Total Care for General Population (TCGP)
Value Based Payment Quality Measure Set
Measurement Year 2023
- Measure Set is also available in Portable Document Format (PDF)
January 2023 NYS Medicaid Value Based Payment
INTRODUCTION
The Measurement Year (MY) 2023 Total Care for General Population (TCGP) Quality Measure Set was created in collaboration with the Primary Care (Physical Health), Maternity Care, Behavioral Health/HARP, People Living with HIV, and Clinical Advisory Groups (CAGs), as well as the New York State Department of Health (NYS DOH) CAG Strategy team. The goal of this measure set is to align with measures put forth in the NYS Quality Assurance Reporting Requirements (QARR), the Healthcare Effectiveness Data and Information Set® (HEDIS)1 Technical Specifications for Health Plans, the CMS Core measure set, 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
Beginning in MY2020, to encourage a broader diversity of quality measures, appropriate to member populations being served by a TCGP arrangement, the State recommended all measures in the TCGP measure set be grouped into domains and added the following requirement to the VBP Roadmap.
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 persons living with HIV/AIDS are not required to include quality measures from these respective quality measure set domains. However, TCGP arrangements that carve out 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.
These requirements carry through to TCGP Arrangements for MY2023. For MY2023, 21 measures have remained the same, two measures have been added and eight measures' reporting specifications/requirements have been revised, culminating in a total of 31 TCGP Category 1 measures.
VBP ARRANGEMENT REQUIREMENTS FOR MY2023 - HEALTH EQUITY
In MY2022, NCQA added race and ethnicity stratification for five HEDIS measures to help promote transparency into health plan performance. By doing so, NCQA hopes to better identify where disparities exist, so they can be addressed. They also hope to identify and learn from top performers in areas where disparities don't exist. To align with this initiative, NYS required payers and providers to incorporate race and ethnicity measure stratification in Value-Based Payment (VBP) arrangements starting in July 2022. For MY2023 HEDIS® is adding eight additional measures.
Stratification Specifications:
- Payers are required to include at least one of the following measures in all level 1 or higher VBP contracts and stratify results by race and ethnicity categories as outlined in the HEDIS MY2023 specifications.2
| NQCA Measure Name | Measure Inclusion by Arrangement Type | |||||
|---|---|---|---|---|---|---|
| TCGP | HARP/BH | Maternity | HIV/AIDs | Children's | ||
| Adult Immunization Status (AIS-E)* | ||||||
| Asthma Medication Ratio (AMR)* | ✓ | ✓ | ✓ | ✓ | ||
| Breast Cancer Screening (BCS-E)* | ✓ | ✓ | ✓ | |||
| Child and Adolescent Well-Care Visits (WCV) | ✓ | ✓ | ||||
| Colorectal Cancer Screening (COL; COL-E) | ✓ | ✓ | ✓ | |||
| Controlling High Blood Pressure (CBP) | ✓ | ✓ | ✓ | |||
| Follow-Up After Emergency Department Visit for Substance Use (FUA)* | ✓ | ✓ | ||||
| Hemoglobin A1c Control for Patients with Diabetes (HBD) | ✓ | ✓ | ✓ | |||
| Immunizations for Adolescents (IMA, IMA-E)* | ✓ | ✓ | ||||
| Initiation and Engagement of Substance Use Disorder Treatment (IET)* | ✓ | ✓ | ✓ | |||
| Pharmacotherapy for Opioid Use Disorder (POD)* | ✓ | ✓ | ||||
| Prenatal and Postpartum Care (PPC) | ✓ | ✓ | ||||
| Well-Child Visits in the First 30 Months of Life (W30)* | ✓ | ✓ | ||||
*Added for MY2023
- Stratification of selected measures will be classified as pay-for-reporting (P4R).
- Payers are required to include the following detail in the Provider Contract Statement and Certification form and Contract language:
- Indicate what measure(s) will be included for race and ethnicity stratification.
- Indicate how the stratified measure results for applicable measures will be shared with the VBP contractor.
- Plans are required to include the race and ethnicity data to NYS using the following method:
Race and ethnicity fields have been added to the annual VBP member attribution submission file specifications. This will allow the State to stratify measure performance by race and ethnicity categories for applicable performance measures at the VBP contract and VBP Contractor levels.
All new contracts submitted on or after July 1, 2022, must meet this requirement to be approved by NYS DOH. All other existing contracts must be updated at the end of the contract's current measurement period and before the contract's next measurement period begins, or no later than April 1, 2023.
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 MY2023 the TCGP Measure Set consists of 31 Category 1 measures. The following measure domains were incorporated into the TCGP Measure Set for MY2023: 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 MY2023 the TCGP Measure Set consists of 30 P4P and 1 P4R measures, 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.
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 2023-2024 Value-Based Payment Reporting Requirements Technical Specifications Manual (MY2023) 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.
MY2023 QUALITY MEASURE SET
The measures provided on the following pages are recommendations for MY2023. 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.
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, MY2023 TCGP Quality Measure Set, arranged alphabetically within domains and includes the measure title, measure steward, the National Quality Forum (NQF) number and/or another measure identifier (where applicable), and State-recommended measure classification. The measure set is redlined to highlight changes made between MY2022 and MY2023, please refer to the key at the end of this table for an explanation of redlined formatting.
| TCGP Measure | Measure Steward | Measure Identifier | Classification |
|---|---|---|---|
| 2023 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 | CMS | NQF 1880 | P4P |
| Antidepressant Medication Management - Effective Acute Phase Treatment & Effective Continuation Phase Treatment (AMM) | NCQA | NQF 0105 | P4P |
| Asthma Medication Ratio (AMR)^ | NCQA | NQF 1800 | P4P |
| Breast Cancer Screening (BCS-E)^* | NCQA | NQF 2372 | P4P |
| Cervical Cancer Screening (CCS; CCS-E)* | NCQA | NQF 0032 | P4P |
| Chlamydia Screening in Women (CHL) | NCQA | NQF 0033 | P4P |
| Colorectal Cancer Screening (COL; COL-E)^ | NCQA | NQF 0034 | P4P |
| Controlling High Blood Pressure (CBP)^ | NCQA | NQF 0018 | P4P |
| COVID-19 Immunization Measure (CVS)* | NYS | P4P | |
| Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD) | NCQA | NQF 1932 | P4P |
| Eye Exam for Patients with Diabetes (EED) | NCQA | P4P | |
| Hemoglobin A1c Control for Patients with Diabetes (HBD)^ | NCQA | P4P | |
| Initiation and Engagement of Substance Use Disorder Treatment (IET)^ | NCQA | NQF 0004 | P4P |
| Kidney Health Evaluation for Patients with Diabetes (KED) | NCQA | P4P | |
| Social Need Screening and Intervention (SNS-E)* | NCQA | P4R | |
| 2023 TCGP Mental Health Domain You must choose at least 1 measure from the following domain to be included in the VBP Contract. |
|||
| Adherence to Antipsychotic Medications for Individuals with Schizophrenia (SAA) | CMS | NQF 1879 | P4P |
| Depression Remission or Response for Adolescents and Adults (DRR-E) | NCQA | P4P | |
| Follow-Up After Emergency Department Visit for Mental Illness (FUM) | NCQA | NQF 3489 | P4P |
| Follow-up After Hospitalization for Mental Illness (FUH) | NCQA | NQF 0576 | P4P |
| Potentially Preventable Mental Health Related- Readmission Rate 30 Days | NYS | | P4P |
| 2023 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 Emergency Department Visit for Substance Use (FUA)^ | NCQA | NQF 3488 | P4P |
| Follow-Up After High-Intensity Care for Substance Use Disorder (FUI) | NCQA | P4P | |
| Initiation of Pharmacotherapy upon New Episode of Opioid Dependence (POD-N) | NYS | P4P | |
| Pharmacotherapy for Opioid Use Disorder (POD)^ | NCQA | P4P | |
| Unless you are excluding or carving out HIV+ individuals, pregnant women, and/or child members in your TCGP arrangement, you must choose at least one Category 1 P4P measure from each of the applicable domains below. | |||
| 2023 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. |
|||
| HIV Viral Load Suppression (HIV-AD) | HRSA | NQF 2082 | P4P |
| 2023 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 (PPC)^ | NCQA | NQF 1517 | P4P |
| 2023 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(PDI 14) | AHRQ | NQF 0728 | P4P |
| Child and Adolescent Well-Care Visits (WCV)^ | NCQA | P4P | |
| Childhood Immunization Status – Combination 3 (CIS; CIS-E) | NCQA | NQF 0038 | P4P |
| Immunizations for Adolescents – Combination 2 (IMA)^ | NCQA | NQF 1407 | P4P |
| Well-Child Visits in the First 30 Months of Life (W30)^ | NCQA | P4P | |
Measure removed from HEDIS/NYS 2023 Measure Set
*New Measure for MY2023/Measure revised for 2023
^ HEDIS Stratified Measure - new for MY2023
*Measures' reporting specifications/requirements revised for MY2023
^HEDIS Stratified Measure
Appendix A
The tables below identify the changes to the Category 1 measures for the MY2023 TCGP Quality Measure Set.
Category 1 Measure Changes from 2022 to 2023
| Measure Name | Change | Rationale for Change |
|---|---|---|
| Asthma Medication Ratio (AMR) | HEDIS Stratified Measure | Added to NCQA list of Race and Ethnicity measures – New for MY2023 |
| Breast Cancer Screening (BCS-E) | HEDIS Stratified Measure | Added to NCQA list of Race and Ethnicity measures – New for MY2023 |
| Breast Cancer Screening (BCS-E) | Measure reporting specifications revised by NCQA for HEDIS MY2023 | Electronic Clinical Data Systems (ECDS) reporting only. |
| Cervical Cancer Screening (CCS)(CCS-E) | Measure reporting specifications revised by NCQA for HEDIS MY2023 | First-year using ECDS |
| COVID-19 Immunization Measure (CVS) | New | Measure added to VBP list of CAT1 recommended measures |
| Follow–Up After Emergency Department Visit for Substance Use (FUA) | HEDIS Stratified Measure | Added to NCQA list of Race and Ethnicity measures – New for MY2023 |
| Immunizations for Adolescents (IMA, IMA-E) | HEDIS Stratified Measure | Added to NCQA list of Race and Ethnicity measures – New for MY2023 |
| Initiation and Engagement of Substance Use Disorder Treatment (IET) | HEDIS Stratified Measure | Added to NCQA list of Race and Ethnicity measures – New for MY2023 |
| Pharmacotherapy for Opioid Use Disorder (POD) | HEDIS Stratified Measure | Added to NCQA list of Race and Ethnicity measures – New for MY2023 |
| Social Need Screening and Intervention (SNS-E) | New | Measure added to NCQA list of required reporting. |
| Well-Child Visits in the First 30 Months of Life (W30) | HEDIS Stratified Measure | Added to NCQA list of Race and Ethnicity measures – New for MY2023 |
__________________________________________________________
1. HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).1
2. HEDIS® Measurement Year 2023 Volume 2 Technical Specification for Heath Plans, General Guidelines section 31. 2
3. New York State Department of Health, Medicaid Redesign Team, A Path Toward Value-Based Payment: Annual Update, May 2022. (Link) 3
Follow Us