Medicaid Advantage Plus and Fully Integrated Duals Advantage

Value Based Payment Quality Measure Set
Measurement Year 2018

  • Measure Set is also available in Portable Document Format (PDF)

February 2018                     NYS Medicaid Value Based Payment


2018 VBP MAP and FIDA Quality Measure Set

The measurement year (MY) 2018 value based payment (VBP) quality measure set for Medicaid Advantage Plus (MAP) and Fully Integrated Duals Advantage (FIDA) was created in collaboration with the Managed Long Term Care (MLTC) Clinical Advisory Group (CAG), a Sub–team empaneled by the CAG to discuss VBP approaches and quality measures for Medicaid Advantage Plus (MAP), Fully Integrated Duals Advantage (FIDA), Programs of All–Inclusive Care for the Elderly (PACE), and the New York State (NYS) VBP Workgroup. The Sub–team convened in November of 2017 to discuss the design strategy and quality measurement selection process for Fully Capitated Product Lines: MAP, FIDA, and PACE. The measure set includes measures classified by category based on an assessment of reliability, validity, and feasibility, and according to suggested method of use, either as Pay for Reporting (P4R) or Pay for Performance (P4P). Efforts to align New York StateĀ“s Medicaid VBP arrangements with Medicare, to allow for VBP arrangements to span across the Medicaid–Medicare divide, will continue.

The primary and preventive care measures in Table 1 are currently in the MAP and FIDA quality frameworks with the Centers for Medicare and Medicaid Services (CMS) and overlap with other VBP measure sets including Integrated Primary Care (IPC) and Total Care for the General Population (TCGP). The classification for these measures for MY 2018 is P4R in order to incentivize appropriate data collection and establish measure use. Plans are required to report on these measures for plan-provider ("VBP Contractor") combinations. However, plans and their providers/VBP Contractors may select among recommended measures and opt to use measures as either P4R or as P4P per the terms of their specific contracts.

In addition to the measures listed in Table 1, the current list of recommended Category 1 and Category 2 VBP MLTC measures for partially capitated MLTC plans for MY 2018 can be used for VBP contracts for MAP and FIDA. The MLTC partially capitated Category 1 measures are considered valid and feasible for use in VBP MAP and FIDA contracts and are listed below in Table 2. Category 2 measures, listed in Table 3, are also considered valid but may warrant additional implementation effort stemming from feasibility issues. Nearly all of the recommended VBP measures for partially capitated MLTC plans have been selected from the MLTC Quality Incentive and the Nursing Home Quality Initiative measure sets.

MEASURE CLASSIFICATION

In August of 2017, NYS published the updated recommendations of the MLTC CAG for MY 2018. The recommendations of the MLTC CAG are reflected in the measure sets displayed in Table 2 and Table 3 in this document.

Based on Sub–team recommendations and feedback from MAP and FIDA Plans and PACE Organizations, the State developed quality measure sets specific to MAP, FIDA, and PACE to reflect the unique components of these plans. The measures specifically recommended for MAP and FIDA Plan use are listed in Table 1.

Category 1

Category 1 quality measures as identified by the MLTC CAG and accepted by the State are determined to be clinically relevant, reliable and valid, and also feasible for use by VBP Contractors. These measures are also intended to be used to determine the amount of shared savings for which VBP contractors are eligible1.

The State has further classified each Category 1 measure as either P4P or P4R:

  • P4P measures are intended to be used in the determination of shared savings amounts for which VBP Contractors are eligible. Measures can be included in both the determination of the target budget and in the calculation of shared savings for VBP Contractors.
  • P4R measures are intended to be used by the Managed Long Term Care plans to incentivize VBP Contractors to report data on the quality of care delivered to members under a VBP contract. Incentive payments for reporting will be based on the timeliness, accuracy, and completeness of data submitted. Measures can be reclassified from P4R to P4P through annual CAG and State review, or by the MLTC plan and VBP Contractor.

Categories 2 and 3

Category 2 measures have been accepted by the State based on agreement of measure importance, validity, and reliability, but present implementation feasibility concerns. These measures will be further investigated with VBP program participants.

Measures designated as Category 3 were identified as unfeasible at this time, or presented additional concerns including accuracy or reliability when applied to the attributed member population for the MLTC VBP Arrangement.

MEASUREMENT YEAR 2018 QUALITY MEASURE SET

The measures and classifications provided on the following pages are recommendations for MY 2018. Note that measure classification is a State recommendation. MLTC plans and VBP Contractors can choose the measures they want to link to payment, and how they want to pay on them (P4P or P4R) in their specific contracts.

Measure sets and classifications are considered dynamic and will be reviewed annually. Updates will include additions, deletions, reclassification of measure category, and reclassification from P4R to P4P based on experience with measure implementation in the prior year. During 2018, the CAGs and the VBP Workgroup will re–evaluate measures and provide recommendations for MY 2019.

VBP Quality Measures for MAP and FIDA Plans

Table 1 displays the primary and preventive care measures recommended for use by MAP and FIDA plans and includes measure title, measure steward and/or other measure identifier (where applicable), and State determined classification for measure use. These measures are classified as P4R for MY 2018.

Table 1: Primary and Preventive Care Measures

Measure Measure Source/ Steward Measure Identifier Classification
Comprehensive Diabetes Care: Eye Exam (Retinal) Performed* NCQA/ HEDIS NQF 0055 P4R
Comprehensive Diabetes Care: Medical Attention for Nephropathy* NCQA/ HEDIS NQF 0062 P4R
Colorectal Cancer Screening * NCQA/ HEDIS NQF 0034 P4R
Antidepressant Medication Management – Effective Acute Phase Treatment & Effective Continuation Phase Treatment* NCQA/ HEDIS NQF 0105 P4R
Follow–up After Hospitalization for Mental Illness^ NCQA/ HEDIS NQF 0576 P4R
Initiation and Engagement of Alcohol and Other Drug Dependence Treatment * NCQA/ HEDIS NQF 0004 P4R
* Included in the IPC/TCGP measure set
^ Included in the Health and Recovery Plan (HARP) measure set
Acronyms: NCQA denotes the National Committee for Quality Assurance; HEDIS denotes the Healthcare Effectiveness Data and Information Set; NQF denotes National Quality Forum

Category 1 VBP Quality Measures for Partially Capitated MLTC Plans

Table 2 displays the complete Category 1 MLTC VBP Measure Set for Partially Capitated Plans and includes measure title, measure steward and/or other measure identifier (where applicable), and State determined classification for measure use. All Category 1 measures for use in MLTC VBP for Partially Capitated Plans are classified as P4P for MY 2018.

Table 2: Category 1 VBP Quality Measures for Partially Capitated MLTC Plans

Measure Measure Source/ Steward Classification
Percentage of members who did not have an emergency room visit in the last 90 days* UAS – NY/
New York State
P4P
Percentage of members who did not have falls resulting in medical intervention inthe last 90 days * UAS – NY/
New York State
P4P
Percentage of members who received an influenza vaccination in the last year * UAS – NY/
New York State
P4P
Percentage of members who remained stable or demonstrated improvement in pain intensity * UAS – NY/
New York State
P4P
Percentage of members who remained stable or demonstrated improvement in Nursing Facility Level of Care (NFLOC) score * UAS – NY/
New York State
P4P
Percentage of members who remained stable or demonstrated improvement in urinary continence * UAS – NY/
New York State
P4P
Percentage of members who remained stable or demonstrated improvement in shortness of breath * UAS – NY/
New York State
P4P
Percentage of members who did not experience uncontrolled pain * UAS – NY/
New York State
P4P
Percentage of members who were not lonely and not distressed * UAS – NY/
New York State
P4P
Potentially Avoidable Hospitalizations (PAH) for a primary diagnosis of heart failure, respiratory infection, electrolyte imbalance, sepsis, anemia, or urinary tract infection * UAS – NY/
New York State with linkage to SPARCS data
P4P
Potentially Avoidable Hospitalizations (PAH) for a primary diagnosis of heart failure, respiratory infection, electrolyte imbalance, sepsis, anemia, or urinary tract infection ǂ MDS 3.0/ New York State with linkage to SPARCS data P4P
* Included in the NYS DOH MLTC Quality Incentive measure set
ǂ Included in the NYS DOH Nursing Home Quality Initiative measure set
Acronyms: UAS – NY denotes the Uniform Assessment System for New York for MLTC members; SPARCS denotes the State wide Planning and Research Cooperative System; MDS 3.0 denotes the Centers for Medicare and Medicaid Services Minimum Data Set for nursing home members

Category 2: VBP Quality Measures for Partially Capitated MLTC Plans

Table 3 displays the complete Category 2 MLTC VBP Measure set for Partially Capitated Plans and includes measure title, measure steward and/or other measure identifier (where applicable), and the recommended measure use classification.

Table 3: Category 2 VBP Quality Measures for Partially Capitated MLTC Plans

Measure Measure Source/ Steward Classification
Percent of long stay high risk residents with pressure ulcers ǂ MDS 3.0/CMS P4P
Percent of long stay residents who received the pneumococcal vaccine ǂ MDS 3.0/CMS P4P
Percent of long stay residents who received the seasonal influenza vaccine ǂ MDS 3.0/CMS P4P
Percent of long stay residents experiencing one or more falls with major injury ǂ MDS 3.0/CMS P4P
Percent of long stay residents who lose too much weight ǂ MDS 3.0/CMS P4P
Percent of long stay residents with a urinary tract infection ǂ MDS 3.0/CMS P4P
Care for Older Adults – Medication Review NCQA P4R
Use of High–Risk Medications in the Elderly NCQA P4R
Percent of long stay low risk residents who lose control of their bowel or bladder ǂ MDS 3.0/CMS P4P
Percent of long stay residents whose need for help with daily activities has increased ǂ MDS 3.0/CMS P4P
Percentage of members who rated the quality of home health aide or personal care aide services within the last 6 months as good or excellent * MLTC Survey/New York State P4R
Percentage of members who responded that they were usually or always involved in making decisions about their plan of care * MLTC Survey/New York State P4R
Percentage of members who reported that within the last 6 months the home health aide or personal care aide services were always or usually on time * MLTC Survey/New York State P4R
Percent of long stay residents who have depressive symptoms ǂ MDS 3.0/CMS P4P
Percent of long stay residents with dementia who received an antipsychotic medication ǂ MDS 3.0/Pharmacy Quality Alliance P4P
Percent of long stay residents who self– report moderate to severe pain ǂ MDS 3.0/CMS P4P
ǂ Included in the NYS DOH Nursing Home Quality Initiative measure set
* Included in the NYS DOH MLTC Quality Incentive measure set
Acronyms: MDS 3.0 denotes the Centers for Medicare and Medicaid Services Minimum Data Set for nursing home members; CMS denotes the Centers for Medicare and Medicaid Services; NCQA denotes the National Committee for Quality Assurance

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1. New York State Department of Health, Medicaid Redesign Team, A Path Toward Value Based Payment: Annual Update, June 2016. (Link)  1
Update, June 2016: Year 2, New York State Roadmap for Medicaid Payment Reform, June 2016. (Link)