Medicaid Advantage Plus

Value Based Payment Quality Measure Set
Measurement Year 2023

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

January 2023                                                         NYS Medicaid Value Based Payment

The measurement year (MY) 2023 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), and Programs of All-Inclusive Care for the Elderly (PACE).

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 2023 is Pay for Reporting (P4R) 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, Table 2 lists the recommended Category 1 and Category 2 VBP MLTC measures for MAP Plans for MY 2023 and can be used for VBP contracts for MAP. The MAP Category 1 measures are considered valid and feasible for use in VBP MAP contracts. 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 (Pay for Performance) 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.

Category 2

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.

MEASUREMENT YEAR 2023 MEASURE SET

The measures and classifications provided on the following pages are recommendations for MY 2023. 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 2023, the CAGs may re-evaluate measures and provide recommendations for MY 2024.

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 2023 and must be reported to the State by the plans for their VBP Contractors.

Table 1: Primary and Preventive Care Measures
Measures Measure Source/ Steward Measure Identifier Classification
Eye Exam for Patients with Diabetes (EED)* NCQA/ HEDIS NQF 0055 P4R
Kidney Health Evaluation for Patients with Diabetes (KED)* NCQA/ HEDIS   P4R
Colorectal Cancer Screening (COL)* NCQA/ HEDIS NQF 0034 P4R
Antidepressant Medication Management - Effective Acute Phase Treatment & Effective Continuation Phase Treatment (AMM)* NCQA/ HEDIS NQF 0105 P4R
Follow-up After Hospitalization for Mental Illness (FUH)^ NCQA/ HEDIS NQF 0576 P4R
Initiation and Engagement of Substance Use Disorder Treatment (IET)* NCQA/ HEDIS NQF 0004 P4R

* Included in the TCGP measure set
^ Included in the Health and Recovery Plan (HARP) measure set

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 2023.

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 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

* Included in the NYS DOH MLTC Quality Incentive 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;

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.

Table 3: Category 2 VBP Quality Measures for MAP and PACE
Measures Measure Source/ Steward Classification
Care for Older Adults - Medication Review NCQA P4R
Use of High-Risk Medications in the Elderly NCQA P4R
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

* Included in the NYS DOH MLTC Quality Incentive measure set
Acronyms: NCQA denotes the National Committee for Quality Assurance

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1. New York State Department of Health, Value Based Payment: Update, New York State Roadmap for Medicaid Payment Reform: Update, May 2023 (Link)  1