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Medicaid Evolves to Focus on Quality Outcomes

By Dawn Weimar, RN, senior consultant, payment method development

Dawn Weimar
“As Medicaid expands in scope and influence, it is evolving toward being a “purchaser” of quality health care.” – Dawn Weimar, RN, senior consultant, Payment Method Development

Did you know that the largest health insurance program in America is Medicaid?

Yes – the program once derided as a “poor program for poor people” now covers 72 million people.

Medicaid was developed over 50 years ago, but it has certainly come a long way since its early days. It has evolved from a reimburser to a payer, and now is continuing to grow as a purchaser of quality care. It has become more inquisitive, questioning the costs associated with care procedures and more strictly evaluating the quality of care provided.

Today, 37 states are either adopting or expanding initiatives to control costs, reward quality and encourage integrated care. While much of the conversation on the shift to value-based care has focused on Medicare, we also need to consider how to translate those practices for Medicaid programs, as they serve very different populations with very different needs.

My colleagues and I have been studying and researching how Medicaid is managing its growing influence, and our resulting article “Thinking About Clinical Outcomes in Medicaid” was recently published in the Journal of Ambulatory Care Management. We explore what types of measures are currently employed by Medicaid programs and provide suggestions for implementing outcome-oriented, value-based measures.

What are we measuring?

We’re measuring a lot of things. Concern is actually growing that our measures “are proliferating at an astonishing rate,” causing confusion, cost and lack of focus. Two categories of outcomes exist – process measures and outcome measures. Neither is inherently superior, but momentum has long been growing to adopt more outcome-based measures in healthcare.

While outcome measures come with certain challenges typically avoided by process measures, they also have significant advantages. For instance, most patients care more about the goal – like preserving life, avoiding infection, maximizing functional status – than about the steps that are taken along the way.

In our journal article, we explore three examples of outcome-based measures:

  • Preventable hospital admissions
  • Preventable hospital readmissions
  • Potentially preventable complications

If you’re interested in learning more about these outcome measures and Medicaid’s evolution, I encourage you to read “Thinking About Clinical Outcomes in Medicaid” and let me know what you think.