On September 25, 2026, CMS launched Investing in Health Outcomes, a voluntary pledge signed by a founding group of 37 states (CMS). Its four commitments are reasonable on their face. Each also carries a familiar way of going wrong, and the difference between the two lies in the details of measurement design.
What states pledged
Primary recordSignatory states commit to (Medicaid.gov):
- prioritize health outcomes over process, with emphasis on primary prevention, chronic disease management and behavioral health;
- rationalize their inventories of quality measures, converging on a set that reduces burden without sacrificing accountability;
- move toward digital quality measurement using near-real-time data, replacing claims and chart abstraction wherever feasible;
- align financial accountability so that payment meaningfully rewards performance on outcome measures.
CMS's stated basis is a May 2026 analysis of Medicaid managed-care contracts in 42 states and programs, which found about 450 quality-reporting requirements representing 258 unique measures, many tied to utilization and process rather than health. As of September 24, the 37 pledging states covered about 56 million Medicaid and CHIP enrollees and about $701 billion in fiscal year 2024 Medicaid spending.
Whether California's Department of Health Care Services is among the signatories could not be confirmed from the agency's published table. With about 80 million people enrolled in Medicaid and CHIP nationally, the 56 million covered by pledging states means some large programs have not signed.
Why measurement design is the story
Analysisoutcomes need risk adjustment. A plan or practice that serves sicker, poorer or more rural patients will post worse outcomes for reasons it does not control. Without credible risk adjustment, outcome-based payment rewards whoever enrolls the healthiest population. In Medicaid managed care, that is an incentive to select patients, not to improve care.
Analysisfewer measures can mean fewer alarms. Many process measures exist because they detect underuse: a missed screening, an unfilled prescription, an absent follow-up visit after a psychiatric hospitalization. Retiring them reduces paperwork, but it also removes early warning. The test for each retired measure is whether an outcome measure replaces it that would have caught the same failure.
Analysisdigital measurement depends on who can extract the data. Near-real-time digital measures favor organizations with integrated electronic records and analytics staff. Federally qualified health centers, small practices and rural clinics will need support, or the measure set will quietly reward size.
Analysispayment alignment turns definitions into money. Once payment follows outcomes, measure specifications, exclusions and attribution rules become contested financial terms and deserve the same scrutiny as rates.
What physicians should watch
- Whether Medicaid managed-care contracts in pledging states drop or replace measures in 2027 procurements.
- Whether outcome measures come with published risk-adjustment methods.
- Whether the reporting burden on practices actually falls, or shifts from chart abstraction to data-feed obligations.
These are the same questions this site's research asks of state regulators: what is counted, who chooses the denominator, and what a smaller inventory stops seeing.