DOH Circulates 2023 MLTC Quality Incentive Methodology

The Department of Health (DOH) has circulated the set of measures and methodology that will be used to calculate 2023 Managed Long Term Care (MLTC) Quality Incentive payments. Although the two-year lag between measurement and payment means that actual payments based on these measures will not be made until State Fiscal Year (SFY) 2025-26, quality measures will be calculated primarily based on Uniform Assessment System (UAS) Community Health Assessment (CHA) data spanning January through December 2023, compliance measures based on 2022 data submissions, and satisfaction survey results collected in 2023. After the 2022 methodology that emphasized preventive medicine quality measures, the 2023 methodology retains four of the seven measures from the previous, incorporates four risk-adjusted performance measures, and adds a COVID-19 vaccination measure.

The methodology returns to four domains: nine quality measures worth a total of 50 points, six satisfaction measures worth a total of 30 points, five compliance measures worth a total of 10 points, and an efficiency measure worth 10 points.

The quality measures, most of which are calculated from the UAS, include:

Risk-adjusted percentage of members with no emergency department (ED) visit in the last 90 days (new in 2023)
Risk-adjusted percentage of members with no falls with injury in the last 90 days (new in 2023)
Risk-adjusted percentage of members who did not experience uncontrolled pain (new in 2023)
Risk-adjusted percentage of members who were not lonely or were not distressed (new in 2023)
Percentage of members who received their COVID-19 vaccine in the last year or as required (new in 2023)
Percentage of members who received an influenza vaccination in the last year (same as 2022)
Percentage of members age 65 or older who received a pneumococcal vaccination in the last five years or after age 65 (same as 2022)
Percentage of members who received a dental exam in the last year (same as 2022)
Percentage of members who responded that a health plan representative talked to them about appointing someone to make decisions about their health if they are unable to do so (same as 2022, from 2023 satisfaction survey)

The following 2022 quality measures were dropped for 2023:

Percentage of members who received an eye exam in the last year
Percentage of members who received a hearing exam in the last two years
Percentage of female members ages 50 to 74 who received a mammogram or breast exam in the last two years

Each measure that is greater than or equal to the 90^th percentile in the state is awarded the maximum 5.6 points. For those above the 75^th and below the 90^th percentile, 4.2 points are awarded, with 2.8 points awarded to those between the 50^th and 75^th percentile.

The satisfaction survey measures the age/education/self-reported health status of the risk-adjusted percentage of members who:

rated their MLTC plan as good or excellent
responded that they are usually or always involved in making decisions about their plan of care
reported that within the last six months, the home health aide/personal care aide/personal assistant services were usually or always on time
rated the helpfulness of the plan in assisting them and their family to manage their illnesses as good or excellent
rated the quality of care manager/case manager services within the last six months as good or excellent
rated the quality of home health aide/personal care aide/personal assistant services within the last six months as good or excellent (this measure is also risk-adjusted for cognition)

Results significantly higher than the state average score five points, while results in line with the average score 2.5 points.

Potentially Avoidable Hospitalizations (PAH) comprise the efficiency measure, which measures hospital stays that may have been avoided with proper, timely outpatient care. This measure is confined to the following conditions: heart failure, respiratory infection, electrolyte imbalance, sepsis, anemia, and urinary tract infection. The calculation will be based on UAS CHA data spanning January 2021 through December 2022, along with 2022 inpatient Statewide Planning and Research Cooperative System (SPARCS) data. Ten points are awarded to plans whose rates are significantly better than the statewide average, with those in line with the state average receiving five points.

The final domain provides up to 10 points, which are awarded based on compliance with submission requirements of network data, cost reports, and encounter data submission for 2022, as well as cost report and encounter data reporting congruity. New for this year is an added measure that awards points if no statement of deficiency is received related to Performance Improvement Project participation. Each of the five measures is worth two points.

We invite members to share any comments or questions regarding the methodology with us or directly with DOH at MLTC_OQPS@health.ny.gov.

Contact: Darius Kirstein, dkirstein@leadingageny.org, 518-867-8841