Years of escalating health care costs, mounting evidence of substandard care, and a rising number of uninsured Americans are pressuring states to seek efficiencies and improved quality within Medicaid and other public insurance programs, state employee coverage programs, and public and private health systems. Many states are adopting components of "value-based" health care purchasing, but only a few appear to be taking a broad, comprehensive approach. Through four state case studies, this project will provide an objective source of information about state and public–private purchasing activities designed to improve effectiveness and efficiency in health care. The series of reports developed from this work will help state planners, administrators, and policymakers sort through a complex set of options for improving health system performance.