Focus on outcomes: Time to relook at value and quality programs – Part 2

In part one of this series, I talked about regulatory process measures and the need to redirect the focus to preventing adverse events. Today, I’d like to focus on how states prioritize value and improve their quality programs.

During an interview, CMS Administrator Dr. Mehmet Oz noted that "The most expensive care we give is bad care because you pay to do it poorly, then you pay to fix the problem, then you pay downstream costs that go along with someone not getting the right care at the right time."

Finding those avoidable events that lead to poor patient outcomes and higher costs is key to making our system more efficient and effective for everyone — from the patient to the taxpayer — and especially after the passage of the One Big Beautiful Bill Act (OBBBA).

There are states doing just this with their Medicaid programs and starting to see real, tangible impact – measurably improved patient care and reduced costs. For example:

• Texas focuses on potentially avoidable hospital admissions and emergency department (ED) visits for their STAR, STAR Health, STAR Kids and STAR plus programs. Between 2019-2023, they saw a nearly double digit reduction in these events in almost every program — with an almost 50% reduction in admissions for the STAR Health program. They’ve also had a 12% reduction in the rate of readmissions.
• Florida has experienced a nearly 10% and over 5% reduction, respectively, in potentially avoidable ED visits and hospital admissions between 2019 and 2023 – and an almost 20% reduction in the same period for admissions at risk for a potentially avoidable readmission. 
   

Why do their outcomes-focused approaches work?  

At Solventum, we often look to the “why” behind the implementation of the Medicare inpatient prospective payment system (IPPS) success as our guiding star for other outcomes-based approaches. IPPS was the initial value-based payment initiative – and it was a success. In fact, it was so successful we take it for granted. But it set a price with a procedure and left it to the provider to figure out how to manage it and be efficient.  IPPS had three key elements: 

1. Clear and understandable financial impact
2. Comprehensive approach (not just isolated initiatives here and there)
3. Outcomes-based (not process oriented)

For programs in Texas, Florida, Mississippi, Maryland and other states:

• The financial impact of their quality programs is clear
• The approach is comprehensive
• The quality measures focus on care outcomes (such as mortality rates for heart attack patients instead of the aspirin on admission measure)

So, after 20 years of the current approach, it is time to adjust and ensure we are still on track for truly achieving value within our system – value that improves patient outcomes and reduces healthcare spending.

Megan Carr is the head of the regulatory and payer solutions team at Solventum.