Medicaid Advantage Plus
Value Based Payment Quality Measure Set
Measurement Year 2020
- Measure Set also available in Portable Document Format (PDF)
March 2020 NYS Medicaid Value Based Payment
The measurement year (MY) 2020 value based payment (VBP) quality measure set for Medicaid Advantage Plus (MAP) 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), Programs of All–Inclusive Care for the Elderly (PACE), and the New York State (NYS) VBP Workgroup.
The primary and preventive care measures in Table 1 are currently in the MAP 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 2020 is P4R in order to incentivize appropriate data collection and establish measure use. Plans are required to report on the P4R measures for plan–provider (“VBP Contractor”) combinations.
In addition to the measures listed in Table 1, the current list of recommended Category 1 and Category 2 VBP MLTC measures for MAP Plans for MY 2020 can be used for VBP contracts for MAP. The MAP Category 1 measures are considered valid and feasible for use in VBP MAP 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 MAP Plans have been selected from the MLTC Quality Incentive and the Nursing Home Quality Initiative measure sets.
MEASURE CLASSIFICATION
Based on Sub–team recommendations and feedback from MAP Plans and PACE Organizations, the State developed quality measure sets specific to MAP and PACE to reflect the unique components of these plans. The measures specifically recommended for use by PACE Organizations are listed in Table 1. MAP plans may also use the measures from the recommended VBP measure set for MLTC partial plans.
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 eligible.1
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 MLTC 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 2020 MEASURE SET
The measures and classifications provided on the following pages are recommendations for MY 2020. 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 them (P4P or P4R) in their specific contracts. However, one measure recommended for VBP must be used as a P4P measure in VBP 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 2020, the CAGs and the VBP Workgroup will re–evaluate measures and provide recommendations for MY 2021.
VBP Quality Measures for MAP Plans
Table 1 displays the primary and preventive care measures recommended for use by MAP 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 2020 and must be reported to the State by the plans for their VBP Contractors.
| Measures | 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 MAP Plans
Table 2 displays the complete Category 1 MLTC VBP Measure Set for MAP 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 MAP Plans are classified as P4P for MY 2020.
Note: Additions are highlighted in yellow, deletions are in red strikethrough.
| Measures | 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 in the last 90 days | UAS – NY/New York State | P4P |
| Percentage of members who did not experience falls that resulted in major or minor injury in the 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 or 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 Statewide 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 MAP Plans
Table 3 displays the complete Category 2 MLTC VBP Measure set for MAP Plans and includes measure title, measure steward and/or other measure identifier (where applicable), and the recommended measure use classification.
| Measures | 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, September 2019 (Link) 1
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