Programs of All-Inclusive Care for the Elderly
Value Based Payment Quality Measure Set
Measurement Year 2021
- Measure Set also available in Portable Document Format (PDF)
April 2021 NYS Medicaid Value Based Payment
Please note: Due to COVID-19 and the Department's continued suspension of Community Health Assessments for reassessment of MLTC enrollees during the current public health emergency, the calculation of the MLTC VBP Category 1 measures, except for the Potentially Avoidable Hospitalization (PAH) measure, will likely not be possible for 2021. As a result, both parties, plan and provider, should pre-plan how to evaluate VBP contracts should only PAH be available.
The measurement year (MY) 2021 value based payment (VBP) quality measure set for Programs of All-Inclusive Care for the Elderly (PACE) 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).
The PACE-specific measures in Table 1 have been selected from Streams 2 and 3 of the PACE measures currently under development with the Centers for Medicare and Medicaid Services (CMS). To reflect the developmental nature of the measures the recommended classification for these measures for MY 2021 is P4R to incentivize appropriate data collection and establish measure use. PACE Organizations will be required to report on these measures for the PACE. If a PACE chooses to contract with a downstream provider for VBP, measure selection is at the discretion of the plan and provider. PACE Organizations qualifying as Level 3 VBP arrangements by virtue of meeting the social determinants of health intervention requirements can choose whether to pursue VBP with downstream providers.
In addition to the measures listed in Table 1, Table 2 lists the recommended Category 1 and Category 2 VBP measures for PACE plans for MY 2021, if a PACE chooses to contract with any of its downstream providers. The Table 2 Category 1 measures are considered valid and feasible for use . Category 2 measures, listed in Table 3, are also considered valid but may warrant additional implementation effort stemming from feasibility issues.
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.
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 2021 MEASURE SET
The measures and classifications provided on the following pages are recommendations for MY 2021. Note that measure classification is a State recommendation. Plans and VBP Contractors may use measures as P4R or P4P per the terms of their individual 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 2021, the CAGs and the VBP Workgroup may re-evaluate measures and provide recommendations for MY 2021.
VBP Quality Measures Specific to PACE Organizations
Table 1 displays the quality measures specific to PACE Organizations and includes measure title, measure steward, and State determined classification for measure use. All PACE-specific measures recommended for use in MLTC VBP for PACE Organizations are classified as P4R for MY 2021. The P4R measures shown in Table 1 must be reported to the State by PACE plans for the PACE.
Table 1: VBP Quality Measures for Specific to PACE
| Measures | Measure Source/ Steward | Measure Identifier | Classification |
|---|---|---|---|
| Percentage of PACE Participants with an Advance Directive or Surrogate Decision Maker Documented in the Medical Record AND Percentage of PACE Participants with Annual Review of their Advance Directive or Surrogate Decision Maker Document | CMS | -- | P4R |
| Percent of Participants Not in Nursing Homes | CMS | -- | P4R |
| PACE Participant Emergency Department Use Without Hospitalization | CMS | - | P4R |
Acronym: CMS denotes the Centers for Medicare and Medicaid Services
Category 1: VBP Quality Measures PACE Organizations
Table 2 displays the complete Category 1 MLTC VBP Measure Set for PACE Organizations and includes measure title, measure steward and/or other measure identifier (where applicable), and State determined classification for measure use. All Category 1 measures recommended for use in MLTC VBP for PACE Organizations are classified as P4P for MY 2021.
Table 2: Category 1 VBP Quality Measures for MAP and PACE
| 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 * Percentage of members who remained stable or demonstrated improvement in urinary continence * | UAS - NY/ New York State UAS - NY/ New York State | P4P 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 UAS - NY/ New York lonely or not distressed * State | UAS - NY/ New York State | P4P |
| Potentially Avoidable Hospitalizations (PAH) UAS - NY/ New York State for a primary diagnosis of heart failure, with linkage to respiratory infection, electrolyte imbalance, SPARCS data sepsis, anemia, or urinary tract infection * | UAS - NY/ New York State with linkage to SPARCS data | P4P |
| Potentially Avoidable Hospitalizations (PAH) MDS 3.0/ New York State for a primary diagnosis of heart failure, with linkage to respiratory infection, electrolyte imbalance, SPARCS data sepsis, anemia, or urinary tract infection ǂ | UAS - NY/ 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 PACE Organizations
Table 3 displays the complete Category 2 MLTC VBP Measure set 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 MAP and PACE
| 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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