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DOH Presents Update on MLTC Value-Based Payment Quality Measures

The Department of Health (DOH) presented a webinar to its Managed Long Term Care Value-Based Payment Clinical Advisory Group (MLTC VBP CAG) last week to solicit feedback on updates to the approved quality measures for MLTC VBP. The only significant change was the restoration of the emergency room utilization measure to the list of Category 1 measures. The measure is used to calculate and compare the percentage of members who did not have an emergency room visit within the last 90 days. The measure was originally included in the approved list and was later removed due to inconsistencies in data reporting instructions.

Under the State's Medicaid Redesign Team (MRT) waiver, by April 2020, 80 to 90 percent of managed care payments to providers must be made via Level 1 VBP arrangements, and 35 percent of Medicaid payments to providers by fully-capitated (i.e., mainstream, Program of All-Inclusive Care for the Elderly (PACE), Medicaid Advantage Plus (MAP), and Fully Integrated Duals Advantage (FIDA) plans) must be made via Level 2 or 3 VBP arrangements. Fifteen percent of payments to providers by partially-capitated MLTC plans must be made via Level 2 or 3 VBP arrangements by April 2020. For partially-capitated MLTC plans, Level 1 arrangements involve a quality bonus, and Level 2 arrangements involve both bonuses and penalties based on quality. For fully-capitated MLTC plans (i.e., PACE, MAP, and FIDA plans), Level 1 arrangements entail shared savings linked to quality; Level 2 arrangements provide for upside and downside risk linked to quality; and Level 3 arrangements transfer risk for the total cost of care or a prospectively paid bundle to the provider. PACE programs are deemed to be Level 3 arrangements.

All MLTC VBP arrangements must include the approved potentially avoidable hospitalization (PAH) measure and may include other approved measures, such as the emergency room utilization measure. VBP Level 2 arrangements must include the PAH measure and at least one other approved MLTC measure.

In addition to discussing the emergency room utilization measure, the Department used the webinar to address some misconceptions about MLTC VBP quality measures. Specifically, the Department noted that the PAH measure that is used for MLTC VBP is not the same as the PAH measure under the MLTC Quality Incentive (MLTC QI). The MLTC QI PAH measure is based on the MLTC plan's entire community-based population, whereas the VBP PAH measure is based on the MLTC's population attributed to each VBP provider, or in the case of nursing homes, the residents of each facility, whether or not they are MLTC members. Thus, the MLTC QI cut points are not necessarily appropriate for calculating relative performance under VBP. For nursing home VBP arrangements, plans and providers should use the "unadjusted" nursing home PAH results for year-over-year performance comparisons.

The Department reminded plans that attribution files are due on Aug. 1st. Instructions can be found in the 2019 Technical Specifications Manual available here. New measures for 2020 will be released in October 2019.

The slide deck from the webinar is available here. Comments and questions may be submitted to DOH here.

Contact: Karen Lipson, klipson@leadingageny.org, 518-867-8383 ext. 124