Programs of All-Inclusive Care for the Elderly

Value Based Payment Quality Measure Set
Measurement Year 2019

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

December 2018                     NYS Medicaid Value Based Payment


2019 VBP PACE Quality Measure Set

The measurement year (MY) 2019 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), Fully Integrated Duals Advantage (FIDA), Programs of All-Inclusive Care for the Elderly (PACE), and the New York State (NYS) VBP Workgroup.

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 2019 is P4R in order 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 or not to pursue VBP with downstream providers.

In addition to the measures listed in Table 1, the current list of recommended Category 1 and Category 2 VBP MLTC measures for partially capitated MLTC plans for MY 2019 can be used for VBP contracts for PACE, if a PACE chooses to contract with any of its downstream providers. The MLTC partially capitated Category 1 measures are considered valid and feasible for use 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 partially capitated MLTC plans have been selected from the MLTC Quality Incentive and the Nursing Home Quality Initiative measure set.

MEASURE CLASSIFICATION

Based on Sub–team recommendations and feedback from MAP and FIDA Plans and PACE Organizations, the State developed quality measure sets specific to MAP, FIDA, 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 eligible1.

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 the 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 2019 QUALITY MEASURE SET

The measures and classifications provided on the following pages are recommendations for MY 2019. 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. For mainstream VBP contracts, partially capitated MLTC plans and providers, and MAP and FIDA plans one measure is required to be used as a P4P measure.

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 2019, the CAGs and the VBP Workgroup will re–evaluate measures and provide recommendations for MY 2020.


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 2019. . 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

Measure 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 Utilization Without Hospitalization CMS –– P4R
Acronym: CMS denotes the Centers for Medicare and Medicaid Services

Category 1 VBP Quality Measures for Partially Capitated MLTC Plans

Table 2 displays the complete Category 1 MLTC VBP Measure Set for Partially Capitated 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 recommended for use in MLTC VBP for Partially Capitated Plans are classified as P4P for MY 2019.

Please note the removal of the measure "Percentage of members who did not have falls resulting in medical intervention in the last 90 days" for MY 2019. The components of this measure have changed and it will be reconsidered for MY 2020.

Table 2: Category 1 VBP Quality Measures for Partially Capitated MLTC Plans

Measure 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 and 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 State wide 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 Partially Capitated MLTC Plans

Measure 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, November 2017: Year 2, New York State Roadmap for Medicaid Payment Reform, November 2017. (Link)  1