Total Care for General Population (TCGP)

Value Based Payment Quality Measure Set
Measurement Year 2020

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

January 30, 2020                     NYS Medicaid Value Based Payment

INTRODUCTION

The Measurement Year (MY) 2020 Total Care for General Population (TCGP) Quality Measure Set was created in collaboration with the Primary Care (Physical Health), Maternity Care, Behavioral Health/HARP, HIV/AIDS, and Children´s Health Clinical Advisory Groups (CAGs), as well as the New York State (NYS) Value Based Payment (VBP) Workgroup. The goal of this measure set is to align with measures put forth in the Delivery System Reform Incentive Payment (DSRIP) Program, the Quality Assurance Reporting Requirements (QARR), 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

During the spring, summer, and fall of 2019, the Physical Health, Maternity Care, HIV/AIDS, Behavioral Health, and Children´s Health CAGs reconvened and made recommendations to the State on quality measures, data collection, data reporting, and support required for providers to be successful in a VBP environment.

Beginning in June of 2017, the State initiated regular meetings of the VBP Measure Support Task Force. The goal of the Task Force is to make recommendations to the State to support and inform the Annual Measure Review Cycle. Members of the Task Force include professionals from various Managed Care Organizations (MCOs), VBP Pilot Contractors, clinical Subject Matter Experts, and State Agencies, along with other professionals who have experience in quality measurement and health information technology. The Task Force provided feedback to DOH on quality measure feasibility, reporting, and calculation.

Upon receiving the CAGs and Task Force recommendations, and 2019 VBP Proposed Roadmap updates ; the State defined a final list of measures to be included for MY2020. Measure domains were added to the TCGP measure set. All measures in the TCGP measure set are newly grouped into domains, to align with the populations being included in TCGP contracts. As a result, some measures were removed, some measures were recategorized, and additional measures were added to fill these domains and ensure adequate representation for all populations covered in a TCGP arrangement. For MY2020, 27 measures have been removed, five measures have been added, six measures changed categories, and one changed measure steward and name. This leaves 14 measures unchanged, culminating in a total of 30 Category 1 measures in the 2020 TCGP Measure Set.

Proposed Roadmap Requirements for 2020 – Quality Measures

During the fall and winter of 2018/2019, the VBP Quality Measure Team completed a comprehensive analysis of quality measures being used in shared savings within approved VBP Contracts. Results revealed that most providers and plans have contracted TCGP arrangements, while attributing all populations to the agreements. This has helped MCOs and providers successfully transition over 60% of expenditures into a Level 1 or higher VBP arrangement, surpassing the NYS VBP Roadmap goal of 50% for year 4 of the Delivery System Reform Incentive Payment Program. To encourage a broader diversity of quality measures appropriate to member populations being served by an arrangement, the State recommends the following changes to the VBP Roadmap for 20201.

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 person living with HIV/AIDS are not required to include quality measures from these respective quality measure set domains. TCGP arrangements that carve out Behavioral Health/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.

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 MY2020 the TCGP Measure Set consists only of Category 1 measures. The following measure domains were incorporated into the TCGP Measure Set for MY2020: Primary Care, Mental Health, Substance Use Disorder, HIV/AIDS, Maternity, and Children´s. As a result, some measures were moved from Category 2 to Category 1 and additional measures were added to fill these domains and ensure adequate representation for all populations covered in a TCGP arrangement.

    Categorizing and Prioritizing Quality Measures

CATEGORY 1
Approved quality measures that are deemed to be clinically relevant, reliable, valid, and feasible.

CATEGORY 2
Measures that are clinically relevant, valid, and reliable, but where the feasibility could be problematic. These measures were investigated during the 2017 & 2018 pilot programs.

CATEGORY 3
Measures that are insufficiently relevant, valid, reliable and/or feasible.

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

The State 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 Managed Care Organizations (MCOs) to incentivize VBP Contractors for reporting data to monitor quality of care delivered to members under the VBP contract. Incentives for reporting will be based on timeliness, accuracy, and completeness of data. Measures can be reclassified from P4R to P4P through annual CAG and State review or as determined by the MCO and VBP Contractor.

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 Value Based Payment Reporting Requirements Technical Specifications Manual (MY2020) 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.

MY2020 QUALITY MEASURE SET

The measures and State–determined classifications provided on the following pages are recommendations for MY 2020. Note that measure classification is a State recommendation and implementation is to be determined between the MCO and VBP Contractor.

The measures provided on the following pages are recommendations for MY2020. 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. During 2020, the CAGs and the VBP Workgroup will re–evaluate measures and provide recommendations for MY2021.

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 MY2019 TCGP Quality Measure Set, arranged alphabetically, and includes measure title, measure steward, the National Quality Forum (NQF) number and/or other measure identifier (where applicable), and the measure classification. The measure set is redlined to highlight changes made between MY2019 and MY2020. Additions are made in red text while deletions are in red text with a strikethrough.

Measure Measure Steward Measure Identifier Classification
2020 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 Centers for Medicare & Medicaid Services (CMS) NQF 1880 P4P
Adolescent Preventive Care Measures – Assessment and Counseling on Sexual Activity, Tobacco Use, Alcohol and Drug Use, and Depression NYS – P4R
Adolescent Well–Care Visits National Committee for Quality Assurance (NCQA) – P4R
Annual Dental Visit NCQA NQF 1388 P4R
Antidepressant Medication Management – Effective Acute Phase Treatment & Effective Continuation Phase Treatment NCQA NQF 0105 P4P
Asthma Medication Ratio NCQA NQF 1800 P4P
Breast Cancer Screening NCQA NQF 2372 P4P
Cervical Cancer Screening NCQA NQF 0032 P4P
Chlamydia Screening in Women NCQA NQF 0033 P4P
Colorectal Cancer Screening NCQA NQF 0034 P4P
Comprehensive Diabetes Care: Eye Exam (retinal) Performed NCQA NQF 0055 P4P
Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) NCQA NQF 0059 P4P
Comprehensive Diabetes Care: Medical Attention for Nephropathy NCQA NQF 0062 P4P
Controlling High Blood Pressure NCQA NQF 0018 P4P
Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications NCQA NQF 1932 P4P
Follow–Up Care for Children Prescribed ADHD Medication NCQA NQF 0108 P4R
Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment NCQA NQF 0004 P4P
Low Birth Weight [Live births weighing less than 2,500 grams (preterm v. full term)] Agency for Healthcare Research and Quality (AHRQ) NQF 0278 (lost endorsement) P4R
Medication Management for People with Asthma NCQA NQF 1799 P4P
Potentially Avoidable Complications (PAC) in Routine Sick Care or Chronic Care Altarum Institute – P4R
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow–Up Plan CMS NQF 0421 P4R
Preventive Care and Screening: Influenza Immunization AMA PCPI NQF 0041 P4R
Preventive Care and Screening: Screening for Clinical Depression and Follow–Up Plan CMS NQF 0418 P4R
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention AMA PCPI NQF 0028 P4R
Statin Therapy for Patients with Cardiovascular Disease NCQA – P4R
Use of Pharmacotherapy for Alcohol Abuse or Dependence NYS – P4R
Use of Spirometry Testing in the Assessment and Diagnosis of COPD NCQA NQF 0577 P4R
Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents NCQA NQF 0024 P4P
2020 TCGP Mental Health Domain
You must choose at least 1 measure f rom the following domain to be included in the VBP Contract.
Adherence to Antipsychotic Medications for Individuals with Schizophrenia CMS NQF 1879 P4P
Depression Remission or Response for Adolescents and Adults  NCQA   P4P
Follow–Up After Emergency Department Visit for Mental Illness NCQA NQF 2605 P4P
Follow–up After Hospitalization for Mental Illness​ NCQA NQF 0576 P4P
Potentially Preventable Mental Health Related Readmission Rate 30 Days​ NYS ​ P4P
2020 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 High–Intensity Care for Substance Use Disorder NCQA   P4P
Follow–Up After Emergency Department Visit for Alcohol and Other Drug Dependence NCQA NQF 2605 P4P
Initiation of Pharmacotherapy upon New Episode of Opioid Dependence NYS   P4P
Pharmacotherapy for Opioid Use Disorder NCQA NQF 3175 P4P
Unless you are If you are including HIV+ individuals, pregnant women, and/or children in your TCGP arrangement, you must choose at least  one Category 1 P4P measure from each of the applicable domains below.
2020 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.
Viral Load Suppression HRSA NQF 2082 P4P
2020 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 NCQA NQF 1517
(lost endorsement)		 P4P
2020 TCGP Children´s Do
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 AHRQ NQF 0728 P4P
Childhood Immunization Status – Combination 3 NCQA NQF 0038 P4P
Immunizations for Adolescents – Combination 2 NCQA NQF 1407 P4P
Well–Child Visits in the Third, Fourth, Fifth, and Sixth Year of Life NCQA NQF 1516 P4P
Well–Child Visits in the First 15 Months of Life NCQA NQF 1392 P4P

Category 2

As a result of the changes made to the 2020 TCGP category 1 measures, some category 2 measures were moved from category 2 to category 1 to fill the added domains and ensure adequate representation for all populations covered in a TCGP arrangement. All other category 2 measures were removed from the 2020 TCGP Measure Set. The category 2 measures set below is redlined to highlight changes made between MY2019 and MY2020. Moved/changed measures are made in red text while deletions are made with a strikethrough.

Measure Measure Steward Measure Identifier
Asthma Action Plan American Academy of Allergy, Asthma & Immunology (AAAAI) –
Asthma: Assessment of Asthma Control – Ambulatory Care Setting AAAAI –
Asthma: Spirometry Evaluation AAAAI –
Continuing Engagement in Treatment (CET) Alcohol and Other Drug Dependence NYS –
Continuity of Care from Inpatient Detox to Lower Level of Care NYS –
Continuity of Care from Inpatient Rehabilitation for Alcohol and Other Drug Abuse or Dependence Treatment to Lower Level of Care NYS –
Depression Remission or Response for Adolescents and Adults* TBD –
Developmental Screening in the First Three Years of Life Oregon Health & Science University NQF 1448
Follow–Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence NCQA –
Follow–Up After Emergency Department Visit for Mental Illness NCQA NQF 2605
Home Management Plan of Care (HMPC) Document Given to Patient/Caregiver The Joint Commission (TJC) NQF 0338
Initiation of Pharmacotherapy upon New Episode of Alcohol Abuse or Dependence NYS –
Maternal Depression Screening NCQA NQF 1401
Screening for Reduced Visual Acuity and Referral in Children CMS NQF 2721
Topical Fluoride for Children at Elevated Caries Risk, Dental Services American Dental Association (ADA) NQF 2528
Use of First–Line Psychosocial Care for Children and Adolescents on Antipsychotics NCQA NQF 2801
Pharmacotherapy for Opioid Use Disorder NYS NCQA NQF3175

Appendix A

The tables below identify the changes to the Category 1 and Category 2 measures for the MY2020 TCGP Quality Measure Set.

Category 1 Measure Changes from 2019 to 2020

Measure Name Change Rationale for Change
Adolescent Preventive Care Measures – Assessment and Counseling on Sexual Activity, Tobacco Use, Alcohol and Drug Use, and Depression Removed Align with VBP Roadmap changes
Adherence to Antipsychotic Medications for Individuals with Schizophrenia Added To provide adequate representation for all populations covered in a TCGP arrangement.
Adolescent Well–Care Visits Removed Align with VBP Roadmap changes
Annual Dental Visit Removed Align with VBP Roadmap changes
Asthma Admission Rate PDI #14 Moved Domain To provide adequate representation for all populations covered in a TCGP arrangement.
Childhood Immunization Status – Combination 3 Moved Domain To provide adequate representation for all populations covered in a TCGP arrangement.
Depression Remission or Response for Adolescents and Adults Moved Domain & Category To provide adequate representation for all populations covered in a TCGP arrangement.
Follow–Up After Emergency Department Visit for Alcohol and Other Drug Dependence Moved Domain & Category To provide adequate representation for all populations covered in a TCGP arrangement.
Follow–Up After Emergency Department Visit for Mental Illness Moved Domain & Category To provide adequate representation for all populations covered in a TCGP arrangement.
Follow–Up After High–Intensity Care for Substance Use Disorder Added To provide adequate representation for all populations covered in a TCGP arrangement.
Follow–up After Hospitalization for Mental Illness Added To provide adequate representation for all populations covered in a TCGP arrangement.
Follow–Up Care for Children Prescribed ADHD Medication Removed Align with VBP Roadmap changes
Immunizations for Adolescents – Combination 2 Moved Domain To provide adequate representation for all populations covered in a TCGP arrangement.
Initiation of Pharmacotherapy upon New Episode of Opioid Dependence Moved Domain To provide adequate representation for all populations covered in a TCGP arrangement.
Low Birth Weight [Live births weighing less than 2,500 grams (preterm v. full term)] Removed Align with VBP Roadmap changes
Potentially Avoidable Complications in Routine Sick Care or Chronic Care Removed Align with VBP Roadmap changes
Pharmacotherapy for Opioid Use Disorder Added / Moved Domain, Category, Changed Measure Steward [previously: Use of Opioid Dependence Pharmacotherapy] To provide adequate representation for all populations covered in a TCGP arrangement.
Potentially Preventable Mental Health Related Readmission Rate 30 Days Added To provide adequate representation for all populations covered in a TCGP arrangement.
Prenatal and Postpartum Care Moved Domain To provide adequate representation for all populations covered in a TCGP arrangement.
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow–Up Plan Removed Align with VBP Roadmap changes
Preventive Care and Screening: Influenza Immunization Removed Align with VBP Roadmap changes
Preventive Care and Screening: Screening for Clinical Depression and Follow–Up Plan Removed Align with VBP Roadmap changes
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention Removed Align with VBP Roadmap changes
Statin Therapy for Patients with Cardiovascular Disease Removed Align with VBP Roadmap changes
Use of Pharmacotherapy for Alcohol Abuse or Dependence Removed Align with VBP Roadmap changes
Use of Spirometry Testing in the Assessment and Diagnosis of COPD Removed Align with VBP Roadmap changes
Viral Load Suppression Added To provide adequate representation for all populations covered in a TCGP arrangement.
Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents Removed Align with VBP Roadmap changes
Well–Child Visits in the First 15 Months of Life Moved Domain To provide adequate representation for all populations covered in a TCGP arrangement.
Well–Child Visits in the Third, Fourth, Fifth, and Sixth Year of Life Moved Domain To provide adequate representation for all populations covered in a TCGP arrangement.

Category 2 Measure Changes from 2019 to 2020

Measure Name Change Rationale for Change
Asthma Action Plan Removed Align with VBP Roadmap changes
Asthma: Assessment of Asthma Control – Ambulatory Care Setting Removed Align with VBP Roadmap changes
Asthma: Spirometry Evaluation Removed Align with VBP Roadmap changes
Continuing Engagement in Treatment Alcohol and Other Drug Dependence Removed Align with VBP Roadmap changes
Continuity of Care from Inpatient Detox to Lower Level of Care Removed Align with VBP Roadmap changes
Continuity of Care from Inpatient Rehabilitation for Alcohol and Other Drug Abuse or Dependence Treatment to Lower Level of Care Removed Align with VBP Roadmap changes
Depression Remission or Response for Adolescents and Adults* Moved Domain & Category To provide adequate representation for all populations covered in a TCGP arrangement.
Developmental Screening in the First Three Years of Life Removed Align with VBP Roadmap changes
Follow–Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence Moved Domain & Category To provide adequate representation for all populations covered in a TCGP arrangement.
Follow–Up After Emergency Department Visit for Mental Illness Moved Domain & Category To provide adequate representation for all populations covered in a TCGP arrangement.
Home Management Plan of Care (HMPC) Document Given to Patient/Caregiver Removed Align with VBP Roadmap changes
Initiation of Pharmacotherapy upon New Episode of Alcohol Abuse or Dependence Removed Align with VBP Roadmap changes
Maternal Depression Screening Removed Align with VBP Roadmap changes
Screening for Reduced Visual Acuity and Referral in Children Removed Align with VBP Roadmap changes
Topical Fluoride for Children at Elevated Caries Risk, Dental Services Removed Align with VBP Roadmap changes
Use of First–Line Psychosocial Care for Children and Adolescents on Antipsychotics Removed Align with VBP Roadmap changes
Use of Opioid Dependence Pharmacotherapy Moved Domain, Category Change, Measure Steward Change, Name Change Align with VBP Roadmap changes & to provide adequate representation for all populations covered in a TCGP arrangement.

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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
2. New York State Department of Health, Medicaid Redesign Team, A Path Toward Value Based Payment: Annual Update, September 2019. (Link)  2
3. New York State Department of Health, Medicaid Redesign Team, A Path Toward Value Based Payment: Annual Update, September 2019. (Link)  3