Total Care for General Population (TCGP)

Value Based Payment Quality Measure Set
Measurement Year 2021

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

February 10, 2021                     NYS Medicaid Value Based Payment

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INTRODUCTION

The Measurement Year (MY) 2021 Total Care for General Population (TCGP) Quality Measure Set was created in collaboration with the Primary Care (Physical Health), Maternity Care, Behavioral Health/HARP, HIV/AIDS, and Children´s Health Clinical Advisory Groups (CAGs), as well as the New York State (NYS) Measure Support Task Force. The goal of this measure set is to align with measures put forth in the Delivery System Reform Incentive Payment (DSRIP) Program, the Quality Assurance Reporting Requirements (QARR), and the Merit-based Incentive Payment System (MIPS), where applicable. The measure set is designed to encourage providers to meet high standards of patient-centered clinical care and coordination across multiple care settings.

MEASURE SELECTION AND FEASIBILITY

During the spring, summer, and fall of 2020, the Physical Health, Maternity Care, HIV/AIDS, Behavioral Health, and Children´s Health CAGs reconvened and made recommendations to the State on quality measures, data collection, data reporting, and support required for providers to be successful in a VBP environment.

Beginning in June of 2017, the State initiated regular meetings of the VBP Measure Support Task Force. The goal of the Task Force is to make recommendations to the State to support and inform the Annual Measure Review Cycle. Members of the Task Force include professionals from various Managed Care Organizations (MCOs), VBP Pilot Contractors, clinical Subject Matter Experts, and State Agencies, along with other professionals who have experience in quality measurement and health information technology. The Task Force provided feedback to DOH on quality measure feasibility, reporting, and calculation.

Upon receiving the CAGs and Task Force recommendations, and 2019 VBP Proposed Roadmap updates1; the State defined a final list of measures to be included for MY2021. Measure domains were incorporated into the TCGP measure set. All measures in the TCGP measure set are grouped into domains, to align with the populations being included in TCGP contracts. As a result, some measures were removed, some measures were recategorized, and additional measures were added to fill these domains and ensure adequate representation for all populations covered in a TCGP arrangement.

Upon receiving the CAG recommendations, Task Force feedback, and updates to the HEDIS measure set, the State defined a final list of measures for inclusion for MY2021. For MY2021, four measures have been removed, three measures have been added, and one measure's specifications have changed, culminating in a total of twenty-nine TCGP Category 1 measures.

During the fall and winter of 2018/2019, the VBP Quality Measure Team completed a comprehensive analysis of quality measures being used in shared savings within approved VBP Contracts. Results revealed that most providers and plans have contracted TCGP arrangements while attributing all populations to the agreements. To encourage a broader diversity of quality measures, appropriate to member populations being served by an arrangement, the State recommended the following changes to the VBP Roadmap for 2019², these changes carry through to TCGP Arrangements for MY2021.

Managed Care Organizations (MCOs) (excluding MLTC) that execute a TCGP VBP arrangement must base shared savings and risk distribution on quality measures that include at least one, Category 1 P4P measure from each of the following domains:

• Primary Care
• Mental Health
• Substance Use Disorder
• HIV/AIDS
• Maternity
• Children´s

TCGP VBP arrangements that exclude pregnant women, children, or person living with HIV/AIDS are not required to include quality measures from these respective quality measure set domains. TCGP arrangements that carve out Behavioral Health/HARP members are still required to include quality measures from the primary care, mental health, and substance use disorder quality measure domains, in addition to the maternity, children, and HIV/AIDS domains if these latter populations are included.

MEASURE CLASSIFICATION

In previous years, measures have been designated by the State as Category 1, 2, or 3 with associated recommendations for implementation and testing for future use in VBP Arrangements.

For MY2021 the TCGP Measure Set consists only of Category 1 measures. The following measure domains were incorporated into the TCGP Measure Set for MY2021: Primary Care, Mental Health, Substance Use Disorder, HIV/AIDS, Maternity, and Children´s.

Category 1

Category 1 quality measures as identified by the CAGs and accepted and deemed reportable by the State are to be reported by VBP Contractors to the MCOs. These measures are also intended to be used to determine the amount of shared savings for which VBP contractors are eligible.³

For MY2021 the TCGP Measure Set consists of 32 P4P measures and one P4R, as defined below.

• 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 Care Organizations (MCOs) to incentivize VBP Contractors for reporting data to monitor the quality of care delivered to members under a VBP contract. Incentives for reporting should be based on timeliness, accuracy, and completeness of data. Measures can be reclassified from P4R to P4P or vice versa through annual CAG and State review or as determined by the MCO and VBP Contractor.

Not all Category 1 measures will be reportable for the measurement year, as reporting on some of these measures will be phased in over the next few years. Please refer to the Value Based Payment Reporting Requirements Technical Specifications Manual (MY2021) for details as to which measures must be reported for the measurement year. This manual will be updated annually each fall, in line with the release of the final VBP measure set for the subsequent year.

MY2021 QUALITY MEASURE SET

The measures and State-determined classifications provided on the following pages are recommendations for MY 2021. Note that measure classification is a State recommendation and implementation is to be determined between the MCO and VBP Contractor.

The measures provided on the following pages are recommendations for MY2021. Note that measure classification is a State recommendation and implementation is to be determined between the MCO and VBP Contractor.

Measure sets and classifications are considered dynamic and will be reviewed annually. Updates will include measure additions, deletions, recategorizations, and/or reclassifications from P4R to P4P or vice versa, based on experience with measure implementation in the prior year. Please see Appendix A for a full list of these changes. In 2021, the CAGs and the VBP Workgroup will re-evaluate measures and provide recommendations for MY2022.

Note: Additional changes have been made to the names for some of the measures presented below to ensure alignment with the naming conventions used by the official measure steward. There have not been any changes to the measure specifications associated with these name changes.

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Category 1

The table below displays the Category 1 MY2021 TCGP Quality Measure Set, arranged alphabetically and includes measure title, measure steward, the National Quality Forum (NQF) number and/or another measure identifier (where applicable), and the measure classification. The measure set is redlined to highlight changes made between MY2020 and MY2021, please refer to the key at the end of this table for an explanation of redlined formatting.

TCGP Measure	Measure Steward	Measure Identifier	Classification
2021 TCGP Primary Care Domain You must choose at least 1 measure from the following domain to be included in the VBP Contract.
Adherence to Mood Stabilizers for Individuals with Bipolar I Disorder	Centers for Medicare & Medicaid Services (CMS)	NQF 1880	P4P
Antidepressant Medication Management - Effective Acute Phase Treatment & Effective Continuation Phase Treatment	NCQA	NQF 0105	P4P
Asthma Medication Ratio	NCQA	NQF 1800	P4P
Breast Cancer Screening	NCQA	NQF 2372	P4P
Cervical Cancer Screening	NCQA	NQF 0032	P4P
Chlamydia Screening in Women	NCQA	NQF 0033	P4P
Colorectal Cancer Screening	NCQA	NQF 0034	P4P
Comprehensive Diabetes Care: Eye Exam (retinal) Performed	NCQA	NQF 0055	P4P
Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%)	NCQA	NQF 0059	P4P
Comprehensive Diabetes Care: Medical Attention for Nephropathy*	NCQA	NQF 0062	P4P
Controlling High Blood Pressure	NCQA	NQF 0018	P4P
Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications	NCQA	NQF 1932	P4P
Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment	NCQA	NQF 0004	P4P
Kidney Health Evaluation for Patients with Diabetes (KED)^^	NCQA		P4P
Medication Management for People with Asthma*	NCQA	NQF 1799	P4P
2021 TCGP Mental Health Domain You must choose at least 1 measure f rom the following domain to be included in the VBP Contract.
Adherence to Antipsychotic Medications for Individuals with Schizophrenia	CMS	NQF 1879	P4P
Depression Remission or Response for Adolescents and Adults	NCQA		P4P
Follow-Up After Emergency Department Visit for Mental Illness	NCQA	NQF 2605	P4P
Follow-up After Hospitalization for Mental Illness**	NCQA	NQF 0576	P4P
Potentially Preventable Mental Health Related Readmission Rate 30 Days​	NYS	​	P4P
2021 TCGP Substance Use Domain You must choose at least 1 measure from the following domain to be included in the VBP Contract.
Follow-Up After High-Intensity Care for Substance Use Disorder	NCQA		P4P
Follow-Up After Emergency Department Visit for Alcohol and Other Drug Dependence	NCQA	NQF 2605	P4P
Initiation of Pharmacotherapy upon New Episode of Opioid Dependence	NYS		P4P
Pharmacotherapy for Opioid Use Disorder	NCQA	NQF 3175	P4P
Unless you are excluding or carving out HIV+ individuals, pregnant women, and/or children members in your TCGP arrangement, you must choose at least one Category 1 P4P measure from each of the applicable domains below.
2021 TCGP HIV/AIDS Domain You must choose at least 1 measure from the following domain to be included in the VBP Contract, if including HIV+ individuals in the contract.
Viral Load Suppression	HRSA	NQF 2082	P4P
2021 TCGP Maternity Domain You must choose at least 1 measure from the following domain to be included in the VBP Contract, if including pregnant women in the contract.
Prenatal & Postpartum Care	NCQA	NQF 1517 (lost endorsement)	P4P
2021 TCGP Children´s Domain You must choose at least 1 measure from the following domain to be included in the VBP Contract, if including children in the contract.
Asthma Admission Rate - PDI #14	AHRQ	NQF 0728	P4P
Child and Adolescent Well-Care Visits^^	NCQA		P4P
Childhood Immunization Status - Combination 3	NCQA	NQF 0038	P4P
Immunizations for Adolescents - Combination 2	NCQA	NQF 1407	P4P
Well-Child Visits in the Third, Fourth, Fifth, and Sixth Year of Life**	NCQA	NQF 1516	P4P
Well-Child Visits in the First 30 Months of Life^^	NCQA	NQF 1392	P4P
Well-Child Visits in the First 15 Months of Life**	NCQA	NQF 1392	P4P

* Measure removed from HEDIS 2021 Measure Set
** Measure specifications revised by NCQA for 2021 HEDIS Measure set
^^ Measure replaced by NCQA/HEDIS measure
^^ Replacement HEDIS measure – first year measure

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Appendix A

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The tables below identify the changes to the Category 1 measures for the MY2021 TCGP Quality Measure Set.

Category 1 Measure Changes from 2020 to 2021

Measure Name	Change	Rationale for Change
Child and Adolescent Well - Care Visits	Added	Replacement HEDIS measure - first year measure
Comprehensive Diabetes Care: Medical Attention for Nephropathy	Removed	Measure removed from HEDIS 2021 Measure Set
Follow-Up After Hospitalization for Mental Illness	Changed	Measure specifications changed by NCQA for 2021 Measure set
Kidney Health Evaluation for Patients With Diabetes	Added	Replacement HEDIS measure - first year measure
Medication Management for People with Asthma	Removed	Measure removed from HEDIS 2021 Measure Set
Well-Child Visits in the First 15 Months of Life	Removed	Measure removed from HEDIS 2021 Measure Set
Well-Child Visits in the First 30 Months of Life	Added	Replacement HEDIS measure - first year measure
Well-Child Visits in the Third, Fourth, Fifth, and Sixth Year of Life	Removed	Replaced measure with HEDIS 2021 measure

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<sup>1. New York State Department of Health, Medicaid Redesign Team, A Path Toward Value Based Payment: Annual Update, September 2019. (Link)  1
2. New York State Department of Health, Medicaid Redesign Team, A Path Toward Value Based Payment: Annual Update, September 2019. (Link)  2
3. New York State Department of Health, Medicaid Redesign Team, A Path Toward Value Based Payment: Annual Update, September 2019. (Link)  3</sup>