Over the past few years there have been efforts to streamline Medicaid quality measures and start to move to measures that matter in terms of outcomes. During a recent Manatt webinar, Stephanie Carlton, CMS’ deputy administrator and chief clinical AI officer, said CMS will soon roll out an “Investing in Health Outcomes Pledge” for states to signal that they want to double down on measuring health outcomes improvement in the Medicaid program.

In doing an inventory of the current quality measure data from 42 states, Carlton’s team found that there are about 450 different quality reporting requirements. “When you measure 450 different things, it's hard to get really good at a subset of those and move the needle on health outcomes, which is where we're laser-focused when it comes to the Medicaid program,” she said. 

When you break down the current measures, she said, some measure descriptive statistics, some measure beneficiary experience, some measure health outcomes, some measure care processes, and some measure avoidable utilization. “What we wanted to focus on is that 24% that reflect measurements around health outcomes — where we can say we're investing in an individual's health and we can prove that we are moving the needle and making it better,” said Carlton, a former McKinsey consultant. “Obviously, that's the gold standard we'd like to get to. There are some things that we measure today because we can measure them, and they represent an important starting place to get better at measuring actual health outcomes over time. But we’d love to substantially expand that 24% so that's the vast majority of what we measure, and we measure fewer things in Medicaid, but we're essentially measuring what matters.”

Carlton said there is growing urgency to enhance the focus on outcomes. “We could do so much better on chronic disease, on behavioral health, on prevention, so that is a laser focus for us at CMS and for many of the states that we have talked to as we've started this work,” she explained. “Also, there’s a growing recognition that the quality metric system we have today is overburdened. Some data we've seen shows we spend at least $5 billion just on the reporting piece of quality metrics today, and there's a lot we can do to make that much more efficient.” She said digital measures but also AI tools have the potential to make the process much simpler for various stakeholders. 

She stressed that this is not just a CMS exercise. “We have a big role at the federal government, but it really requires the other stakeholders to ultimately benefit the patients that we're serving,” she said. It requires deep collaboration with state governments and the managed care plans, which about 80% of beneficiaries today. The work also involves measure stewards such as NCQA and ONC, she added. 

“What we've done is build out our north star or aspiration, and we are bringing different stakeholders together to say, ‘Here's the vision we want to chart. Do we all agree on that? If so, let's work together to get this done,’ so we drafted this pledge,” she said. “We’re calling it the Investing in Health Outcomes Pledge. 

She described a number of components. The first is to prioritize outcomes over process measures. “We know we can't measure outcomes perfectly today. There's a lot of work we need to do to continue to evolve the measurement system over time, but we can start today with what we have,” she said. “Second, there's a process of rationalizing measure inventories. If you look across states, we may be measuring the same thing in multiple different ways, and that lack of standardization makes it hard to get really good at moving the needle on the objective.”

Moving toward digital measures

CMS also want to modernize the quality measurement enterprise by moving toward digital measures, Carlton said. “The more you move to digital, the easier it gets to start to change behavior in real time, and it also reduces the reporting burden,” she explained. “We don't want to have to spend as much time on paperwork.”

CMS has done a lot of work on digital quality measures in Medicare, and has started a multi-year process toward that goal. Carlton said CMS can share learnings with the states as they are doing procurement and moving toward those digital quality measure goals in the Medicaid program. 

Once you get the measurement system right, she said, you can align financial accountability around outcomes measures. “We want to set the bar high and set the incentives in place so that our partners in serving beneficiaries, are investing in the right things,” she said. “This is a pledge that we have been working with states and various stakeholders on. We're very excited to see the momentum gathering around this from a bipartisan and robust group of states.” 

She said to expect an announcement about which states are making the pledge sometime in the next few weeks. 

As they focus on health outcomes, she said, three categories are key. One is prevention and behavior changes that have an outsized impact on health downstream — things like exercise, diet, sleep, and community engagement. The second is around chronic disease management, and the third is around behavioral health. 

“We've asked a number of states to join us and gotten an enthusiastic response, but we're not trying to say we have all the answers,” Carlton said. “It is the beginning of a process to work closely with states on implementation, and the implementation will look a bit different state by state because states are starting at different points. Some are very far ahead and have talked about digital measures already and have already made commitments to health outcomes, and others will learn from states that are leading the charge.”

Mentioning the timeline, Carlton said the rest of this year will have a focus on planning, education, and supporting states with technical assistance, and then 2027 is when the implementation period will start.