PHP QualityPerformance and Accountability ConceptPaper FINAL 20180320

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1 Medicaid Managed Care Proposed Concept Paper Provider Health Plan Quality Performance and Accountability North Carolina Department of Health and Human Services March 20 , 2018 1

2 Contents ... 3 I. Introduction ... 3 Quality Overview dvancing Quality through PHPs ... 4 Vision for A Levers for Quality Improvement ... 5 II. Quality Measurement and Withholds ... 6 Quality Measure Reporting 6 ... Qual ity Withholds Measures ... 9 III. Quality Measurement in Provider Incentives/Value -based Purchasing ... 12 Provider Incentive Programs ... 12 ... Va lue -based Payments 13 IV. Tactical Efforts to Advance Quality in Managed Care ... 13 PHP Quality Assessment and Performance Improvement Programs ... 14 PHP Performance Improvement Projects ... 14 V. Next Steps ... 14 Appendix A: Quality Performance Measures ... 15 Appendix B: Estimated Comprehensive Managed Care Enrollment by Cohort Based on the Department’s Proposed Phase in Schedule ... 31 This document is part of a series of concept papers that the Department of Health and Human Services scheduled for release from late 2017 through early 2018 to provide additional details to s takeholders regarding the transition of North Carolina Medicaid and NC Health Choice programs to a predominantly managed care model. This technical paper is written primarily for providers and health plans that will participate directly in Medicaid managed care, but anyone may respond and provide feedback to the Department, including beneficiaries, advocates or other interested parties. Some topics mentioned in this document may be covered in more detail in other concept papers in the series. For more infor mation on the Department’s proposal, stakeholders are encouraged to review the Amended North Carolina Section 1115 Demonstration Waiver Application and previously . ncdhhs.gov/nc -medicaid -transformation released concept papers available at Input is welcome and appreciated. Send comments to [email protected] . 2

3 I. Introduction The North Carolina Department of Health and Human Services (the Department) is dedicated to designing a comprehensive Medicaid managed care program that optimizes health and well -being for all North Carolinians. Central to these efforts is a com mitment to the delivery of high -quality health care thr ough the development of a -driven, outcomes -based , continuous quality improvement process that focuses on rigorous measurement data , and appropriately rewards PHPs and providers for advancing quality goals. against relevant targets Quality Overview 1 As North Carolina transitions to a managed care structure for its Medicaid and NC Health Choice programs, the Department seeks to advance high -value care, improve population health, engage and support providers, and establish a sustainable program with predictable costs. The Department’s goal is to improve the health of North Carolinians through an innovative, whole -coordinated system of care, which addresses -person centered and well -medical drivers of health. both medical and non ment for health care are changing, the goal of North Carolina Medicaid remains While the mechanics of reimburse that of improving beneficiaries’ health and well- being by delivering the right care, in the right place, at the right time. In designing this transition, the Department is committed to leveraging engagement throug h the managed care program with p health plans (PHPs) and their contracted providers to improve the quality of health repaid care benefi ciaries receive. North Carolina identified targeted quality indicators that will serv e as a “north star” for the Department, contracted plans and providers; performance against these indicators will be crucial to assess the success of its new payment approach. —inte grated managed care products In July 2019, most Medicaid beneficiaries will begin transitioning to PHPs -term services and supports (LTSS), pharmacy and providing physical and behavioral health services, long 2 Working with the General Assembly, the Department has proposed to -related resource needs. addressing health create distinc t types of PHPs, which will be customized to the populations they serve: Standard plans will launch in the first year of managed care and will serve the vast majority of Medicaid • beneficiaries. will launch l and developmental disabili ty tailored plans (BH I/DD TPs) Behavioral health and intellectua • in the third year of managed care and focus on the specialized needs of individuals with behavioral health disorders such as severe persistent mental illness, severe emotional disturbance or substance use disorde r, 3, 4 intellectual and developmental d isabilities , and traumatic brain injury (TBI). 1 For purposes of this concept paper, the term “Medicaid” refers to North Carolina Medicaid and NC Health Choice programs, unless specifically described otherwise. 2 Subject to appropriate legislative authority from the North Carolina General Assembly . 3 North Carolina is seeking legislative approval to incorporate behavioral health benefits into standard plans and to create BH I/DD TPs . 4 of March 9, 2018, the proposed target population for initial enrollment in BH I/DD TP s includes individuals with a qualifying I/DD As diagnosis, including those enrolled in or on the waiting list for the Innovations waiver; individuals enrolled in the TBI wai ver who are on the waiting list for the TBI waiver or have used a state -funded TBI service; individuals enrolled in the Transition to Community Living Initiative; individuals with a serious mental illness or serious emotional disturbance diagnosis who have used a Medicaid- covered enhanced e past year; and individuals with a qualifying substance use -funded behavioral health service within th behavioral health service or a state 3

4 Over a five -year period, the majority of North Carolina Medicaid beneficiaries will phase into managed care, with –June 2020). Appendix B displays the populations that will phase the largest portion enrolling in Year 1 (July 2019 f implementation. into managed care by year o North Carolina begins the Medicaid m anaged care transition with a history of commitment to measuring quality and improving health outcomes. As North Carolina transitions to managed care, the Department will work with to develop a data -driven, outcomes PHPs and providers , continuous quality improvement process that will -based build on this history and focus on rigorous outcome measurement against relevant targets and benchmarks, sparities, and appropriately reward PHPs and, in promote equity through reduction or elimination of health di turn, providers for advancing quality goals and health outcomes. Consistent with the Department’s commitment to transparency throughout the managed care planning, design and implementation process, the Depa rtment is releasing this concept paper to provide information about how PHPs will be held accountable for achieving high quality outcomes. This paper aims to articulate the specific strategies – or “levers” – that the Department will deploy to ensure PHPs are focused on achieving quality, and align PHPs and providers to advance quality at the practice level. Accompanyi “North ng this paper is a draft of Medicaid Managed Care Carolina’s ,” which provides a n overview of the Department’s Quality Quality Strategy Framework and specific quality priorities, and further details how the Department will set standards for access, plan structure and operations to ensure the quality priorities are addressed. Thi s concept paper and the draft Quality Strategy focus exclusiv ely on the quality accountability structure for standard plans. Unique Quality Measures and considerations for BH I/DD TPs will be addressed in subsequent amendments to the Quality Strategy . The Department welcomes feedback on this concept paper as it con tinues to refine the approach to ensuring PHPs are held accountable for advancing quality in the Medicaid program. hrough PHPs Vision for Advancing Quality t As noted in the draft Quality Strategy , the Department seeks to develop a data -ba sed -driven, outcomes continuous quality improvement process that rewards PHPs for advancing quality outcomes in targeted areas that : 1) B etter C are D elivery; 2) Healthier P eople , Healthier C ommunities; and 3) Smarter support three central Aims s are tied to each of these Aims , along with a series of interventions, including Spending. Goals and Objective (AMH s) and a advanced medical homes social determinants of health strategy , outlined in more detail in previous papers and specifically designed to improve quality outcomes in North Carolina. This concept paper describe s the specific levers and mechanisms that will be used to hold PHPs and providers accountable for improving quality outcomes in a standard plan. The Department is committed to rewarding PHPs that accurately report and demonstrate meaningful improvement against specified quality targets. Working with PHPs, the Department will collect a robust set of quality data, w hich will paint a clear picture of service delivery and clinical care at a statewide and , eventually , a regional level, and across demographic measures, such disorder diagnosis who have used a Medicaid- covered enhanced behavioral health service or state -funded behavioral health service within the past year. Other individuals with a TBI, serious mental illness, serious emotional disturbance or substance use disorder may also be s, please see the BH I/DD TP eligible to enroll in a BH I/DD TP . For additional details on BH I/DD TP concept paper . 4

5 with providers as race and ethnicity. The Department will require PHPs to quickly establish working relationships and other community stakeholders to support plan -level financial accountability for Quality Measures , including selected clinical outcomes in Year 1. Later years will build on these relationships to attain increasingly ambitious quality per formance targets focused on priority outcomes specified by the Department (f igure 1.1). The Department will also collect and report on select public health measures to link PHP quality improvement efforts to larger state public health initiatives and goals . The Department will support this vision through investments in quality performance initiatives and advancement of required infrastructure. In turn, the Department expects PHPs to invest in establishing the infrastructure required to measure quality perfo rmance, embed continuous quality improvement efforts to improve outcomes, and possess the capabilities to execute successful strategies to reduce and eliminate health disparities. Figure 1.1: The Quality Vision Over Time Over time, PHPs should plan for an increasing proportion of provider contracts to be in advanced payment models that may require alternative approaches to contracting, data sharing , and provider and beneficiary engagement. These contracts will drive t a accountability, over time, for outcomes not just a -benchmarking level, but at a regional level and state extending across populations. Levers for Quality Improvement The Department will use a variety of tools to ensure PHPs move towards plan -level accountability for health outcomes, and will offer resources to support PHPs and providers in their quality improvement efforts. Most directly, the Department will set goals for PHP quality improvement efforts through the establishment of quality and calculation of baselines, targets and benchmarks for , which PHPs will be required to report, measure sets 5

6 these measures. These requirements are likely to be a major focus of PHP efforts, and (through the quality , described in greater detail in Section II) will give PHPs direct financial withhold program accountability for a subset of overall quality performance improvement and reduction or elimination of disparities. Additional levers include the following: The Department has established requirements for PHP deployment of V alue • Payments (VBP), and -based Provider Incentive Programs as tools to incentivize quality improvement among contracting providers. • The Department expects PHPs will work with their contracting providers to improve quality through PHP Performance I rojects , for which the Department will provide broad guidelines. PHPs will submit ncentive P an annual Q uality Assessment and P erformance I mprovement (QAPI) plan , delineating their plans for Performance Incentive Projects and other quality improvement efforts. • The Department expects PHPs will engage with external entities to improve quality, including an Accrediting body that will assess quality improvement efforts and offer additional guidance and an rformance and provide feedback Review External Quality that will validate quality pe Organization (EQRO) to PHPs, including a separate report on health disparities. • The Department expects PHPs, contracting providers, enrollees and other community stakeholders to share feedback on quality improvement and offer suggestions that c an lead to better processes and outcomes. Most of these levers are described in greater detail in this paper. Additional details on the EQRO and Accreditation are provided in the accompanying Quality Strategy . II. Quality Measurement and Withholds To ensure that all North Carolina Medicaid managed care beneficiaries receive high -quality care, PHPs will be expected to report, and be held accountable for performance against, measures aligned to a range of specific s used to drive quality imp Goals and Objective rovement and operational excellence. The Department’s use of specific quality levers to advance toward these and Objective s will evolve, as PHPs’ and providers’ Goals infrastructure and experience increase, with greater rewards for excellence and more significant penalties for poor performance. The Department recognizes that PHPs will need to invest substantial resources to meet quality reporting requirements, and believes this investment is essential to ensuring the provision of high -quality care. The Depa rtment intends to invest in improved technology and infrastructure to support PHP reporting and will streamline reporting requirements when feasible, based on the results of reporting in early years. Quality Measure Reporting PHPs must report a set of 64 q uality and administrative measures ( “ Quality Measures ”) that are meant to provide PHPs’ processes and performance. These measures include a the Department with a complete picture of the 6

7 5 measures required for accreditation, and a select set of additional dult and c core measures, hild select set of a uality measures, including administrative measures aligned with key Department interventions. A draft of these q measures is shown in Appendix A. QUALITY STRATEGY A subset of these 64 measures that most Quality Strategy are closely aligned to the In addition to this paper, the Department has released a designated as “ Priority Measures . ” Priority for assessing and improving the quality of Quality Strategy measures serve as a basis for several specific health care and services delivered by PHPs. North Carolina’s initiatives under the Quality Strategy , including Quality Strategy is built around the desire to build an (Section III), PHP Provider Incentive Programs -coordinated system of care on, well innovative, whole -pers performance improvement p rojects (Section that addresses both medical and non -medical drivers of ithhold program IV), and for the quality w s distilled health and promotes health equity. This vision i ). These measures may change next (discussed : into three central aims from year to year as the Department considers 1) Better care d elivery PHP performance on the larger measure set. The Department will report publicly on all 2) Healthier people, healthier c ommunities Priority Measures n, and may, at its discretio ending 3) Smarter sp Quality Measures also report against all . Inclu goals is a series of ded within each of these three aims To provide a clear picture of health disparities bjectives, intended to highlight key areas of expected and o and a foundation for additional granularity for and progress and quality focus. Together, these aims, g oals measure reporting and targets, PHPs will be objectives create a framework through which North Carolina required to report against a set of stratification defines and drives the overall vision for advancing the criteria that may include, but are not limited quality of care provided to Medicaid beneficiaries. See the to, race and ethnicity, region (rural vs. urban), Quality Strategy draft for additional detail. eligibility category, and age and gender where appropriate and feasible for many of the Quality Measures . The specific measures that will require stratified , all Healthcare Effectiveness Data and Information Set (HEDIS) and reporting include, b ut are not limited to . Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures, and all Withhold Measures 5 Adult and Child core measures are a standardized set of health Quality Measures for Medicaid enrollees that are identified and published by the Secretary of Health and Human Se rvices as a requirement of the Affordable Care Act (Section 1139B). 7

8 Figure 2.1: Quality Measure Reporting Framework In addition to t above , the Department will provide a select set of public health population -level he measure sets measures, such as measures related to infant and maternal mortality, that are intended to inform PHPs about regional trends and link PHP performance improveme nt efforts with larger public health goals. Additional details for how PHPs will be engaged in public health efforts is in Section IV. PHPs will be given historical baselines , calculated by the QUALITY MEASUREMENT TERMINOLOGY Department, for all measures for which comparable av ailable at the state level. The historical data are Baseline: Historic performance on a measure • Department will also calculate , representing benchmarks • Benchmark: Optimal performance on a . For optimal performance levels , for all Priority Measures measure Withhold Measures , the Department will also calculate targets , representing the level PHPs much achieve to Performance level required for a PHP • Target: to receive some or all quality withhold funds receive some or all of their quality withhold amount. In the first year, all PHPs will be held to a single attainment target, which will be set as a percentile of national performance but informed by historic state -level performance -to-goal quality on the measure. In subseq uent years, PHPs may receive individualized baselines for gap -to-goal measurement, PHPs are scored based on the degree to which they have closed the measurement. In gap gap between their historical baseline and a predetermined target by imp roving their performance. While PHPs will not receive separate targets for different population subgroups for all measures, they may receive additional credit on selected measures for reducing disparities between those groups. PHPs will be responsible for collecting and reporting on many of the 64 Quality Measures . The EQRO will be tasked with conducting the CAHPS survey and a few measures will be reported at the PHP level by the 8

9 All measures except “Controlling High Blood Department. OVERVIEW OF WITHHOLD PROGRAM 6 ” rely solely on encou nter, survey or Pressure ” refer to a federally authorized option “Withholds administrative data available at the PHP level. to withhold a share of a PHP’s capitation payment All reported measures will be collected annually and on achieving specific program goals. contingent validated by the EQRO. The EQRO will also be responsible The Department is implementing withholds for developing public facing reports that assess PHP related to quality performance and other performance against the Quality Measures and a priorities. These withholds are: Department disparities report which will also report PHPs performance • Intended to incent PHP behavior beyond against select, stratified measures. basic program requirements and against specific performance goals; Quality Withholds Measures • Compliant with all federal requirements Quality Strategy , the As noted above and in the -setting and actuarial related to rate Department will utilize a withhold program to reward soundness, including that withholds must be PHPs for eff orts in a range of areas, not only for quality “reasonably achievable”; and improvement but also operational effectiveness, Department. I Budget neutral to the • ar 1, n Ye advancement of initiatives around addressing unmet each PHP will be able to earn back its resource needs, telemedicine and accreditation, and AMH withhold based on its performance against t of -related componen Tier 3 contracting goals. The quality each program element. the withhold program is discussed within this paper; it will account for at least 30% of the total withhold in year 1 and at least 60% in subsequent years. Withhold measures will be selected annually from the Priority Measures set. PHPs will report s tratified withhold measure performance data for a range of population subgroups to ensure equity in performance improvement. The being considered for Year 1 are included in Figure 2.2 below. The Department expects to Withhold Measures narrow this list to a core group of six or seven Withhold Measures for use in the first year of contracting. Figure 2.2 Proposed Year 1 Quality Withhold Measures MEASURE Prenatal and Postpartum Care (Both Rates) Cervical Cancer Screening Grams Live Births Weighing Less than 2,500 -Child Visits in the Third, Fourth, Fifth and Sixth Years of Life Well Asthma Medication Ratio (Total Rate) Medical Assistance with Smoking and Tobacco Use Cessation ontrol (>9.0%) Comp rehensive Diabetes Care: HbA1c Poor C Follow - Up After Hospitalization for Mental Illness Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (Both Rates) 6 The Department is further considering if hypertension will stay in the measure given that it requires collection of systolic and diastolic blood pressures. 9

10 The Year 1 quality withhold measure set focuses on maternal health, childhood immunizations, and cardiovascular areas where the Department intends to further advance measurement in future health and related risk factors— , as defined by attainment against years. PHPs will be assessed for overall performance on these Quality Measures a national benchmark. Because the Department intends fo r PHPs to build on North Carolina providers’ earlier successes in quality improvement, the Department will expect PHPs to be accountable for selected outcomes and ar 1 measures: reduction of disparities in these areas in the first year of contracting for the following Ye • Intermediate outcome and outcome measures : PHP performance will be assessed using these outcomes o Comprehensive Diabetes Care (HbA1c P oor C ontrol) 7 o Live B irths W eighing L ess than 2,500 G rams • Promotion of equity : PHPs will receive partial poin ts for minimizing gaps between selected population subgroup performance o Prenatal and P ostpartum Care The Department aims to maintain a small withhold measure set, ensuring that each measure carries sufficient ear 1 withhold is devoted to quality, a quality weight to influence PHP behaviors. For example, if 30% of the Y withhold set of six measures would mean that each individual measure could account for up to 5% of the total withhold ; a meaningful sum. When the quality withhold weight increases to at least 60% in Year 2, the Department may elect to increase the size of the withhold set or may maintain the current size and increase each measure’s weight. The Department may also consider weighting measures, by assigning different percentages of the total withhold amount by measure, rather than assigning an equal percentage to each measure. Year 1 Measurement Scoring Process As noted previously, in Year 1 PHPs’ performance on quality with holds will be measured based on attainment. The attainment target for a measure will generally be set as a percentile of national performance on that measure, but the target will be informed by historic state performance. As one potential example, if the average North Carolina th score on a given measure in 2017 was 28%, and that performance corresponded with the 50 percentile of th percentile of national national performance in that year, the target for Year 1 would be set at the 50 performance in Year 1. Measures will be scored against their preset targets. For measures where 95% confidence intervals for PHP performance overlap the target, the PHP will receive partial credit toward their quality withhold score. For measures where 95% confidence intervals fo r PHP performance lie completely above the target, the PHP will receive full credit. For measures where 95% confidence intervals for PHP performance lie completely below the target, the PHP will receive no credit. For measures that are calculated using a full population rather than a sample, population means will be used rather than confidence intervals. When possible, the Department will 8 However, when the Department release targets at least 90 days before the beginning of each performance year. 7 This measure is currently specified for population -level reporting and will require re- specification for reporting at the PHP level. The Department -specification process. expects to incorporate PHP feedback into the re 8 prior to managed will release the Ye ar 1 Withhold Measures and targets in the fall of 2018 to provide PHPs with notice The Department care beginning on July 1, 2019. 10

11 shifts to an improvement -based measurement process in future years, PHPs may not receive their plan -specific baselines until several months into the performance year, because of the additional time required to receive and analyze end -of -year encounter data. Figure 2.3 Illustrative Example of a Year 1 Withhold 11

12 Future Uses of Quality Withholds and Overall Quality Results As previously noted, the withhold measure set will shift toward outcome measures over time, with an increasing focus on not only improving performa nce under a gap -to-goal assessment approach, but also on eliminating disparities. In later years, Withhold Measures will likely involve more outcomes measures and incorporate clinical data in addition to encounter, survey and administrative data. In futur e years, the Department will also implement new uses for PHPs’ quality scores that go beyond calculation of quality withholds. For example, the Department will expect PHPs to further incorporate quality scores into internal continuous quality improvement and value -based purchasing efforts, described further below. The Department will also use PHP quality scores in the PHP auto -assignment algorithm, allowing PHPs with higher quality scores to disproportionally be assigned new beneficiaries. If quality performance is unacceptably low over a continued period , the Department may decline to renew or terminate a PHP contract. III. Quality Measurement in Provider Incentives/Value -based Purchasing To advance the Department’s vision for quality and to ensure that payments to providers are increasingly focused on population health, appropriateness of care and other measures related to value, the Department is encouraging accelerated adoption of VBP arrangements between PHPs and providers, and requiring that PHPs’ Provider Incentive Programs be aligned with the Quality Strategy and related measures. Use of VBP and Provider Incentive Programs will ensure that PHPs and providers are recognized and rewarded for quality gains. Provider Incentive Programs PHPs will be required to have performance incentive programs designed to fit within categories 2 through 4 of the earning and Action Network (HCP Health Care Payment L -LAN) framework (explained in further detail, below). AMH Tier 3 providers an Specifically, PHPs must contract with d may, at their discretion, target additional providers (AMH or otherwise). Provider incentive programs must align with the Quality Strategy , must use a sub - Priority Measures set of the Quality Strategy and in Appendix A of this document, and must base noted within the rewards on practice performance against a specific threshold. The Department will review these Provider Incentive Programs , and the specific incentives that will be tied to such programs, prior to their de ployment by concept As noted earlier and in the “North Carolina’s Care Management Strategy under Managed Care” PHPs. paper that that will count , the Department expects to raise the bar on the types of Provider Incentive Programs toward VBP targets. For example, in the early years of managed care, a pay -for -performance model through which a provider earns additional upside bonus dollars based on quality measure performance is allowed, but over time, Provider Incentive Programs may shift to alternative payment models with shared savings based on the total cost of care for individual practices or groups of individual practices that can together meet minimum beneficiary attributions. For AMH Tier 4 practices , which formally will be officially recognized in Year 3 of managed care, payments will be based on alternative payment models within broad criteria to be set by the Department, including larger upside shared savings payments including downside risk for to tal cost of care with capped downside risk (similar to the Medicare Shared Savings Program’s “Track 1+”). 12

13 The Department will also require that PHPs pay Pregnancy Medical Home providers the current levels of PMH irst year of managed care, which are 1) completing a standardized incentive payments through the end of the f -screening tool at initial visit ($50) , and 2) conducting a postpartum visit ($150). risk In addition to the above incentive programs, PHPs will be allowed and encouraged to develop physician incentive requirements , and are aligned with the Quality Strategy . This flexibility is plans that sit outside VBP and PMH If a PHP chooses to develop an additional physician meant to encourage innovation between PHPs and providers. incentive plan, they w ill be required to submit that plan for review with the Department before use. Value-b ased Payments PHPs are required to develop and lead innovative strategies to increase the use of VBP arrangements over time. Prior to the launch of managed care and annu ally thereafter, PHPs will be required to submit a VBP p lan that will describe their VBP strategies to the Department. PHPs will also be required to report on their use of VBP contracting arrangements each year. The VBP p lan will indicate the specific prog rams and VBP arrangements the PHPs will implement, the specific provider incentives that will be tied to these arrangements, and the outcomes that these programs will target, which must be aligned with the Quality Strategy . Additionally, the plan must addr ess how the PHP will incorporate addressing social determinants of health in its VBP strategy. For the first two years of PHP operations, the Department defined VBP as payment arrangements that meet the 9 Within this framework, the criteria of the HCP -LAN Advanced Payment Model (APM) Categories 2 through 4. Department requires that by the end of Year 2 of PHP operations, the portion of each PHP’s medical expenditures governed under VBP arrangements will either: , or • Increase by 20 percentage points • at least 50 % of total medical expenditures. Represent The Department expects to see increasing levels of APMs in Categories 3B (Downside Ris k) and 4 (Full -Risk -based Payments). In the early years of PHP operations, and once additional information on VBP Population arrangements in the market is collected, the Department plans to convene stakeholder -term s to develop a longer VBP r oadmap, and to provide input into how to drive the market toward payment models based on higher LAN Categories. Stakeholders will also weigh in on assessin g PHPs’ advancements to -date and opportunities to align VBP arrangements across payers and in accordance with statewide priorities. IV. Tactical Efforts to Advance Quality in Managed Care In addition to the quality efforts already discussed, the Department will deploy several practical tactics to ensure PHP alignment with the Quality Strategy and to address emerging quality priorities. All items below are discussed in detail in the Quality Strategy , and are summarized here for reference. 9 products/ For more information on the HCP -LAN APM framework, see: https://hcp- lan.org/groups/apm -fpt -work- 13

14 PHP Quality Assessment and Performance Improvement Programs The Department requires PHPs to establish and maintain an ongoing comprehensive QAPI. Each year, PHPs must submit their QAPI, which the Department reviews and approves. QAPIs must include PHP perform ance improvement projects (described next ) and documentation of the PHP’s submissi on of all required quality data; and descriptions of mechanisms to detect and address underutilization and overutilization of services, assess quality and appropriateness of care for beneficiaries with special health care needs and those requiring long -term services supports, remediation of critical incidents, and a process for assessing the PHP’s performance, including . Quality Measures underperformance on PHPs must include i n the QAPI how PHPs will assess and address health disparities. As PHPs report against -specific programs into the QAPI designed to reduce stratified Quality Measures , they will incorporate PHP disparities and track how efforts progress, over time. Addition ally, to the extent PHPs and the Department work together on targeted public health initiatives (e.g. opioid crisis, infant mortality) that involve select quality interventions, the Department will require that those interventions be embedded in the QAPIs. Additionally, PHPs will be expected to engage as active partners in Healthy NC 2020 and 2030 planning, including th orough review and discussion of PHP -level data and quality performance. PHP Performance Improvement Projects To improve performance, PHPs a ired to conduct at least three PIPs annually, including two clinical PIPs, re requ from among the topics of pregnancy intendedness, tobacco cessation, diabetes and behavioral health integration, and one non -clinical PIP, which must be aligned to the Aims , Goals , Objective s and interventions outlined within the Quality Strategy . In addition to the required PIPs, PHPs with low rates of Early and Periodic Screening, Diagnostic and Treatment (EPSDT) of below 75% must submit an additional PIP on EPSDT screening a nd community outreach plans. PIP progress must be assessed using measures drawn from the priority measure set listed in Appendix A. V. Next Steps The Department will continue to engage with stakeholders as it refines the Quality Strategy and works with PHPs and providers to measure and advance quality in North Carolina. Providers, PHPs, beneficiaries and advocacy groups will play an important role in this planning process to ensure a strong focus on high quality care from the start of managed care implementat ion. The final list of Q uality, P riority, and Withhold Measures will be released in fall 2018, along with state baselines, The Department will also continue to develop its infrastructure for managed care and benchmarks and targets. will be releasing detailed guidance on the collection and monitoring of data and specific reporting requirements in advance of the July 1, 2019 , start date for managed care implementation. 14

15 Appendix A: Quality Performance Measures PRIORITY WITHHOLD MEASURE DESCRIPTION MEASURE NAME MEASURE STEWARD # MEASURE MEASURE Adherence to Antipsychotic The percentage of beneficiaries 19 –64 years of age during the Medications for Individuals with measurement year with schizophrenia who were dispensed and 1 - HEDIS NCQA Schizophrenia remained on an antipsychotic medication for at least 80% of their treatment period. NQF #: 1879 The percentage of beneficiaries 18 –74 years of age who had an Adult Body Mass Index (BMI) outpatient visit and whose body mass index (BMI) was documented Assessment 2 X NCQA - HEDIS during the measurement year or the year prior to the measurement NQF #: 0023 year. –17 years of age who had an The percentage of beneficiaries 3 outpatient visit with a PCP or OB/GYN and who had evidence of the following during the measurement year. and Counseling Weight Assessment • BMI percentile documentation* for Nutrition and Physical Activity • Counseling for nutrition for Children/Adolescents (the total 3 - HEDIS X NCQA • Counseling for physical activity of all ages for each of the 3 rates) NQF #: 0024 *Because BMI norms for youth vary with age and gender, this measure ather than an absolute evaluates whether BMI percentile is assessed r BMI value. The percentage of beneficiaries 2 –20 years of age who had at least one Annual Dental Visits (Total Rate) dental visit during the measurement year. This measure applies only if 4 - HEDIS NCQA dental care is a covered benefit in the organization’s Medicaid NQF #: 1388 contract. Dental Sealants for 6 -9 Year Old ADA on behalf of the Percentage of beneficiaries ages 6 to 9 at elevated risk of dental caries Children at Elevated Carries Risk Dental Quality (i.e., “moderate” or “high” risk) who received a sealant on a permanent 5 Alliance first molar tooth within the measurement year. NQF #: 2508 15

16 WITHHOLD PRIORITY MEASURE DESCRIPTION MEASURE STEWARD MEASURE NAME # MEASURE MEASURE Percentage of individuals ages 1 to 20 who are enrolled in Medicaid or Percentage of Eligibles Who CHIP Medicaid Expansion programs for at least 90 continuous days, are CMS (collected via Received Preventive Dental Services eligible for Early and Periodic Screening, Diagnostic, and Treatment 6 X CMS -416) (EPSDT) services, and who received at least one preventive dental NQF #: 1334 ng the reporting period. service duri The percentage of beneficiaries 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression and who remained on an antidepressant medication treatment. Two rates are reported. Antidepressant Medication 1. The percentage of beneficiaries Effective Acute Phase Treatment. Management (Both Rates) 7 - HEDIS NCQA who remained on an antidepressant medication for at least 84 days (12 NQF #: 0105 weeks). The percentage of Effective Continuation Phase Treatment. 2. beneficiaries who remained on an antidepressant medication for at least 180 days (6 months). –18 years of age who were diagnosed with The percentage of children 3 Appropriate Testing for Children pharyngitis, dispensed an antibiotic and received a group A with Pharyngitis 8 NCQA - HEDIS streptococcus (strep) test for the episode. A higher rate represents NQF #: 0002 better performance (i.e., appropriate testing). Appropriate Treatment for Children The percentage of children 3 months –18 years of age who were given a with Upper Respiratory Infection diagnosis of upper respiratory infection (URI) and were not dispensed 9 NCQA - HEDIS an antibiotic prescription. NQF #: 0069 The percentage of beneficiaries 5 –64 years of age during the measurement year who were identified as having persistent asthma anagement for People Medication M and were dispensed appropriate medications that they remained on with Asthma (Medication during the treatment period. Two rates are reported: 10 - HEDIS NCQA Compliance 75% Rate only) 1. The percentage of beneficiaries who remained on an asthma controller medication for at least 50% of their treatment period. NQF #: 1799 ma 2. The percentage of beneficiaries who remained on an asth controller medication for at least 75% of their treatment period. 16

17 PRIORITY WITHHOLD MEASURE DESCRIPTION MEASURE STEWARD # MEASURE NAME MEASURE MEASURE –64 years of age who were identified The percentage of beneficiaries 5 Asthma Medication Ratio (Total as having persistent asthma and had a ratio of controller medications Rate) 11 X X NCQA - HEDIS to total asthma medications of 0.50 or greater during the NQF #: 1800 measurement year. Avoidance of Antibiotic Treatment The percentage of adults 18 –64 years of age with a diagnosis of acute in Adults with Acute Bronchitis 12 NCQA - HEDIS bronchitis who were not dispensed an antibiotic prescription. NQF #: 0058 Breast Cancer Screening The percentage of women 50 –74 years of age who had a mammogram 13 - HEDIS NCQA to screen for breast cancer. NQF #: 2372 The percentage of women 21 –64 years of age who were screened for cervical cancer using either of the following criteria: Cervical Cancer Screening • Women 21 –64 years of age who had cervical cytology performed 14 X X - HEDIS NCQA every 3 years NQF #: 0032 o had cervical cytology/human –64 years of age wh • Women 30 papillomavirus (HPV) co -testing performed every 5 years The percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV); one measles, Childhood Immunization Status mumps and rubella (MMR); three haemophilus influenza type B (HiB); (Combination 10) 15 X - HEDIS NCQA three hepatitis B (HepB), one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (HepA); two or three rotavirus (RV); NQF #: 0038 two influenza (flu) vaccines by their second birthday. The measure and calculates a rate for each vaccine and nine separate combination rates. Chlamydia Screening in Women The percentage of women 16 –24 years of age who were identified as (Total Rate) 16 - HEDIS sexually active and who had at least one test for chlamydia during the NCQA measurement year. NQF #: 0033 17

18 PRIORITY WITHHOLD MEASURE NAME MEASURE DESCRIPTION MEASURE STEWARD # MEASURE MEASURE –75 years of age with diabetes (type The percentage of beneficiaries 18 1 and type 2) who had each of the following: • Hemoglobin A1c (HbA1c) testing. • HbA1c poor control (>9.0%). • HbA1c control (<8.0%). Comprehensive Diabetes Care (BP • HbA1c control (<7.0%) for a selected population* Control [<140/90], HbA1c Control 17 • Eye exam (retinal) performed. - HEDIS NCQA [<8.0%], Eye Exam) • Medical attention for nephropathy. NQF #: 0061; 0575; 0055 • BP control (<140/90 mm Hg). * Additional exclusion criteria are required for this indicator that will her indicators. This result in a different eligible population from all ot indicator is only reported for the commercial and Medicaid product lines. -75 years of age with diabetes (type 1 The percentage of patients 18 Comprehensive Diabetes Care: type 2) whose most recent HbA1c level during the measurement and 10 HbA1c poor control (>9.0%). 18 - HEDIS X X NCQA year was greater than 9.0% (poor control) or was missing a result, or if NQF #: 0059 an HbA1c test was not done during the measurement year. –75 years of age during the The percentage of beneficiaries 40 measurement year with diabetes who do not have clinical atherosclerotic cardiovascular disease (ASCVD) who met the following Statin Therapy for Patients with criteria. Two rates are reported: th Rates) Diabetes (Bo 19 - HEDIS NCQA tatin Therapy . Beneficiaries who were dispensed at least 1. Received S NQF #: 0547 one statin medication of any intensity during the measurement year. 2. Statin Adherence 80% . Beneficiaries who remained on a statin d. medication of any intensity for at least 80% of the treatment perio 10 ure and the Comprehensive Diabetes Care measure are included because the Department believes HbA1c: poor control (>9.0%) is m Both this meas ore feasible for inclusion in emoved. the Quality Withhold program in the first year. In future years, HbA1c: poor control (>9.0%) may be r 18

19 PRIORITY WITHHOLD MEASURE DESCRIPTION MEASURE STEWARD MEASURE NAME # MEASURE MEASURE The focus is on the percentage of beneficiaries 18 -75 years of age with a diagnosis of Diabetes (Type 1 and Type 2) who had each of the following during the measurement year, as identified by Comprehensive Diabetes Care (CDC) claim/encounter or automated laboratory data. Hemoglobin A1c 20 - HEDIS NCQA NQF #: 0731 (HbA1c) testing in the current measurement year, HbA1c poor control (>9.0%), HbA1c control, Eye exam (retinal) performed, Medical attention for Nephropathy, B/P control (<140/90 mm Hg.) –85 years of age who had a The percentage of beneficiaries 18 diagnosis of hypertension (HTN) and whose BP was adequately controlled during the measurement year based on the following criteria: • Beneficiaries 18– 59 years of age whose BP was <140/90 mm Hg Controlling High Blood Pressure 22 X - HEDIS • Beneficiaries 60 NCQA –85 years of age with a diagnosis of diabetes whose NQF #:0018 BP was <140/90 mm Hg • Beneficiaries 60 –85 years of age without a diagnosis of diabetes whose BP was <150/90 mm Hg he Hybrid Method for this measure. A single rate is reported Note: Use t and is the sum of all three groups. Diabetes Screening for People with Schizophrenia or Bipolar Disorder The percentage of –64 years of age with schizophrenia beneficiaries 18 Who Are Using Antipsychotic - HEDIS NCQA or bipolar disorder, who were dispensed an antipsychotic medication 23 Medications and had a diabetes screening test during the measurement year. NQF #: 1932 19

20 PRIORITY WITHHOLD MEASURE DESCRIPTION MEASURE STEWARD MEASURE NAME # MEASURE MEASURE The percentage of males 21 –75 years of age and females 40 –75 years of age during the measurement year, who were identified as having clinical atherosclerotic cardiovascular disease (ASCVD) and met the ia. The following rates are reported: following criter Statin Therapy for Patients with 1. Received Statin Therapy . Beneficiaries who were dispensed at least se (Both Rates) Cardiovascular Disea 24 - HEDIS NCQA one high -intensity or moderate -intensity statin medication during the NQF #: 0543 —adherence measurement year. h- . Beneficiaries who remained on a hig 2. Statin Adherence 80% intensity or moderate -intensity statin medication for at least 80% of the treatment period. This measure assesses the percentage of patients 18 years of age and who received a least 180 treatment days of ambulatory older medication therapy for a select therapeutic agent during the measurement year and at least one therapeutic monitoring event for the therapeutic agent in the measurement year. Report the following three rates and a total rate: 1. Annual Monitoring for patients on angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB): At least one Annual Monitoring for Patients on serum potassium and a serum creatinine therapeutic monitoring test in Persistent Medications 25 -HEDIS NCQA the measurement year. NQF #: 2371 2. Annual monitoring for patients on digoxin: At least one serum potassium, one serum creatinine and a serum digoxin therapeutic monitoring test in the measurement year. 3. Annual monitoring for patients on diuretics: At least one serum potassium and a seru m creatinine therapeutic monitoring test in the measurement year. Total rate. (the sum of the three numerators divided by the sum of the three denominators) - Flu Vaccinations for Adults Ages 18 AHRQ (CAHPS Health The percentage of beneficiaries 18 –64 years of age who received a flu 64 vaccination between July 1 of the measurement year and the date 26 Plan Survey 5.0H, when the CAHPS 5.0H Adult Survey was completed. Adult Version) NQF #: 0039 20

21 PRIORITY WITHHOLD MEASURE NAME MEASURE DESCRIPTION MEASURE STEWARD # MEASURE MEASURE The percentage of discharges for beneficiaries 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had a follow -up visit with a mental health -Up After Hospitalization fo r Follow orted: practitioner. Two rates are rep Mental Illness 27 X X - HEDIS NCQA 1. The percentage of discharges for which the beneficiary received NQF #: 0576 -up within 30 days after discharge. follow 2. The percentage of discharges for which the beneficiary received -up within 7 days after discharge. follow The percentage of children newly prescribed attention- deficit/hyperactivity disorder (ADHD) medication who had at least three follow- month period, one of which was up care visits within a 10- within 30 days of when the first ADHD medication was dispensed. Two rates are reported. Initiation Phase 1. –12 years of age as . The percentage of beneficiaries 6 of the IPSD with an ambulatory prescription dispensed for ADHD -Up Follow for Children Prescribed medication, who had one follow -up visit with practitioner with ADHD Medication (Both Rates) 28 NCQA - HEDIS -day Initiation Phase. prescribing authority during the 30 NQF #: 0108 . The percentage of Continuation and Maintenance (C&M) Phase 2. 12 years of age as of beneficiaries 6– HD the IPSD with an ambulatory prescription dispensed for AD medication, who remained on the medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two -up visits with a practitioner within 270 days (9 months) after the follow Initiation Phase ended. 21

22 PRIORITY WITHHOLD MEASURE DESCRIPTION MEASURE STEWARD # MEASURE NAME MEASURE MEASURE The percentage of Medicaid deliveries on or between November 6 of the year prior to the measurement year and November 5 of the measurement year that had the following numbe r of expected prenatal visits: • <21 percent of expected visits –40 percent of expected visits • 21 percent Frequency of Prenatal Care (≥81 • 41 percent –60 percent of expected visits percent of expected visits only) • 61 percent –80 percent of expected visits 29 - HEDIS NCQA • ≥81 percent of expected visits NQF #: 1391 Note: this measure uses the same denominator as the Prenatal and Postpartum Care measure. Note: this measure has the same structure as measures in the Effectiveness of Care domain. The organization must follow the Guidelines for Effectiveness of Care Measures when calculating this meas ure. The percentage of deliveries of live births on or between November 6 of the year prior to the measurement year and November 5 of the measurement year. For these women, the measure assesses the following facets of prenatal and postpartum care. Prenatal and Postpartum Care (Both • Timeliness of Prenatal Care . The percentage of deliveries that Rates) 30 - HEDIS X X NCQA received a prenatal care visit as a beneficiary of the organization in the NQF #: 1517 first trimester, on the enrollment start date or within 42 days of enrollment in the organization. Postpartum Care . The percentage of deliveries that had a postpartum • visit on or between 21 and 56 days after delivery. 22

23 PRIORITY WITHHOLD MEASURE NAME MEASURE DESCRIPTION MEASURE STEWARD # MEASURE MEASURE Among women ages 15 through 44 who had a live birth, the percentage that is provided: 1) A most effective (i.e., sterilization, implants, intrauterine devices or systems (IUD/IUS)) or moderately (i.e., injectables, oral pills, patch, contraception within 3 and 60 ring, or diaphragm) effective method of days of delivery. 2) A long- acting reversible method of contraception (LARC) within 3 and 60 days of delivery. Two time periods are proposed (i.e., within 3 and within 60 days of Contraceptive Care: Postpartum US Office of 31 delivery) because each reflects important cl inical recommendations X Population Affairs NQF #: 2904 from the U.S. Centers for Disease Control and Prevention (CDC) and the American College of Obstetricians and Gynecologists (ACOG). The 60 - day period reflects ACOG recommendations that women should -day receive contraceptive care at the 6 -week postpartum visit. The 3 period reflects CDC and ACOG recommendations that the immediate postpartum period (i.e., at delivery, while the woman is in the hospital) is a safe time to provide contraception, which may offer greater lient and avoid missed opportunities to provide convenience to the c contraceptive care. The percentage of women aged 15 -44 years at risk of unintended pregnancy that is provided a most effective (i.e., sterilization, implants, intrauterine devices or systems (IUD/IUS)) or moderately effective (i.e., Contraceptive Care: Most & approved injectables, oral pills, patch, ring, or diaphragm) FDA- US Office of Moderately Effective Method 32 methods of contraception. The proposed measure is an interm ediate X Population Affairs outcome measure because it represents a decision that is made at the NQF #: 2903 end of a clinical encounter about the type of contraceptive method a woman will use, and because of the strong association between type of contraceptive method used and risk of uni ntended pregnancy. The percentage of adolescents 13 years of age who had one dose of Immunizations for Adolescents meningococcal conjugate vaccine, one tetanus, diphtheria toxoids and (Combination 2) acellular pertussis (Tdap) vaccine, and have completed the human - HEDIS NCQA X 33 papillomavirus (HPV) vaccine series by their 13th birthd ay. The NQF #: 1407 measure calculates a rate for each vaccine and two combination rates. 23

24 PRIORITY WITHHOLD MEASURE STEWARD # MEASURE NAME MEASURE DESCRIPTION MEASURE MEASURE Percentage of adolescents ages 12 to 21 who had at least one -Care Visit Adolescent Well comprehensive well -care visit with a primary care practitione r (PCP) or 34 NCQA - HEDIS an obstetric/gynecologic (OB/GYN) practitioner during the NQF #: measurement year. with a new The percentage of adolescent and adult beneficiaries episode of alcohol or other drug (AOD) abuse or dependence who received the following. Initiation and Engagement of Initiation of AOD Treatment . The percentage of beneficiaries who • Alcohol and Other Drug initiate treatment through an inpatient AOD admission, outpatient Dependence Treatment (Both 35 NCQA X - HEDIS visit, intensive outpati ent encounter or partial hospitalization, X Rates) telehealth or medication assisted treatment (MAT) within 14 days of the diagnosis. NQF #: 0004 Engagement of AOD Treatment . The percentage of beneficiaries who • initiated treatment and who had two or more additional AOD servi ces or MAT within 34 days of the initiation visit. The following components of this measure assess different facets of providing medical assistance with smoking and tobacco use cessation: • Advising Smokers and Tobacco Users to Quit. A rolling average represents the percentage of beneficiaries 18 years of age and older who were current smokers or tobacco users and who received advice r. to quit during the measurement yea Medical Assistance with Smoking AHRQ (CAHPS Health • Discussing Cessation Medications. A rolling average represents the and Tobacco Use Cessation 36 X X Plan Survey 5.0H, percentage of beneficiaries 18 years of age and older who were current Adult Version) NQF #: 0027 smokers or tobacco users and who discussed or were recommended cessation medications during the measurement year. • Discussing Cessation Strategies. A rolling average represents the percentage of beneficiaries 18 years of age and older who were current smokers or tobacco users and who discussed or were provided ear. cessation methods or strategies during the measurement y 24

25 WITHHOLD PRIORITY MEASURE DESCRIPTION MEASURE STEWARD MEASURE NAME # MEASURE MEASURE The percentage of COPD exacerbations for beneficiaries 40 years of age and older who had an acute inpatient discharge or ED visit on or –November 30 of the measurement year and who between January 1 Pharmacotherapy Management of were dispensed appropriate medications. Two rates are reported: COPD Exacerbation (Both Rates) 37 - HEDIS NCQA 1. Dispensed a systemic corticosteroid (or there was evidence of an NQF #: 2856 vent. active prescription) within 14 days of the e 2. Dispensed a bronchodilator (or there was evidence of an active prescription) within 30 days of the event. The percentage of children 15 months old who had the recommended Visits in the First 15 Months of Life 38 number of well -child visits with a PCP during their first 15 months of - HEDIS NCQA NQF #: 1392 life. Well -Child Visits in the Third, - -6 years of age who had one or more well The percentage of children 3 Fourth, Fifth, and Sixth Years of Life 39 X NCQA - HEDIS X child visits wi th a PCP during the measurement year. NQF #: 1516 Percentage of children and adolescents ages 12 months to 19 years who had a visit with a primary care practitioner (PCP). Four separate percentages are reported: Children and Adolescents' Access to •Children ages 12 to 24 months and 25 months to 6 years who had a 40 - HEDIS NCQA Primary Care Practitioners visit with a PCP during the measurement year •Children ages 7 to 11 years and adolescents 12 to 19 years who had a visit with a PCP during the measurement year or the year prior to the measurement year Live Births Weighing Less than 2,500 Grams CDC X X 41 The percentage of births with birthweight <2,500 grams NQF #: 1382 Use of Opioids at High Dosage in The proportion (XX out of 1,000) of individuals without cancer receiving Persons Without Cancer PQA 42 prescriptions for opioids with a daily dosage greater than 120mg morphine equivalent dose (MED) for 90 consecutive days or longer. NQF #: 2940 25

26 PRIORITY WITHHOLD MEASURE STEWARD # MEASURE DESCRIPTION MEASURE NAME MEASURE MEASURE This measure examines the percentage of individuals 18 years and older with concurrent use of prescription opioids and benzodiazepines. The denominator includes individuals 18 years and older by the first day of the measurement year with 2 or more prescription claims for opioids filled on 2 or more separate days, for which the sum of the Concurrent use of Prescription 43 days’ PQA supply is 15 or more days during the measurement period. X Benzodiazepines Opioids and Patients in hospice care and those with a cancer diagnosis are excluded. The numerator includes individuals from the denominator with 2 or more prescription claims for benzodiazepines filled on 2 or more separate days, and concurrent use of opioids and benzodiazepines for 30 or more cumulative days. The survey asks beneficiaries how often they got care as soon as -urgent appointments as soon needed when sick or injured and got non AHRQ (CAHPS Health as needed and allows the following response options: never; Plan Survey 5.0H, sometimes; usually; or always. Getting Care Quickly Adult Version and 44 • Q4: Respondent got care for illness/injury as soon as needed (or, for X CAHPS Health Plan NQF #: 0006 the Child Version: Child got care for illness/injury as soon as needed) Survey 5.0H, Child urgent appointment as soon as needed (or, • Q6: Respondent got non- Version) -urgent appointment as soon as for the Child Version: Child got non needed) The survey asks beneficiaries how often it was easy for them to get appointments with specialists and get the care, tests, or treatment they needed through their health plan and allows the following AHRQ (CAHPS Health ver; sometimes; usually; or always. response options: ne Plan Survey 5.0H, Getting Needed Care • Q9: Easy for respondent to get necessary care, tests, or treatment Adult Version and 45 X (or, for the Child Version: Easy for child to get necessary care, tests, or CAHPS Health Plan NQF #: 0006 treatment) Survey 5.0H, Child eded • Q18: Respondent got appointment with specialists as soon as ne Version) (or, for the Child Version: Respondent got child an appointment with specialists as soon as needed) 26

27 PRIORITY WITHHOLD MEASURE DESCRIPTION MEASURE STEWARD MEASURE NAME # MEASURE MEASURE Parents' Experiences with Coordination of Their Child's Care AHRQ (CAHPS Health • CC7: Respondent got the help needed from doctors or other health Plan Survey 5.0H, Coordination of Care 46 providers in contacting child’s school or daycare Item Set for Children X NQF #: 0009 • CC18: Someone from child's health plan, doctor's office, or clinic with Chronic Conditions) helped coordinate child's care among different providers or services The survey asks beneficiaries how often customer service staff were AHRQ (CAHPS Health helpful and treated them with courtesy and respect and allows the Plan Survey 5.0H, following response options: never; sometimes; usually; or always. Customer Service Ad ult Version and 47 • Q22: Customer service gave necessary information/help (or, for the X CAHPS Health Plan NQF #:0006 Child Version: Q25: Customer service gave necessary information/help) Survey 5.0H, Child • Q23: Customer service was courteous and respectful (or, for the Child Version) Version: Q26: Customer service was courteous and respectful) AHRQ (CAHPS Health Plan Survey 5.0H, The survey asks beneficiaries for several ratings on a scale of 0 to 10, Rating of Health Plan with 0 being the worst and 10 being the best. Adult Version and 48 • Q26: Rating of health plan (or, for the Child Version: Q29: Rating of CAHPS Health Plan NQF #:0006 Survey 5.0H, Child health plan) Version) AHRQ (CAHPS Health Plan Survey 5.0H, The survey asks beneficiaries for several ratings on a scale of 0 to 10, Rating of All Health Care Adult Version and with 0 being the worst and 10 being the best. 49 X CAHPS Health Plan • Q8: Rating of all health care (or, for the Child Version: Q8: Rating of NQF #:0006 Survey 5.0H, Child all health care) Version) CAHPS Health AHRQ ( Plan Survey 5.0H, The survey asks beneficiaries for several ratings on a scale of 0 to 10, Rating of Personal Doctor Adult Version and with 0 being the worst and 10 being the best. 50 X CAHPS Health Plan • Q16: Rating of personal doctor (or, for the Child Version: Q19: Rating NQF #:0006 Survey 5.0H, Child of Personal Doctor) Version) 27

28 PRIORITY WITHHOLD MEASURE DESCRIPTION MEASURE STEWARD # MEASURE NAME MEASURE MEASURE AHRQ (CAHPS Health Plan Survey 5.0H, The survey asks beneficiaries for several ratings on a scale of 0 to 10, Rating of Specialist Seen Most Often Adult Version and with 0 being the worst and 10 being the best. 51 CAHPS Health Plan • Q16: Rating of specialist (or, for the Child Version: Q23: Rating of NQF #:0006 Survey 5.0H, Child specialist) Version) asking providers overall experience and satisfaction with PHP Survey Overall Provider Satisfaction with based on rating scale of PHP meeting the community providers’ needs 52 X 11 PHP and expectations within the measurement period. Number of Medicaid Beneficiaries 53 X of beneficiaries attributed to an AMH The number 12 Attributed to AMH, Tier 3 The percentage of beneficiaries with MH/DD/SU needs with at least Percent of Beneficiaries with measurement one visit with their attributed AMH PCP within the same MH/DD/SU Visit with PCP Visit in X 54 13 period Same Measurement Year -Emergency deliveries with a completed The percentage of Non 14 55 X Pregnancy risk screening form standardized pregnancy risk screening within the measurement period The percentage of beneficiaries with LTSS needs with a completed Percent of LTSS population with a X health risk assessment within 90 days of enrollment during the 56 health risk assessment completed 15 measurement period within 90 days of enrollment 11 Administrative and financial measures designed by the Department. Technical specifications currently under development. 12 Ibid. 13 Ibid. 14 Ibid. 15 Ibid. 28

29 PRIORITY WITHHOLD MEASURE DESCRIPTION MEASURE STEWARD MEASURE NAME # MEASURE MEASURE The number of beneficiaries with LTSS who report improved or Participants in the Demonstration remained stable for # of 5 classic activities of daily living (ADL) from who remained stable or improved 57 X initial health risk assessment to identified period ic assessment period in ADL function between previous 16 * interval and most recent assessment The percentage of beneficiaries screened for unmet social needs from Rate of Screening for Unmet Social 58 X 17 * the health risk screening by the PHP within measurement period Needs Use of Imaging Studies for Low Back The percentage of beneficiaries with a primary diagnosis of low back Pain - HEDIS NCQA 59 pain who did not have an imaging study (plain X -ray, MRI, CT scan) NQF #:0052 within 28 days of the diagnosis. 18 * Total Medicaid spend per beneficiary per month 60 Total Cost of Care This measure summarizes utilization of ambulatory care in the NCQA 61 following categories: outpatient visits, ED visits. Results reported as - HEDIS Ambulatory Care (AMB) visits per 1,000 beneficiary months Inpatient Utilization - General This measure summarizes utilization of acute inpatient care and Hospital/Acute Care (IPU) X - HEDIS NCQA 62 services in the following categories: total inpatient, maternity, surgery, medicine. NQF #: 1598 16 urrently under development. Administrative and financial measures designed by the Department. Technical specifications c 17 Ibid. 18 Ibid. 29

30 PRIORITY WITHHOLD MEASURE NAME MEASURE DESCRIPTION MEASURE STEWARD # MEASURE MEASURE For beneficiaries 18 years of age and older, the number of acute inpatient stays during the measurement year that were followed by an unplanned acute readmission for any diagnosis within 30 days and the predicted probability of an acute readmis sion. Data are reported in the Cause Readmissions Plan All- following categories: 63 NCQA - HEDIS NQF #: 1768 Count of Index Hospital Stays (IHS) (denominator) 1. 2. -Day Readmissions (numerator) Count of 30 3. Expected Readmissions Rate The portion of medical expenses that are in VBP arrangements as 19 64 VBP Penetration Rate * X -LAN Framework, Categories 2 -4 defined by the HCP Population Health Indicators as reported by the Division of Public Select Public Health measures -- TBD ed within the Health, for attributed Medicaid beneficiaries as indicat 65 20 BY the Department measurement period including Infant Mortality (Medicaid), Health Days, Tobacco Use Rates, Overweight/Obesity Rates. 19 Ibid. 20 Administrative and financial measures designed by the Department. Technical specifications currently under development. 30

31 Appendix B: Estimated Comprehensive Managed Care Enrollment by Proposed Phase in Schedule Cohort Based on the Department’s AL ENROLLMENT BENEFICIARIES BASED ON SFY 2016 HISTORIC POPULATION COHORT WITH PROPOSED TIMING FOR Estimated Average Estimated Average COMPREHENSIVE MANAGED CARE as Percent of Cohort Beneficiaries by Beneficiaries by ENROLLMENT Total Beneficiaries Cohort Group Year 1: Standard Plan - Aged, Blind, Disabled 140,000 1,525,000 73% Year 1: Standard Plan - All Other 1,385,000 Year 3: Tailored Plan - -Duals 85,000 Non 27,000 Duals Year 3: Tailored Plan - 135,000 6% Year 3: Foster Children 23,000 Year 5: Non -Dual LTSS 5,000 217,000 10% Year 5: Full Duals (Non -TP) 212,000 103,000 Excluded: Family Planning 23,000 Excluded: Medically Needy 10% 208,000 82,000 Excluded: Other 100% 2,085,000 2,085,000 Total Source Division of Health Benefits based on “Population Profiles,” Exhibit prepared Feb. 8, 2018, by the Department’s released Nov. 9, 2017 , and av ncdhhs.gov/medicaid -transformation . ailable on the Medicaid website at Notes • Estimates are based on SFY 2016 historical experience and do not include projected enrollment growth. • Timing for man aged care enrollment is proposed and subject to change. • Tailored plan population estimates are subject to change based on legislation and data availability. • “Non -dual LTSS” includes CAP/C, CAP/DA and individuals with a nursing facility stay of 90 days or m ore. • “Excluded: Other” is primarily comprised of partial dual eligible beneficiaries. • See source documentation for calculation methodology, assumptions and limitations. 31

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