyze one aspect of paying for better outcomes that is emerging as critically important-paying for better outcomes for pharmaceuticals on patent. Finally, Fuller and colleagues, again followed by commentaries, detail the pros and cons of different approaches to constructing classification models that can be used in paying for better outcomes.

There are 2 kinds of outcomes-those that can be translated into dollars (eg, potentially preventable complications; Calikoglu et al., 2012) and those that cannot as easily be translated in dollars (eg, mortality, patient confidence). While I prefer the former for its ease of implementation in a pay-for-outcome schema, I recognize that patient confidence and mortality are 2 critical outcomes that must be included-at least in public and/or confidential reporting.

Paying for outcomes is so commonsensical one can ask-who could be against such an approach. There are plenty of entrenched interests against paying for better outcomes. The measurement industry, notably, the National Quality Forum, the National Committee for Quality Assurance, and other similar organizations, would completely lose their reason to exist if we turned to focusing on paying for better outcomes. Instead of thousands of endorsed measures, health care consumers and professionals will be able to concentrate on a small number of outcomes-an aspiration we all have. As a consequence, over time, there is no question in my mind that we will eventually turn the titanic and almost exclusively focus on outcomes. The direction is already shifting. This issue of the Journal in a small way hopefully contributes to this critical change.

-Norbert Goldfield, MD

Editor

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