Total Care for General Population (TCGP)
Value Based Payment Quality Measure Set
Measurement Year 2019
- Measure Set is also available in Portable Document Format (PDF)
December 13, 2018 NYS Medicaid Value Based Payment
INTRODUCTION
The Measurement Year (MY) 2019 Total Care for General Population (TCGP) Quality Measure Set was created in collaboration with the Chronic Pulmonary, Heart, Diabetes, and Primary Care (Physical Health), Maternity Care, Behavioral Health, and Children's Health Clinical Advisory Groups (CAGs), as well as the New York State (NYS) Value Based Payment (VBP) Workgroup. The goal of this measure set is to align with measures sets put forth in the Advanced Primary Care initiative by the Integrated Care Workgroup, 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.
Introduction of Pediatric Measures
The Children´s Health CAG was convened in 2016–2017 and presented its final recommendations to the VBP Workgroup in October of 2017. Based on these recommendations, an additional 14 Children´s Measures (eight Category 1 and six Category 2 measures) were added to the TCGP Measure Set for MY 2018. These measures will continue to be a part of the TCGP Quality Measure Set in MY 2019 to cover the pediatric population included in the TCGP arrangements.
Changes to the Measure Set that do not impact the Integrated Primary Care (IPC) Quality Measure Set
Historically, the VBP Quality Measure Sets for TCGP and IPC have been the same. During the 2018 Measure Review Cycle, the Maternity Care and Physical Health CAGs recommended adding maternity–specific measures to the TCGP Quality Measure Set to better reflect the inclusion of maternity care in TCGP arrangements. These measures were not added to the IPC Quality Measure Set due to its focus on primary care in IPC arrangements. As a result, there are now separate VBP Quality Measure Sets for TCGP and IPC arrangements.
MEASURE SELECTION AND FEASIBILITY
During the spring and summer of 2018, 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 monthly meetings of the VBP Measure Support Task Force and arrangement–level Sub–teams. The goal of the Task Force and Sub–teams 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 CAG recommendations and Task Force feedback, the State defined a final list of measures for inclusion for MY 2019. For MY 2019, five measures have been removed and four measures have been added, culminating in a total of 52 Category 1 and 2 TCGP Quality Measures.
MEASURE CLASSIFICATION
Each measure has been designated by the State as Category 1, 2, or 3 with associated recommendations for implementation and testing for future use in VBP Arrangements. The measures on the following pages are classified by category based on an assessment of reliability, validity, and feasibility, and according to suggested method of use (either Pay for Reporting (P4R) or Pay for Performance (P4P)).
Categorizing and Prioritizing Quality Measures
CATEGORY 1
Approved quality measures that are deemed to be clinically relevant, reliable, valid, and feasible.
CATEGORY 2
Measures that are clinically relevant, valid, and reliable, but where the feasibility could be problematic. These measures were investigated during the 2017 & 2018 pilot programs.
CATEGORY 3
Measures that are insufficiently relevant, valid, reliable and/or feasible.
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.1 At least one Category 1 P4P measure must be included in a VBP contract.
The State 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 Care Organizations (MCOs) to incentivize VBP Contractors for reporting data to monitor quality of care delivered to members under the VBP contract. Incentives for reporting will be based on timeliness, accuracy, and completeness of data. Measures can be reclassified from P4R to P4P 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 see the 2019 Value Based Payment Reporting Requirements Technical Specifications Manual 2 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.
Categories 2 and 3
Category 2 measures have been accepted by the State based on agreement of clinical importance, validity, and reliability, but flagged as presenting concerns regarding implementation feasibility. These measures will be further investigated in the VBP Pilots. The State requires that
VBP Pilots select and report a minimum of one Category 2 measure per VBP Arrangement for MY 2019 (or have a State and Plan approved alternative). VBP Pilot participants will be expected to share meaningful feedback on the feasibility of Category 2 measures when the CAGs reconvene. The State will discuss measure testing approaches, data collection, and reporting requirements with VBP Pilots as a part of the Measure Support Task Force.
Measures designated as Category 3 were identified as unfeasible at this time or as presenting additional concerns including accuracy or reliability when applied to the attributed member population for an arrangement, therefore Category 3 measures are not included in the measure set.
MEASUREMENT YEAR 2018 QUALITY MEASURE SET
The measures and State–determined classifications provided on the following pages are recommendations for MY 2019. 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. During 2019, the CAGs and the VBP Workgroup will re–evaluate measures and provide recommendations for MY 2020. Please see Appendix A for a full list of these changes.
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.
Category 1
The table below displays the Category 1 MY 2019 TCGP Quality Measure Set, arranged alphabetically, and includes measure title, measure steward, the National Quality Forum (NQF) number and/or other measure identifier (where applicable), and State–recommended classification for measure use. The measure set is redlined to highlight changes made between MY 2018 and MY 2019. Additions are made in red text while deletions are made with a strikethrough.
| Measure | Measure Steward | Measure Identifier | Classification |
|---|---|---|---|
| Adherence to Mood Stabilizers for Individuals with Bipolar I Disorder | Centers for Medicare & Medicaid Services (CMS) | NQF 1880 | P4P |
| Adolescent Preventive Care Measures – Assessment and Counseling on Sexual Activity, Tobacco Use, Alcohol and Drug Use, and Depression | NYS | – | P4R |
| Adolescent Well–Care Visits | National Committee for Quality Assurance (NCQA) | – | P4R |
| Annual Dental Visit | NCQA | NQF 1388 | P4R |
| 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 |
| Childhood Immunization Status – Combination 3 | NCQA | NQF 0038 | 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 |
| Follow–Up Care for Children Prescribed ADHD Medication | NCQA | NQF 0108 | P4R |
| Immunizations for Adolescents – Combination 2 | NCQA | NQF 1407 | P4P |
| Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment | NCQA | NQF 0004 | P4P |
| Initiation of Pharmacotherapy upon New Episode of Opioid Dependence | NYS | – | P4P |
| Low Birth Weight [Live births weighing less than 2,500 grams (preterm v. full term)] | Agency for Healthcare Research and Quality (AHRQ) | NQF 0278 (lost endorsement) | P4R |
| Medication Management for People with Asthma | NCQA | NQF 1799 | P4P |
| PDI #14 Asthma Admission Rate | AHRQ | NQF 0728 | P4P |
| Potentially Avoidable Complications (PAC) in Routine Sick Care or Chronic Care | Altarum Institute | – | P4R |
| Prenatal and Postpartum Care | NCQA | NQF 1517 (lost endorsement) | P4R |
| Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow–Up Plan | CMS | NQF 0421 | P4R |
| Preventive Care and Screening: Influenza Immunization | American Medical Association Physician Consortium for Performance Improvement (AMA PCPI) | NQF 0041 | P4R |
| Preventive Care and Screening: Screening for Clinical Depression and Follow–Up Plan | CMS | NQF 0418 | P4R |
| Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | AMA PCPI | NQF 0028 | P4R |
| Statin Therapy for Patients with Cardiovascular Disease | NCQA | – | P4R |
| – | |||
| Use of Pharmacotherapy for Alcohol Abuse or Dependence | NYS | – | P4R |
| Use of Spirometry Testing in the Assessment and Diagnosis of COPD | NCQA | NQF 0577 | P4R |
| Weight Assessment and Counseling for Nutrition and Physical Activity for NCQA Children/Adolescents | NQF 0024 | P4P | |
| Well–Child Visits in the First 15 Months of Life | NCQA | NQF 1392 | P4P |
| Well–Child Visits in the Third, Fourth, Fifth, and Sixth Year of Life | NCQA | NQF 1516 | P4P |
Category 2
The table below displays the Category 2 MY 2019 TCGP Quality Measure Set and includes measure title, measure steward, and the NQF number and/or other measure identifier (where applicable). All Category 2 measures are classified as P4R in MY 2019. The measure set is redlined to highlight changes made between MY 2018 and MY 2019. Additions are made in red text while deletions are made with a strikethrough.
| Measure | Measure Steward | Measure Identifier |
|---|---|---|
| Asthma Action Plan | American Academy of Allergy, Asthma & Immunology (AAAAI) | – |
| Asthma: Assessment of Asthma Control – Ambulatory Care Setting | AAAAI | – |
| Asthma: Spirometry Evaluation | AAAAI | – |
| Continuing Engagement in Treatment (CET) Alcohol and Other Drug Dependence | NYS | – |
| Continuity of Care from Inpatient Detox to Lower Level of Care | NYS | – |
| Continuity of Care from Inpatient Rehabilitation for Alcohol and Other Drug Abuse or Dependence Treatment to Lower Level of Care | NYS | – |
| Depression Remission or Response for Adolescents and Adults* | TBD | – |
| Developmental Screening in the First Three Years of Life | Oregon Health & Science University | NQF 1448 |
| Follow–Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence | NCQA | – |
| Follow–Up After Emergency Department Visit for Mental Illness | NCQA | NQF 2605 |
| Home Management Plan of Care (HMPC) Document Given to Patient/Caregiver | The Joint Commission (TJC) | NQF 0338 |
| Initiation of Pharmacotherapy upon New Episode of Alcohol Abuse or Dependence | NYS | – |
| Maternal Depression Screening | NCQA | NQF 1401 |
| Screening for Reduced Visual Acuity and Referral in Children | CMS | NQF 2721 |
| Topical Fluoride for Children at Elevated Caries Risk, Dental Services | American Dental Association (ADA) | NQF 2528 |
| Use of First–Line Psychosocial Care for Children and Adolescents on Antipsychotics | NCQA | NQF 2801 |
| Use of Opioid Dependence Pharmacotherapy | NYS | – |
* A Depression Remission and Response measure has been identified by the Physical and Behavioral Health/HARP CAGs as a priority measure for MY 2019. Final details regarding steward and specification will be made in the coming year.
Appendix A
The tables below identify the changes to the Category 1 and Category 2 measures for the MY 2019 TCGP Quality Measure Set.
Category 1 Measure Changes from 2018 to 2019
| Measure Name | Change | Rationale for Change |
|---|---|---|
| Asthma Medication Ratio | Added | Recommended by the Chronic Pulmonary, Heart, Diabetes, and Primary Care CAG |
| Comprehensive Diabetes Care: Foot Exam | Removed | alignment with other quality programs |
| Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Control (<8.0%) | Removed | alignment with other quality programs |
| Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) testing [performed] | Removed | Removed to focus on outcome measures |
| Comprehensive Diabetes Screening: All Three Tests (HbA1c, dilated eye exam, and medical attention for nephropathy) | Removed | alignment with other quality programs |
| Low Birth Weight [Live births weighing less than 2,500 grams (preterm v. full term)] | Added | Recommended by Children´s Health CAG |
| Prenatal and Postpartum Care | Added | Recommended by Children´s Health CAG |
| Statin Therapy for Patients with Diabetes | Removed | alignment with other quality programs |
Category 2 Measure Changes from 2018 to 2019
| Measure Name | Change | Rationale for Change |
|---|---|---|
| Depression Remission or Response for Adolescents and Adults | Added | Measure added to prioritize depression remission measure |
__________________________________________________________
1. New York State Department of Health, Medicaid Redesign Team, A Path Toward Value Based Payment: Annual Update, November 2017. (Link) 1
2. 2019 Value Based Payment Reporting Requirements; Technical Specifications Manual, Nov 2018, File found in the Quality Measures tab (Link) 2
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