The landscape of healthcare is constantly evolving, with a growing emphasis on quality and patient satisfaction. In New York State, the Medicaid Managed Care Quality Incentive Program stands as a testament to this commitment, designed to reward health plans that deliver superior care to their members. While the program is not exclusively a “Fidelis Care Incentive Program,” it significantly impacts plans like Fidelis Care, incentivizing them to enhance their services and patient outcomes. This article delves into the intricacies of the New York Medicaid Quality Incentive Program, exploring its structure, components, and how it fosters a higher standard of healthcare within the managed care system.
The Evolution and Goals of New York’s Quality Incentive Program
Established in early 2001 and expanded in 2002, New York’s Medicaid Managed Care Quality Incentive Program is a pioneering initiative aimed at driving quality improvements within Medicaid managed care plans. The program’s core mechanism involves offering financial bonuses, added to the premium, to plans that achieve high composite scores based on quality and satisfaction metrics.
Over the years, the Quality Incentive Program has undergone continuous refinement, incorporating new measures, components, and methodologies to accurately assess and reward performance relative to peer organizations. The program leverages data from various sources, including:
- Quality Assurance Reporting Requirements (QARR): Primarily based on the National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS®).
- State-Specific Performance Measures: Tailored metrics reflecting New York’s healthcare priorities.
- Consumer Assessment of Healthcare Providers and Systems (CAHPS®): Surveys capturing patient experiences and satisfaction.
The program’s success is evident in the steady improvement of performance rates in Medicaid managed care over the past decade. New York State Medicaid plans have consistently demonstrated a high level of care, often surpassing national averages. Notably, the performance gap between commercial and Medicaid managed care has narrowed since the program’s inception, highlighting the effectiveness of financial incentives in motivating plans to invest in quality-enhancing infrastructure, programs, and resources.
The strategic use of financial incentives, directly linking payment to quality, serves as a crucial approach to:
- Elevating the quality of care: Encouraging plans to prioritize and invest in quality improvement initiatives.
- Enhancing accountability: Holding health plans responsible for the care they provide to Medicaid members.
- Rewarding quality-focused investments: Recognizing and financially supporting plans that proactively work to improve care processes and outcomes.
This approach aligns with the broader trend of state Medicaid programs increasingly adopting financial incentives and pay-for-performance (P4P) mechanisms to optimize their healthcare payment systems.
Decoding the 2021 Quality Incentive Structure
The current Quality Incentive Program employs a well-defined methodology to calculate the financial incentive percentage awarded to participating plans. The program assesses performance across key categories, assigning points as follows:
- Quality of Care (80%): Based on QARR measures, encompassing HEDIS® and NYS-specific metrics.
- Experience of Care (20%): Measured through the CAHPS® Health Plan Survey.
Plans can accumulate up to 100 percentage points from these categories. However, deductions may occur for compliance issues. Statements of deficiency in the Compliance category can lead to a reduction of up to 10 points from a plan’s total score.
Furthermore, the program incorporated COVID-19 Vaccine Equity Plan Bonus Points, offering up to 10 additional bonus points to incentivize equitable vaccine distribution.
Summary of the 2021 Quality Incentive Structure:
| Component | Number of Measures | Points |
|---|---|---|
| Quality – QARR (HEDIS® and NYS-specific) | 30 | 100 points |
| Satisfaction – CAHPS® Health Plan Survey | 3 | 20 points |
| Total Points | Sum of 80% of Quality points and Satisfaction points | |
| Compliance (Subtracted from Total) | 7 | Up to 10 points |
| Covid-19 Vaccine Equity Plan Bonus Points | Up to 10 bonus points | |
| Final Score | Up to 110 points |
Historically, incentive programs have categorized plans into five tiers to determine award amounts, based on their earned percentage of points. Achieving or surpassing the threshold for a specific tier is necessary for award eligibility. These quality incentive payments are contingent upon the availability of State funding, as determined through the annual budget process.
Moreover, a plan’s performance in the Quality Incentive directly influences the auto-assignment algorithm for Medicaid members. Plans achieving Tier 1 through Tier 4 receive a quality preference in this algorithm, directing a proportion of auto-assigned members to these higher-performing plans. It’s important to note that the auto-assignment preference is consistent across Tiers 1-4, with all qualifying plans sharing equally in the distribution of auto-assignees.
The tier thresholds for the 2021 program were: Tier 1 (≥63.60), Tier 2 (48.28-63.59), Tier 3 (34.96-48.27), Tier 4 (28.65-34.95), and Tier 5 (<28.65). The COVID-19 Vaccine Equity Plan (CVEP) bonus points allowed plans to move up a maximum of one tier. To earn these bonus points, plans needed to demonstrate a 10% improvement in vaccination rates from baseline or achieve a minimum 50% vaccination rate in specific age groups (12-17 and 18+).
The 2021 Quality Incentive awards took effect on April 1, 2022, influencing capitation rates and auto-assignment preferences.
Deep Dive into Quality Incentive Components and Calculation (2021 Methodology)
The 2021 Quality Incentive framework comprised three core components:
- Quality of Care: Evaluated using 2021 QARR results based on 2021 data.
- Consumer Satisfaction: Assessed through the most recent CAHPS® survey for adults in Medicaid, conducted in Fall 2021 with results released in May 2022.
- Compliance: Determined by regulatory compliance data from 2020 and 2021.
Quality of Care: Detailed Scoring (100 Points)
The point allocation for quality measures followed a specific methodology:
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Alignment with Value-Based Payment Measures: Quality measures were strategically aligned with those used in the State’s Value-Based Payment arrangements, encompassing areas like Primary Care, Mental Health, Substance Use, Maternity, Children’s Health, and HIV. This comprehensive approach provides a holistic view of quality and mitigates the impact of any single underperforming area.
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Weighted Average for Multi-Indicator Measures: For measures with multiple indicators, a weighted average method was employed to calculate a composite measure score. This method ensures that indicators with larger denominators contribute more significantly to the overall score, reflecting a more accurate representation of performance.
Weighted Average Equation:
(Note: As there was no image in the original article, a placeholder image link is used here. In a real scenario, if an actual equation image was available or needed, it would be placed here.)
Where X = final measure score, xi = indicator score, and ni = indicator denominator.
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Even Point Distribution: The 100 points allocated for quality were evenly distributed across all measure scores, with each measure, regardless of the number of indicators, counted as a single measure. For instance, with 30 quality measures, each measure was worth up to 3.33 points.
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Small Sample Size (SS) Considerations: Measures with fewer than 30 members in the denominator were deemed Small Sample Size and results were suppressed. No reweighting occurred for SS measures, but the base quality points were reduced proportionally.
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Pay for Reporting (P4R) and Pay for Performance (P4P) Measures: Measures were categorized as either P4R or P4P.
- P4R Measures: Full points were awarded for valid reporting, irrespective of the measure score. Hybrid measures reported administratively also received full P4R points.
- P4P Measures: Points were awarded based on performance relative to percentile benchmarks:
- 50% of points: Performance at or above the 50th percentile but below the 75th.
- 75% of points: Performance at or above the 75th percentile but below the 90th.
- 100% of points: Performance at or above the 90th percentile.
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Percentile Benchmarks: The 50th, 75th, and 90th percentiles were determined based on the same measurement year’s results, rounded to two decimal places before percentile calculation.
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Quality Percentage Weighting: Each plan’s total quality points were divided by their base points to calculate a quality percentage. This percentage was then weighted at 80% in the final score calculation, maintaining a consistent influence of quality performance on overall scores.
2021 Medicaid Quality Measure Benchmarks
| Measure Name | 90th Percentile | 75th Percentile | 50th Percentile | Points Possible |
|---|---|---|---|---|
| Primary Care | ||||
| Antidepressant Medication Management | 52.08 | 51.11 | 49.71 | 3.33 |
| Asthma Medication Ratio | 68.79 | 63.90 | 61.38 | 3.33 |
| Breast Cancer Screening | 69.38 | 66.34 | 62.68 | 3.33 |
| Cervical Cancer Screening | 74.27 | 71.26 | 67.40 | 3.33 |
| Chlamydia Screening in Women | 80.32 | 75.10 | 69.95 | 3.33 |
| Colorectal Cancer Screening | 69.34 | 61.79 | 56.93 | 3.33 |
| Comprehensive Diabetes Screening: Eye Exam | 65.69 | 64.23 | 59.37 | 3.33 |
| Comprehensive Diabetes Care: Poor Control* | 26.42 | 30.96 | 35.77 | 3.33 |
| Controlling High Blood Pressure | 72.75 | 68.19 | 63.26 | 3.33 |
| Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment | 36.30 | 31.61 | 30.14 | 3.33 |
| Kidney Health Evaluation for Patients with Diabetes | 44.97 | 42.00 | 39.81 | 3.33 |
| Statin Therapy for Patients with Cardiovascular Disease: Statin Adherence 80% | 77.34 | 72.65 | 70.33 | 3.33 |
| Use of Spirometry Testing in the Assessment and Diagnosis of COPD | 46.15 | 45.02 | 35.73 | 3.33 |
| Children’s Health | ||||
| Annual Dental Visit: Ages 2-18 | 58.98 | 58.02 | 54.75 | 3.33 |
| Childhood Immunization: Combination 3 | 76.89 | 75.06 | 72.51 | 3.33 |
| Immunizations for Adolescents: Combination 2 | 53.60 | 44.04 | 40.15 | 3.33 |
| Well Child Visits in the First 30 Months of Life | 78.93 | 77.86 | 75.43 | 3.33 |
| Child and Adolescent Well-Care Visits | 73.94 | 71.15 | 70.22 | 3.33 |
| Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents | 92.38 | 88.33 | 83.23 | 3.33 |
| Mental Health | ||||
| Adherence to Antipsychotic Medications for Individuals with Schizophrenia | 63.96 | 61.87 | 60.87 | 3.33 |
| Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications | 80.32 | 78.98 | 77.24 | 3.33 |
| Follow-Up After Emergency Department Visit for Mental Illness: 7-day rate | 72.99 | 61.98 | 54.37 | 3.33 |
| Follow-Up After Hospitalization for Mental Illness: 7-day rate | 67.47 | 65.26 | 64.81 | 3.33 |
| Follow-Up Care for Children Prescribed ADHD Medication | 64.68 | 61.25 | 57.16 | 3.33 |
| Metabolic Monitoring for Children and Adolescents on Antipsychotics | 49.74 | 42.53 | 38.43 | 3.33 |
| Substance Use | ||||
| Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence: 7-day rate | 25.35 | 21.75 | 20.23 | 3.33 |
| Initiation of Pharmacotherapy Upon New Episode of Opioid Dependence | 55.77 | 49.35 | 45.94 | 3.33 |
| Maternity | ||||
| Timeliness of Prenatal Care | 92.96 | 90.88 | 86.86 | 3.33 |
| Postpartum Care | 85.16 | 81.85 | 79.81 | 3.33 |
| HIV | ||||
| Viral Load Suppression | 79.88 | 78.80 | 74.42 | 3.33 |
* A low rate is desirable
CAHPS Experience of Care Survey: Measuring Satisfaction (20 Points)
The Quality Incentive incorporated three measures from the CAHPS Experience of Care survey, allocating a total of 20 points. Points were awarded based on a plan’s performance relative to the statewide average from the most recent CAHPS survey for adults in Medicaid (Fall 2021).
- 6.66 points: Awarded for results significantly better than the statewide average.
- 3.33 points: Awarded for results not significantly different from the statewide average.
- 0 points: Awarded for results significantly lower than the statewide average.
CAHPS Measures and Points:
| CAHPS Measure | Satisfaction Points |
|---|---|
| Rating of Health Plan | 6.66 points |
| Getting Care Needed | 6.66 points |
| Customer Service and Information | 6.66 points |
| Total | 20 points |
Compliance: Ensuring Regulatory Adherence (Up to 10 Points Deduction)
The Compliance component assessed seven critical areas, with potential point deductions for statements of deficiency (SODs):
| Category | Measure Description | Timeframe | Points |
|---|---|---|---|
| Medicaid Managed Care Operating Report | SODs for MMCOR report timeliness, completeness, or reserve requirements (2021 & 2020 submissions). | MMCOR reports for 2021 & 2020 | Up to 2 points per timeframe |
| Quality Reporting Requirements | SODs for failure to submit complete quality data (CMART, QARR) by deadlines (2021), SODs related to Performance Improvement Projects, quality performance matrix, or Focused Clinical Studies (FCS) (2021). | Quality Reporting for 2021 | Up to 2 points |
| Plan Network | SODs for failure to manage access to care, maintaining 75% compliance with appointment timeframes (2021 Access and Availability survey). | Access and Availability survey 2021 | Up to 1 point |
| Provider Directory | SODs for PNDS/Panel Submission timeliness, completeness, accuracy (2021), SODs for incomplete/inaccurate provider listings or <75% provider participation (2021). | Provider Directory 2021 | Up to 1 point |
| Member Services | SODs or findings for member services failures (functional phone line, correct information, written request responses) (2021). | Member services 2021 | Up to 1 point |
| Behavioral Health Parity Reporting | SODs for Behavioral Health Parity report timeliness, completeness, accuracy, or requirement failures (2021). | Parity reports 2021 | Up to 1 point |
| Claims Payment and/or Denials | SODs or findings related to claims payment/denial issues (2021). | Claims data 2021 | Up to 2 points |
| Total | Up to 10 points |
COVID-19 Vaccine Equity Plan (CVEP) Bonus Points
Plans had the opportunity to earn bonus points by demonstrating improvements in COVID-19 vaccination rates across different age cohorts. Focus was placed on equitable vaccination rates, requiring plans to submit strategies for improving vaccination rates in children (5-11), adolescents (12-17), and adults (18+). Plans could earn bonus points by achieving a 10% improvement in vaccination rates or reaching a 50% vaccination threshold for the 12-17 and 18+ age groups.
Quality Incentive Tiers: Performance Levels
Plans were categorized into five tiers based on their final percentage scores, which are a blend of 80% quality points and 20% satisfaction points, adjusted for compliance deductions and potential bonus points. These tiers determined the incentive award levels.
2021 Quality Incentive Tiers:
- Tier 1: ≥ 63.60
- Tier 2: 48.28-63.59
- Tier 3: 34.96-48.27
- Tier 4: 28.65-34.95
- Tier 5: < 28.65
The CVEP bonus points could move a plan up a maximum of one tier.
2021 Quality Incentive Award Results: Fidelis Care and Peer Performance
The 2021 Quality Incentive results showcased the performance of thirteen NYS Medicaid Managed Care plans, categorized into the five tiers based on their scores. Notably, Fidelis Care New York, Inc. achieved Tier 3 in the 2021 program.
| MMC QUALITY INCENTIVE 2021 |
|---|
| INCENTIVE PREMIUM AWARD (%) |
| TIER 1 |
| TIER 1 |
| TIER 1 |
| TIER 2 |
| TIER 3 |
| TIER 3 |
| TIER 3 |
| TIER 3 |
| TIER 3 |
| TIER 3 |
| TIER 4 |
| TIER 5 |
| TIER 5 |
This table provides a clear overview of how each plan performed across the Quality Incentive metrics, contributing to their final tier placement and associated incentive premium awards. For plans like Fidelis Care, understanding their performance in this program is crucial for strategic planning and continuous quality improvement efforts.
Conclusion: Driving Continuous Improvement in Medicaid Managed Care
The New York Medicaid Managed Care Quality Incentive Program serves as a powerful mechanism for driving continuous quality improvement and enhancing patient experience within the state’s Medicaid system. By linking financial incentives to measurable quality and satisfaction outcomes, the program motivates health plans to prioritize and invest in initiatives that directly benefit their members. While this article focuses on the 2021 methodology and results, the program’s ongoing evolution ensures its continued relevance and effectiveness in promoting high-quality, accountable healthcare for Medicaid beneficiaries in New York.
For further inquiries regarding the incentive premium award, please contact the Bureau of Managed Care Reimbursement at [email protected]. Suggestions and comments on the program are welcomed and can be directed to [email protected] or by phone at (518) 486-9012.
