THE article titled "Moving Toward Paying for Outcomes in Medicaid" by Millwee et al. (2018) describe why it is important for state Medicaid agencies to adopt clear, sustainable incentive programs based on outcome measures. They suggest that outcome measures such as preventable admissions, readmissions, emergency department visits, and inpatient complications will provide a clearer path to improved quality and reduced costs.

The authors have referred to Donabedian's dimensions of quality, in which quality and quality measures fall into 3 categories: structure, process, and outcome (Donabedian, 1988). Quality measures over time have included a disproportionate measures of process with few measures of outcomes. However, outcomes are the real drivers of improved quality and reduced cost.

I agree with the authors suggesting that approaches for Medicaid need to be separate and unique from Medicare. Given the purpose of Medicaid as insurance for the poor, disabled, and aged, the enrollment differs greatly from Medicare, as well as those commercially insured. Medicare has focused measurement on chronic conditions (heart disease, diabetes), and while these conditions are prevalent in the Medicaid population, Medicaid policy makers need to focus on maternal and child health, behavioral health, and care for persons who need community-based or institutional care. For example, given that Medicaid is the insurer of almost 50% of adolescents in this country, an emphasis on anticipatory guidance and healthy habits is imperative.

Setting priorities for State Medicaid programs is essential for improving outcomes and reducing costs. Unfortunately, priorities become complicated by politics and reactive changes in direction and financial stressors, and often the list of priorities expands across too many clinical areas with defined advocacy. States and the Centers for Medicare & Medicaid Services (CMS) need to establish a core set of measures that will be measured and evaluated to focus efforts on quality improvement, not more quality measurement. The goal of quality measurement should not be the measurement itself but a starting point to begin the Plan, Do, Study, Act cycle of quality improvement (Deming, 1993).

The authors state that it is important for financial incentives to be substantive, clear, and credible. New York Medicaid's Quality Incentive has been paying health plans up to 3% of additional premium since 2003. The structure of the incentive includes patient experience (from CAHPS surveys), efficiency as measured by Prevention Quality Indicators and HEDIS quality measures (NYS Department of Health, 2017a). This incentive is valued at more than $300 million annually and has contributed to New York being one of the highest states in the country on Medicaid quality.

Governor Andrew Cuomo announced in April 2014 that New York Medicaid has agreed to terms and conditions with the Centers for Medicare & Medicaid Services for a Delivery System Reform Incentive Payment program that will allow the State to invest $8 billion over 5 years to do the following: (1) transform the health care delivery system from volume to value; (2) reduce preventable hospital use; and (3) reduce Medicaid spending statewide (NYS Department of Health, 2014a). For requirement 1, health plans in New York have to adopt value-based payment systems, reducing the reliance on fee-for-service and also empowering and incenting providers to take a more holistic view of patient care. New York and the CMS through this program have committed to the use of potentially preventable hospitalizations, readmissions, and emergency department use as core metrics for the program. However, New York Medicaid has not reduced the number of measures or prioritized quality measurement in their requirements for value-based payments and, in fact, has expanded measurement through the creation of Clinical Advisory Groups that has expanded the potential measurement activity 2- to 3-fold (NYS Department of Health, 2017b).

The authors suggest some keys points to move Medicaid forward, including transparency of results, focusing on populations, risk adjustment, a clear incentive structure, and a collaborative phased-in implementation plan. State Medicaid policy makers can drive change by making value-based payment methodologies transparent with benchmarks that are attainable by providers. Focusing on population health is essential and should also include collaborative models that work across the public and private payer ecosystems. The CMS has awarded State Innovation Model grants to multiple states with the intent of collaboration of value-based payment models across both public and private payers (CMS, 2014). In New York, an example of successful collaboration across payers is the Adirondack Medical Home Demonstration, in which quality and patient satisfaction have improved over time (NYS Department of Health, 2014b). Collaborative payment models that are risk-adjusted, multipayer, and transparent with realistic time frames for implementation are principles that will ensure success in improving quality and reducing costs for the Medicaid program across this country.

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