June 22, 2016 update: After careful consideration, HHSC has decided not to recoup or award any capitation at-risk in the medical Pay-for-Quality program for calendar years 2014, 2015, and 2016. The medical Pay-for-Quality program was suspended in calendar year 2017 as staff used this time to develop a redesigned program. 

Medical Pay-for-Quality Program

The medical Pay-for-Quality (P4Q) Program creates incentives and disincentives for managed care organizations based on their performance on certain quality measures. Health plans that excel on meeting the at-risk measures and bonus measures may be eligible for additional funds while health plans that don’t meet their at-risk measures can lose up to 3 percent of their capitation rate. The redesigned medical P4Q program is effective January 1, 2018. Measures, methodology, and performance targets are outlined in the Uniform Managed Care Manual, Chapter 6.2.14.

STAR Program Measures

Source Measure Description
3M Potentially Preventable Emergency Room Visits (PPVs) Hospital emergency room or freestanding emergency medical care facility treatment provided for a condition that could be provided in a nonemergency setting
HEDIS Appropriate Treatment for Children with Upper Respiratory Infection (URI) Percentage of children 3 months - 18 years of age who were diagnosed with upper respiratory infection and were not dispensed an antibiotic prescription on or three days after the episode
HEDIS Prenatal and Postpartum Care (PPC)
  • Timeliness of Prenatal Care: the percentage of deliveries that received a prenatal care visit as a member of the organization in the first trimester 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
HEDIS Well Child Visits in the First 15 months of Life (W15) Percentage of members who turned 15 months old during the Measurement Year and who had six or more well-child visits with a PCP during their first 15 months of life

STAR Bonus Pool Measures

Source Measure Description
3M Potentially Preventable Admissions (PPAs) Hospital admission that may have been prevented with access to ambulatory care or health care coordination.
CMS Low Birth Weight Percentage of live births that weighed less than 2,500 grams (5.51 pounds)
CAHPS Children with Good Access to Urgent Care Percent of caregivers who, when surveyed, responded their child always got urgent care for illness, injury or condition as soon as needed
CAHPS Adults Rating their MCO a 9 or 10 Percent of adult members who rated their MCO a 9 or 10 (on a scale of 0-10) when surveyed

STAR+PLUS Program Measures

Source Measure Description
3M Potentially Preventable Emergency Room Visits (PPVs) Hospital emergency room or freestanding emergency medical care facility treatment provided for a condition that could be provided in a nonemergency setting
HEDIS Diabetes Control - HbA1c < 8% (CDC) The percentage of members 18-75 years of age with diabetes (type 1 and type 2) who had HbA1c control (<8.0%).
HEDIS High Blood Pressure Controlled (CBP) The percentage of members 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90).
HEDIS Diabetes Screening for People with Schizophrenia or Bipolar Disorder who are Using Antipsychotics (SSD) Percentage of members 18 to 64 years of age with schizophrenia or bipolar disorder who were dispensed an antipsychotic medication and had a diabetes screening test.
HEDIS Cervical Cancer Screening (CCS) Percentage of women 21 to 64 years of age who were screened for cervical cancer.

STAR+PLUS Bonus Pool Measures

Source Measure Description
3M Potentially Preventable Readmissions (PPRs) Return hospitalizations resulting from care or treatment deficiencies provided during a previous hospital stay or from post-hospital discharge follow-up.
3M Potentially Preventable Complications (PPCs) Hospital-based harmful events (e.g., accidental laceration during a procedure) or negative outcomes (e.g., hospital acquired pneumonia) that may result from the process of care and treatment rather than from a natural progression of underlying disease.
AHRQ Prevention Quality Indicator (PQI) Composite Number of admissions per 100,000 member months ages 18 and older for one of the following conditions: diabetes with short-term complications, diabetes with long-term complications, uncontrolled diabetes without complications, diabetes with lower-extremity amputation, chronic obstructive pulmonary disease, asthma, hypertension, heart failure, angina without a cardiac procedure, dehydration, bacterial pneumonia, or urinary tract infection
CAHPS Adults with Good Access to Urgent Care Percent of adults who, when surveyed, responded they always got urgent care for illness, injury or condition as soon as needed
CAHPS Adults Rating their  MCO a 9 or 10 Percent of adult members who rated their MCO a 9 or 10 (on a scale of 0-10) when surveyed

CHIP Measures

Source Measure Description
3M Potentially Preventable Emergency Room Visits (PPVs) Hospital emergency room or freestanding emergency medical care facility treatment provided for a condition that could be provided in a nonemergency setting
HEDIS Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents (WCC) The percentage of members 3–17 years of age who had an outpatient visit with a PCP or OB/GYN and who had evidence of the following:
  • Counseling for nutrition.
  • Counseling for physical activity.
HEDIS Appropriate Treatment for Children with Upper Respiratory Infection (URI) Percentage of children 3 months - 18 years of age who were diagnosed with upper respiratory infection and were not dispensed an antibiotic prescription on or three days after the episode
HEDIS Adolescent Well Care (AWC) The percentage of enrolled members 12–21 years of age who had at least one comprehensive well-care visit with a PCP or OB/GYN

CHIP Bonus Pool Measures

Source Measure Description
CAHPS Children with Good Access to Urgent Care Percent of caregivers who, when surveyed, responded their child always received urgent care for illness, injury or condition as soon as needed
CAHPS Caregivers Rating their Child's MCO a 9 or 10 Percent of caregivers who rated their child's MCO a 9 or 10 (on a scale of 0-10) when surveyed
HEDIS Childhood Immunization Status (CIS) Combination 10 The percentage of children 2 years of age who had all immunizations as recommended by the Center for Disease Control and Prevention

Dental Pay-for-Quality Program

The 2015 and 2016 dental P4Q incorporated a shared savings approach similar to the medical P4Q, which allowed each dental health plan to potentially earn back more than what it had at risk. The amount at risk was two percent of the capitation. The program retained all existing measures from the 2014 program with some minor changes to how they were calculated.

The redesigned dental P4Q program, effective January 1, 2018, is comprised of three quality measures. A total of 1.5 percent of each DMO’s capitation will be at risk for performance on three measures in Medicaid and CHIP.  If a plan's performance decreases, the recoupment would be calculated based on its performance for all three measures. If the plan performs well on two measures, but performs poorly on the third, the percent recouped would be portion of the 1.5 percent, not the entire amount.  If a plan’s performance is maintained or improves overall, HHS will not recoup (i.e. the plan will keep its entire at-risk capitation). If one dental plan is subject to recoupment, the money will be available as an incentive to the other dental plan. The second plan would only be able to earn this money if its performance improves enough to earn these additional dollars. Note: For the dental P4Q, the reporting year is the measurement year.

Measures, methodology, and performance targets are outlined in the Uniform Managed Care Manual, Chapter 6.2.15.

Medicaid and CHIP Dental Measures

Measure Description Medicaid Age CHIP Age
DQA Oral Evaluation, Dental Services

Percentage of enrolled children:

  • who received a comprehensive or periodic oral evaluation within the reporting year
0-20 years 0-18 years

DQA Topical Fluoride for Children at Elevated Caries Risk, Dental Health Services

Percentage of enrolled children:

  • at “elevated” risk for cavities (i.e. “moderate” or “high”) and
  • received at least 2 topical fluoride applications within the reporting year
1-20 years 1-18 years
DQA Sealants
6-9 year-old Children at Elevated Risk, Dental Services

Percentage of enrolled children:

  • at “elevated” risk for cavities (i.e. “moderate” or “high”) and
  • received a sealant on a permanent tooth within the reporting year
6-9 years 6-9 years

DQA Sealants
10-14 year-old Children at Elevated Risk, Dental Services

Percentage of enrolled children:

  • at “elevated” risk for cavities (i.e. “moderate” or “high”) and
  • received a sealant on a permanent second molar tooth within the reporting year
10-14 years 10-14 years

For more information, email MCD Managed Care Quality