Around 80-90% of payments to Medicaid providers in New York State will be based on quality outcomes by 2020. Much the new system, perhaps the most advanced of its kind in the world, are already up and running. Here John looks in detail at the implication for providers, whether they are delivering elective acute care or chronic disease management programmes. How is the new system affecting consumers and the behaviour of referring doctors? How is New York using big data to analyse outcomes?