The Centers for Medicare and Medicaid Services (CMS) is set to introduce an “Investing in Health Outcomes Pledge” for states to focus on measuring health outcomes improvement in the Medicaid program. According to Stephanie Carlton, CMS’ deputy administrator and chief clinical AI officer, the pledge aims to shift the Medicaid quality measure focus to outcomes.
Currently, there are about 450 different quality reporting requirements across 42 states, making it challenging to improve health outcomes. Carlton’s team found that only 24% of these measures reflect health outcomes, which is the primary focus of the Medicaid program.
Streamlining Quality Measures
Carlton emphasized the need to streamline quality measures, stating that measuring too many things can hinder progress. She explained that the current measures include descriptive statistics, beneficiary experience, health outcomes, care processes, and avoidable utilization. The goal is to expand the measures that focus on health outcomes to become the majority of what is measured.
There is a growing urgency to enhance the focus on outcomes, particularly in areas such as chronic disease, behavioral health, and prevention. Carlton noted that the current quality metric system is overburdened, with at least $5 billion spent on reporting alone. She believes that digital measures and AI tools can simplify the process for stakeholders.
The “Investing in Health Outcomes Pledge” is not just a CMS initiative, but rather a collaborative effort with state governments, managed care plans, and measure stewards such as NCQA and ONC. The pledge prioritizes outcomes over process measures, rationalizes measure inventories, and aims to modernize the quality measurement enterprise through digital measures.
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Once the measurement system is in place, financial accountability can be aligned with outcomes measures. Carlton stated that the goal is to set high standards and incentives for partners serving beneficiaries to invest in the right things. An announcement about which states are making the pledge is expected in the next few weeks.
The focus on health outcomes will be categorized into three key areas: prevention and behavior changes, chronic disease management, and behavioral health. Carlton emphasized that the implementation will vary from state to state, with some already ahead in terms of digital measures and health outcomes commitments.
The rest of the year will focus on planning, education, and supporting states with technical assistance. Carlton noted that the response from states has been enthusiastic, but acknowledged that the process is just beginning and will require close collaboration with states to ensure successful implementation.
As the states prepare to make the pledge, they will be working closely with CMS to develop a plan that suits their specific needs. The Investing in Health Outcomes Pledge is expected to have a significant impact on the Medicaid program, with a focus on improving health outcomes for beneficiaries. The pledge is seen as a step towards a more efficient and effective quality measurement system, one that prioritizes outcomes over process measures.
Implementation and Next Steps
The implementation of the “Investing in Health Outcomes Pledge” will be a process that requires close collaboration with states. Carlton emphasized that this is just the beginning of a long-term process, and that CMS will continue to work closely with states to provide support and guidance as needed. CMS will also share learnings from its work on digital quality measures in Medicare, which has already begun a multi-year process towards this goal.
