Moving Toward Paying for Outcomes in Medicaid

Area of Science:

• Health Services Research
• Health Policy
• Healthcare Management

Background:

• Medicaid beneficiaries' health can be improved through outcome-based payment models.
• Existing state precedents demonstrate the feasibility of payment for outcomes in Medicaid programs.

Purpose of the Study:

• To explore the potential of payment for outcomes in Medicaid for improving beneficiary health and program sustainability.
• To identify key outcome measures and criteria for prioritizing initiatives.

Main Methods:

• Review of existing state-level Medicaid programs that have implemented payment for outcomes.
• Identification and categorization of relevant Medicaid outcome measures.
• Development of criteria for prioritizing payment for outcomes initiatives.

Main Results:

• Successful precedents exist in states like Florida, Maryland, Minnesota, New York, Ohio, Pennsylvania, and Texas.
• Outcome measures encompass preventable admissions, readmissions, ED visits, complications, early elective deliveries, mortality, patient-reported outcomes, and low-value care reduction.
• Prioritization criteria include potential savings, model availability, health status impact, and Medicaid's influence.

Conclusions:

• Embracing payment for outcomes offers a viable strategy for Medicaid to improve health and ensure future sustainability.
• Five principles for success are proposed, focusing on clinical credibility and actionable data for providers.