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The California Department of Health Care Services (DHCS) launched the Quality Withhold and Incentive (QWI) Program in Calendar Year (CY) 2024 to improve the quality of care for Medi-Cal members. This program incentivizes Medi-Cal Managed Care Plans (MCPs) to improve performance on quality metrics that align with DHCS Comprehensive Quality Strategy (CQS) and Bold Goals.
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The QWI Program has two components:
- Quality Withhold: A portion of MCP payments is withheld and can be earned back based on performance on key quality measures.
- Quality Incentive: Any withhold dollars not earned back by MCPs are used to fund the incentive portion of the program. Additional payments are awarded to MCPs that reduce disparities and improve care for underserved populations.
Medi-Cal withhold and incentive arrangements under MCP contracts are federally regulated by sections 438.6 (b)(2) and (b)(3) of Title 42 of the Code of Federal Regulations, and follow all requirements of those sections.
This program will be evaluated annually and renewed based on its outcomes. The QWI program aligns with a value-based strategy. It incentivizes higher performance on key components of value, including clinical quality, member experience, and health equity.
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The quality withhold portion of the program incentivizes MCPs' performance on specific Managed Care Accountability Set (MCAS) and Consumer Assessment of Health Providers and Systems (CAHPS) quality measures. A percentage of the final certified capitation rates are withheld from MCPs.
MCPs performance is measured on the following measures:
- Controlling High Blood Pressure (CBP)
- Glycemic Status Assessment for Patients With Diabetes (>9%) (GSD)
- Prenatal and Postpartum Care: Postpartum Care (PPC-Pst)
- Prenatal and Postpartum Care: Timeliness of Prenatal Care (PPC-Pre)
- Child and Adolescent Well-Care Visists (WCV)
- Well-Child Visits in the First 30 Months of Life: 15 to 30 Months (W30-2)
- Well-Child Visits in the First 30 Months of Life: First 15 Months (W30-6)
- Childhood Immunization Status: Combination (CIS-10)
- Immunizations for Adolescents (IMA)
- CAHPS Getting Care Quickly: Adult
- CAHPS Getting Care Quckly: Child
- CAHPS Getting Needed Care: Adult
- CAHPS Getting Needed Care: Child
The amount withheld from the final certified capitation rates for MCPs subject to the QWI program is calculated from the lower bound base capitation rates (before add-ons) and excluding the maternity supplemental payment for all rate cells. MCPs can earn back up to the full amount of the withheld dollars based on performance on measures.
Any MCPs that are new to a county in CY 2024 where MCP-specific data does not currently exist within the External Quality Review Organization system were excluded from the program for CY 2024 only.
- Withhold Amount: A small percentage (0.5% in CY 2024, and 1.0% in CY 2025 and CY 2026) of MCP payments is withheld. In future years, DHCS may implement a larger percentage withhold (as higher percentages have been seen to be more effective in other contexts).
- Performance Measures: MCPs are evaluated on clnical quality, member experience, and health equity using standardized metrics.
- Scoring: MCPs can earn up to 100 points. Full withhold is returned if a threshold score is met (80 points in CY 2024, 65 points in CY 2025, and 85 points in CY 2026). Plans scoring fewer than 25 points will earn back 0% of their withhold. The points thresholds for future years have not yet been determined and may increase.
- The final score for each quality measure will be the greater of the achievement or improvement score using a specific points allocation methodology.
- Achievment: points are earned by reaching set National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) national benchmark thresholds.
Achievment Criteria (10 possible points)
| Points Earned
|
Greater than or equal to the 66.67th percentile
| 10.0
|
Greater than or equal to the 50th percentile, Less than the 66.67th percentile
| 7.5
|
Greater than or equal to the 33.33rd percentile, Less than the 50th percentile
| 5.0
|
Greater than or equal to the 25th percentile, Less than the 33.33rd percentile
| 2.5
|
Less than the 25th percentile
| 0.0
|
- Imporvement: points are earned according to the MCP's magnitude of gap closure from the prior measurement year metric rate toward NCQA HEDIS 90th percentile benchmarks.
Improvement Criteria (10 Possible Points)
(gap closure to the 90th percentile)
| Points Earned
|
Greater than or equal to the 25% gap closure
| 10.0
|
Greater than or equal to the 20% gap closure, less than the 25% gap closure
| 8.0
|
Greater than or equal to the 15% gap closure, less than the 20% gap closure
| 6.0
|
Greater than or equal to the 10% gap closure, less than the 15% gap closure
| 4.0
|
Greater than or equal to the 5% gap closure, less than the 10% gap closure
| 2.0
|
Kho/Deterioration
| 0.0
|
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The quality incentive is designed to advance health equity by incentivizing MCPs to reduce racial and ethnic disparities. Any withhold dollars not earned back by MCPs are used to fund the incentive portion of the program. All MCPs may earn incentive dollars regardless of their withhold performance.
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- Funding: Unearned withhold funds are redirected to support this incentive.
- Health Equity Focus: Incentives target improvements in care for racial and ethnic groups with historically lower performance. In some cases, the race and ethnicity subgroups identified may be faced with issues that are not driven by racism but rather other barriers to care. These other barriers might include geography, socioeconomics, and other social drivers of health that influence health outcomes.
- Scoring: MCPs earn points on their gap closure performance against a set percentile threshold (NCQA HEDIS 66.67th percentile) with no floor.
Improvement Criteria (10 possible points)
(gap closure to the 66.67th percentile)
| Points Earned
|
Greater than or equal to the 25% gap closure or rate greater than or equal to the 66.67th percentile
| 10.0
|
Greater than or equal to the 20% gap closure, less than the 25% gap closure
| 8.0
|
Greater than or equal to the 15% gap closure, less than the 20% gap closure
| 6.0
|
Greater than or equal to the 10% gap closure, less than the 15% gap closure
| 4.0
|
Greater than or equal to the 5% gap closure, less than the 10% gap closure
| 2.0
|
Kho/Deterioration
| 0.0
|
For additional information, please consult the methodology letters linked below.
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