DOH Releases 2022 Draft VBP Roadmap for Comment

The Department of Health (DOH) released for public comment an update to its Value-Based Payment (VBP) Roadmap last week. Under the draft Roadmap Update, VBP arrangements would be optional for partially capitated Managed Long Term Care (MLTC) plans, but would continue to be required for integrated duals plans – i.e., Medicaid Advantage Plus (MAP) plans and Programs of All-Inclusive Care for the Elderly (PACE). The Department recognizes that the VBP arrangements set forth in the prior versions of the Roadmap were not designed for partially capitated MLTC plans and that implementation has been challenging. Although it continues to encourage VBP within partially capitated MLTC programs, it will no longer be supporting the quality measurement for MLTC VBP as of Measurement Year 2020. It is unclear how this suspension of support for the MLTC measures will impact PACE and MAP plans and existing VBP contracts with partially capitated plans.

Earlier versions of the VBP Roadmap were an integral part of delivery system and payment reforms envisioned under the State's 1115 waiver and Delivery System Reform Incentive Payment (DSRIP) program. With the expiration of DSRIP and the impending submission of a new 1115 waiver application, the State is updating its VBP Roadmap. The new draft Roadmap offers a more clear and concise description of the expected VBP arrangements. With the exception of the elimination of VBP requirements for partially capitated MLTC plans and Integrated Primary Care and Chronic Care Bundles, much of the original Roadmap framework remains intact.

Under the updated Roadmap, VBP goals and requirements for fully capitated MLTC plans would be the same as those that apply to fully capitated Medicaid Mainstream Managed Care. Thus, they would be required to enter into certain types of VBP arrangements (known as "on-menu" arrangements) with specified levels of risk, applying specified attribution methodologies to assign members to the VBP arrangement. Fully capitated MLTC arrangements would continue to apply the attribution methodology used under the prior version of the Roadmap – i.e., attributing members who have four or more months of continuous enrollment to the certified home health agency (CHHA), licensed home care services agency (LHCSA), or nursing home that had the most frequent contact with the member. The Roadmap also requires that arrangements establish a prospective target budget that is derived from an historical baseline, adjusted for changes in the patient population and performance (i.e., efficiency and quality).

In addition, the updated Roadmap continues to require the use of certain quality measures selected by the Department's Clinical Advisory Groups. Fully capitated MLTC plans would be required to list in their provider contracts the quality measures agreed upon for calculating shared savings and losses. At least two "Category 1 pay-for-performance" quality measures would have to be selected from the MAP or PACE measure set. However, the updated Roadmap notes that:

As of December 2021: Due to COVID-19 and the current public health emergency, the calculation of the MLTC VBP Category 1 measures, except for the Potentially Avoidable Hospitalization (PAH) measure, is not currently possible. As a result, both parties, plan, and provider, should pre-plan how to evaluate VBP contracts with only PAH available. The other VBP Category 1 measures can be included once the Department resumes processing.

The Roadmap further requires that all required "pay-for-reporting" (P4R) measures be reported at the contract level, which can be found in the MAP and PACE quality measure set. If one required P4R measure is missing, the VBP arrangement will be considered "off-menu" and will require DOH review and approval. It is unclear how this aligns with the decision to suspend support for the VBP Category 1 measures.

Fully capitated MLTC plans would also be required to continue to incorporate social determinants of health (SDH) interventions. The SDH interventions must align with at least one of the five domains of SDH identified in the Roadmap: housing instability, food insecurity, transportation problems, interpersonal safety and toxic stress, health literacy and education, and economic instability. Managed care plans contracting in VBP Level 2 arrangements (upside and downside risk with retrospective reconciliation) must share in the cost associated with the interventions. In Level 3 arrangements (prospective upside/downside risk arrangements), the VBP contractor (e.g., provider or independent practice association (IPA)) must bear the cost of these investments. All Level 2 and 3 arrangements must include at least one not-for-profit community-based organization (CBO).

Notably, the Roadmap highlights the Department's emphasis on fully integrated MLTC and implicitly references language in the State Fiscal Year (SFY) 2020-21 budget that would phase out partially capitated MLTC. In light of these initiatives, it encourages partially capitated MLTC plans to "examine the outcomes and impacts of their current VBP contracts upon expiration and to make an informed determination as to whether such arrangements should be renewed or expanded, or whether to enter new VBP arrangements." If partially capitated MLTC plans pursue VBP arrangements, they should include, for Level 1 VBP arrangements, the following:

Potentially Avoidable Hospitalization (PAH) measure; and
Performance-based quality bonus between an MLTC Partial Plan and a VBP contractor that is based on meeting performance targets.

For partially capitated MLTC plans that pursue a Level 2 VBP arrangement, the arrangement should include the following:

PAH measure and at least one other MLTC quality measure recommended by the MLTC Clinical Advisory Group (CAG); and
Minimum percentage of potential risk allocated to a provider is at least 1 percent of total annual expenditures in the contract between the plan and provider; and
SDH and CBO requirements outlined in the Roadmap.

Like the prior versions of the Roadmap, Off-Menu Arrangements are permitted, but must meet certain requirements and receive DOH approval.

The Department is holding a webinar on the Roadmap on Tues., Jan. 25, 2022 from 1 to 2 p.m. LeadingAge NY will post a summary of the webinar and the slides when they become available. Comments on the Roadmap are due by 5 p.m. on Feb. 18, 2022. Comments should be submitted using this form. LeadingAge NY will be submitting comments. If you would like LeadingAge NY to consider your organization's comments for inclusion in the association's comments, please send them to Karen Lipson by Feb. 4, 2022.

Contact: Karen Lipson, klipson@leadingageny.org, 518-867-8838