SNP Training – Topic 2: SNP Subset of HEDIS Measures

March 3, 11, 16, 26, April 1, 2009

Overview

• • •

Describe the SNP assessment project NCQA is executing on behalf of CMS Review the SNP HEDIS reporting requirements

– Which measures do SNPs have to report?

– Who has to report?

Overview of individual measures

– Descriptions – – Eligible population Numerator criteria

SNP Training #2 – SNP Subset of HEDIS Measures 2

Introduction to SNP Assessment

Brett Kay Director, SNP Assessment

Objectives of SNP Assessment Program

•

Develop a robust and comprehensive assessment strategy

•

Evaluate the quality of care SNPs provide

•

Evaluate how SNPs address the special needs of their beneficiaries

•

Provide data to CMS to allow plan-plan and year-year comparisons SNP Training #2 – SNP Subset of HEDIS Measures 4

SNP Assessment: How did we get here?

•

Existing contract with CMS to develop measures focusing on vulnerable elderly

•

Revised contract to address SNP assessment

– – –

1 st year—rapid turnaround, adapted existing NCQA measures and processes from voluntary Accreditation programs 2 nd year—focus on SNP-specific measures 3 rd year—Refine measures; identify new SNP specific measures, where appropriate SNP Training #2 – SNP Subset of HEDIS Measures 5

Phase 1 - FY 2008 SNPs Effective as of January 2007 HEDIS 2008 (13 measures) Structure & Process Measures

• SNP 1: Complex Case Management • SNP 2: Improving Member Satisfaction • SNP 3: Clinical Quality Improvements

Three-Year Strategy

Phase 2 - FY 2009 Phase 3 - FY 2010 SNPs Effective as of January 2008 HEDIS 2009 (15 measures) SNPs Effective as of January 2008 HEDIS 2010

• Measure development: • Addition of two 1 Discharge st measures: Care for Older Adults; Medication year Reconciliation Post – – Potentially Avoidable Hospitalizations Inpatient Readmissions – MDS measures (I-SNPs) – Disease-specific measures (C SNPs)

Structure & Process Measures

• SNP1 – 3 • • • SNP 4: Care Transitions SNP 5: Institutional SNP Relationship with Facility SNP6: Coordination of Medicare & Medicaid

Structure & Process Measures

• Refinement of existing S&P measures, includes the potential development of new elements • Potential development of new measures

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Project Time Line – Phase II

• • • • •

March - Release final S&P measures March 30 - Release ISS Data Collection Tool

–

S & P Measures April - Release IDSS Data Collection Tool

–

HEDIS Measures June 30 - HEDIS submissions and S&P measures submissions due to NCQA October 30 - NCQA delivers SNP Assessment Report to CMS SNP Training #2 – SNP Subset of HEDIS Measures 7

Training & Education

•

Five training topic areas, focus is on content and data submission

– – – – –

Introduction to NCQA & SNP Assessment Program SNP Subset of HEDIS Measures Interactive Data Submission System (IDSS) Structure & Process Measures

•

Phase I (SNP 1-3)

•

Phase II (SNP 4-6) Interactive Survey System (ISS) SNP Training #2 – SNP Subset of HEDIS Measures 8

SNP HEDIS Reporting Requirements

Courtney Breece Senior Analyst, Licensure & Certification

•

SNP HEDIS Reporting Requirements

Required Measures

(COL) Colorectal Cancer Screening* (GSO) Glaucoma Screening in Older Adults (COA) Care for Older Adults * (SPR) Use of Spirometry Testing in the Assessment & Diagnosis of COPD (PCE) Pharmacotherapy of COPD Exacerbation (CBP) Controlling High Blood Pressure* (PBH) Persistence of Beta Blocker Treatment After a Heart Attack (OMW) Osteoporosis Management in Older Women (AMM) Antidepressant Medication Management (FUH) Follow-Up After Hospitalization for Mental Illness (MPM) Annual Monitoring for Patients on Persistent Medications (DDE) Potentially Harmful Drug-Disease Interactions (DAE) Use of High Risk Medication in the Elderly (MRP) Medication Reconciliation Post-Discharge * (BCR) Board Certification (HOS) Medicare Health Outcomes Survey * SNP benefit packages under PPO Contracts do not have to report these measures because these measures rely on medical record review.

SNP Training #2 – SNP Subset of HEDIS Measures 10

New SNP-only Measures

• Question: Are the two new SNP-only measures (Care for Older Adults and Medication Reconciliation Post-Discharge) optional because they are 1st year measures?

• Response: These measures are not optional for reporting in HEDIS 2009. They are required.

SNP Training #2 – SNP Subset of HEDIS Measures 11

General Reporting Requirements

•

Who reports & what is the level of reporting?

– –

Every SNP benefit package (identified by the CMS Plan ID) Enrollment of 30 or more members as of CMS’s February 2008 Comprehensive Report

If a SNP benefit package is listed in the February 2008 SNP Comprehensive Report, but had 29 or fewer members, a HEDIS report is not required; however, CMS requires that the organization report the Structure & Process measures regardless of enrollment size.

SNP Training #2 – SNP Subset of HEDIS Measures 12

• •

Reporting Structure

Question: What are the HEDIS reporting requirements for MA plans and SNP benefit packages?

Response: See the chart below for details about the reporting requirements.

MA HEDIS Reporting Requirements SNP HEDIS Reporting Requirements MA Contract Summary Level Reporting Patient Level Reporting Summary Level Reporting Patient Level Reporting

Yes Yes No Not applicable ≥ 1,000 members including no SNP benefit packages < 1,000 members including no SNP benefit packages ≥ 1,000 members including SNP benefit packages No Yes No Yes No Yes* Not applicable Not applicable <1,000 members including SNP benefit packages SNP only benefit packages with ≥ 1,000 SNP members No Yes No Yes Yes* Yes* Not applicable Not applicable SNP-only benefit packages with < 1,000 SNP members ≥ 1,000 Medicaid members with <1,000 in a SNP Dual Eligible benefit package No No No No Yes* Yes* Not applicable Not applicable

* Organizations with SNP benefit packages that have an enrollment of <29 as of the Feb 2008 Comprehensive do not report HEDIS measures.

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Audit Requirement

• Question: Does every submission require an audit?

• Response: Yes, every SNP benefit package level submission must undergo a HEDIS Compliance Audit™.

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Medicare Specifications

• Question: Does the SNP submission use Medicare specifications for the measures?

• Response: Yes, for the required HEDIS measures use the specifications in Volume 2, HEDIS Specifications.

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Patient-Level Detail File

• Question: Does CMS require a Patient Level Detail File for each SNP benefit package submission?

• Response: No, the plan does not need to create a separate patient-level file for each SNP submission. However, the patient-level data submitted for the larger Contract-level must include all MA members, including members enrolled in its SNP benefit packages. (See the Reporting Structure Chart above.)

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Medicare Advantage

• Question: If an MA plan has a SNP benefit package, does it report the members in the Medicare Contract submission AND the SNP submission? • Response: Yes, SNP members will be reported in two submissions – the full Medicare submission at the Contract-level and the SNP benefit package in which they receive benefits.

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Dual-Eligible SNP

• Question: For Dual-Eligible SNP benefit packages, is a member reported to NCQA in the Medicare, Medicaid, and SNP submissions? • Response: Yes, in all three. All HEDIS guidelines about dual eligible members still apply, and these members are also included in the SNP specific submission.

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SNP-only Plan

• Question: If a Medicare Advantage organization, which offers only SNP benefit packages, meets the threshold for reporting HEDIS at the Contract level do they report all HEDIS measures required for Contract-level reporting or only the SNP subset measures?

• Response: If a Medicare Advantage organization with only SNP benefit packages had 1,000 members listed on July 2008 Monthly Enrollment by Contract Report, the plan must report the SNP subset of measures and the other Medicare measures as well. See the memo from CMS dated December 9, 2008 for the complete list of HEDIS measures required for Contract-level reporting.

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Medicare Advantage & Hybrid Method

• Question: If an MA plan uses the hybrid method to report any measure, must they draw a separate sample for the SNP benefit packages?

• Response: Yes, every submission is treated separately; for example, if a plan reports Colorectal Cancer Screening for the full MA plan population and a SNP benefit package, two distinct samples must be drawn.

SNP Training #2 – SNP Subset of HEDIS Measures 20

Hybrid Methodology – Substituting Records

• • Question: If an MA plan draws a sample for the Controlling High Blood Pressure measure for the MA population and a separate sample for the same measure for the SNP benefit package, what does the plan do with the overlapping members?

Response: If there are SNP members in the sample for the full MA plan (main sample), the plan may use them for the SNP sample. For example, the main sample of 411 has 5 SNP members. The SNP sample has 250. Randomly select 5 members from the SNP sample and replace them with 5 SNP members in the main sample. The 5 SNP members are evaluated in both samples. If the plan chooses to use the option to substitute records, all SNP members in the main sample must be used for the SNP sample, the members pulled from the SNP sample must be chosen at random, and the auditor must approve the process.

SNP Training #2 – SNP Subset of HEDIS Measures 21

Continuous Enrollment

• Question: How is continuous enrollment calculated for the SNP benefit packages?

• Response: Calculate continuous enrollment for SNP members according to the standard HEDIS requirement for Medicare products. Members should be reported in the SNP they are enrolled in at the end of the continuous enrollment period. For measures with no continuous enrollment requirement, report members in the SNP they were in at the time of service.

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Small Denominators

• Question: How are small denominators handled?

• • Response: To understand the performance of the entire SNP program, it is important that SNPs report a measure even when there are fewer than 30 members in the measure’s denominator. Each SNP benefit package must collect data and report the required measures according to the specifications regardless of the denominator size. It is important to note, NCQA’s Interactive Data Submission System (IDSS) will not calculate a rate for measures where the denominator is fewer than 30, but NCQA will use the reported measure numerators and denominators for aggregated reporting purposes.

SNP Training #2 – SNP Subset of HEDIS Measures 23

Institutional SNPs & Contract Level Reporting

• Question: If a Medicare Advantage organization, which offers only Institutional SNP benefit packages, meets the threshold for reporting HEDIS at the Contract level (>1,000 members), are they required to report all MA measures?

• Response: Yes, reporting at the Contract Level is required. In some cases, Institutional SNPs may have no members that meet the denominator criteria for some measures because of the required exclusions; however, the plan’s auditor must determine for each measure that the plan calculated the denominator, the exclusions and the measure result. Additionally, the plan must report all counts for the denominators, numerators and exclusions even when they are zeros.

SNP Training #2 – SNP Subset of HEDIS Measures 24

Medicare Health Outcomes Survey

• • Question: Is a Medicare Advantage organization, which offers only SNP benefit packages, required to report HOS and what are the requirements?

Response: Yes, reporting HOS at the Contract Level is required for Medicare contracts with exclusively SNP packages in effect on or before January 1, 2008. See the chart below for details about the reporting requirements. To report HOS data, SNPs must contract with a certified HOS survey vendor and notify NCQA of their survey vendor choice no later than February 2, 2009.

Plan Type Survey Type Contract Date Enrollment Criteria 2009 Reporting

SNP Medicare HOS Contracts in effect on or before January 1, 2008 Minimum of 500 members* Required • *Generally, enrollment size is verified in the fall to determine eligibility and analyzed again prior to sampling to ensure the plan did not drop below the required membership.

SNP Training #2 – SNP Subset of HEDIS Measures 25

Overview of SNP Subset of HEDIS Measures

Aisha T. Pittman, MPH

HEDIS Measures for SNPs

•

Selected in collaboration with SNP Technical Panel

– Excluded measures with upper age limit below 75 – Excluded measures focusing on management of one chronic condition •

Collected by SNP benefit package, regardless of size

– Will be reported in aggregate

SNP Training #2 – SNP Subset of HEDIS Measures 27

HEDIS 2009 Measures

Effectiveness of Care Measures

Colorectal Cancer Screening* Glaucoma Screening in Older Adults Use of Spirometry Testing in the Assessment and Diagnosis of COPD Pharmacotherapy of COPD Exacerbation Controlling High Blood Pressure* Persistence of Beta Blocker Treatment After Heart Attack Osteoporosis Management in Older Women Antidepressant Medication Management Follow-Up After Hospitalization for Mental Illness Annual Monitoring for Patients on Persistent Medications Potentially Harmful Drug-Disease Interactions in the Elderly Use of High Risk Medications in the Elderly Care for Older Adults

*

Medication Reconciliation Post-Discharge*

Health Plan Descriptive Information Measures

Board Certification

* SNP benefit packages under PPO Contracts do not have to report these measures because these measures rely on medical record review.

** This first-year measure is optional for all MA reporting, including the SNP benefit packages.

SNP Training #2 – SNP Subset of HEDIS Measures 28

HEDIS General Guidelines

•

HEDIS 2009, Volume 2: Technical Specifications

•

General Guidelines for Data Collection and Reporting (p. 9) apply to SNP reporting SNP Training #2 – SNP Subset of HEDIS Measures 29

• • •

Components of HEDIS Measures

Measure Description

– Explains what the rate is capturing

Definitions

– Intake Period- time period to identify eligible episodes – Episode Date- date of event or service – Index Episode Start Date (IESD)- the earliest episode date during the intake period

Eligible Population

– The total population that meets the measure specifications -also referred to as the denominator – Exclusions can be applied to the denominator if applicable

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Components of HEDIS Measures

•

Rate

• – The rate is the numerator/eligible population • The numerator is comprised of those people who received the treatment or service indicated in the measure

Data Collection Methodology

– There are three possible methods: • Administrative • Medical Record or Hybrid • Survey

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Eligible Population

• • • • • • •

Product lines

– Commercial, Medicare, Medicaid

Ages Continuous enrollment

– The time period during which a member must be continuously enrolled in the plan

Allowable gap

– Gaps allowed during the continuous enrollment period

Anchor date

– Enrollment date criteria for the eligible population

Benefit

– The type of benefits the member must have to be included in the measure

Event/diagnosis SNP Training #2 – SNP Subset of HEDIS Measures 32

New Measures in HEDIS 2009

SNP Training #2 – SNP Subset of HEDIS Measures 33

Care for Older Adults (COA)

• • •

The percentage of adults 65 years and older who had each of the following during the measurement year.

– – – –

Advance care planning Medication review Functional status assessment Pain screening This measure is collected using the hybrid method or CPT Category II codes Eligible population: Members 65 years and older SNP Training #2 – SNP Subset of HEDIS Measures 34

COA- Advance Care Planning FAQs

• • •

Evidence of an advance care plan during the measurement year CPT II code: 1157F or 1158F Medical record review:

– –

Presence of an advanced care plan in the medical record

•

Advance directives, actionable medical orders, living wills, surrogate decision makers Documentation of and care planning discussion with a provider and the date on which it was discussed

• •

Notation in the medical record Oral statements SNP Training #2 – SNP Subset of HEDIS Measures 35

COA- Advance Care Planning

• •

Can a health plan find an advance care plan executed in 2005 in the medical record and consider the member numerator compliant, even if it is clear that the plan is no longer in force?

–

No. The advance care plan does not have to be executed during the measurement year but it must be active during the measurement year to be compliant. A member would not be compliant if the advance care plan was executed in 2005 and it is clearly no longer active during the measurement year. The intent was for plans to be able to use advance care plans that were executed several years ago that were still active.

Is evidence of advanced care planning done by a licensed social worker or nurse case manager acceptable for this measure?

–

Yes. The measure does not specify the type of visit or physician type for the Advance care planning numerator; thus, Advance care planning performed by a licensed social worker or nurse case manager would be compliant. SNP Training #2 – SNP Subset of HEDIS Measures 36

COA- Medication Review

• • •

At least one medication review conducted by a prescribing practitioner or clinical pharmacist during the measurement year AND the presence of a medication list in the medical record CPT II Code: 1160F (review) AND 1159F (list) Medical Record Review:

–

A medication list in the medical record AND

–

Evidence of a medication review and the date on which it was performed

•

Documentation that a practitioner has reviewed all medications that the member is taking SNP Training #2 – SNP Subset of HEDIS Measures 37

COA- Medication Review FAQs

• •

May a clinical pharmacist consultation be done by phone?

–

Yes, if the information is documented in the medical record. Clinical pharmacists were included so that plans that employ them may get credit. Medication reviews are often a part of plans’ MTM programs Is the date and initials of the provider on a medication list sufficient evidence that the medication list was reviewed?

–

Yes, the initials of the provider on the medication list along with the date of the review would be compliant SNP Training #2 – SNP Subset of HEDIS Measures 38

COA- Functional Status Assessment

•

At least one functional status assessment during the measurement year

•

CPT II code: 1170F

•

Medical record review:

•

Notation of functional independence,

•

Notation of loss of independence, ADLs

•

Notation of level of assistance needed to accomplish tasks

•

Results of assessment using standardized functional status assessment tool SNP Training #2 – SNP Subset of HEDIS Measures 39

COA- Functional Status Assessment FAQs

• • •

If a patient has lost the ability to walk unassisted, and that is noted in the patients chart, could this notation be used as a loss of independent performance?

–

Yes. If the documentation in the medical record states that the "member has lost the ability to walk" and has a date on which the assessment was performed, does meet numerator criteria for loss of independent performance. Would notation of a person’s use of cane or walker meet the criteria?

–

No. These notations are not specific enough to be considered an assessment of functional status Is there criteria around which or how many ADL's, IADL's, etc, need to be notated in the patient’s chart in order for that to be counted toward functional status assessment?

–

No. There is not specific number of ADLs or IADLs that should be assessed in order to meet the functional status assessment. However, a date on which the assessment was performed should be noted. SNP Training #2 – SNP Subset of HEDIS Measures 40

COA- Pain Screening

•

At least one pain screening or development of a pain management plan during the measurement year

•

CPT II code: 1125F, 1126F, 0521F

•

Medical record review:

– –

Notation of presence or absence of pain Results of a screening using a standardized pain screening tool SNP Training #2 – SNP Subset of HEDIS Measures 41

COA- Pain Screening FAQs

•

How detailed does a pain screen have to be? For example, would a notation in a chart indicating the patient was not experiencing chest pain be considered evidence of Absence of Pain and be counted?

–

Yes. Notation in a chart indicating the patient was not experiencing chest pain would be considered evidence of the absence of pain and would be compliant for the pain screening component of the measure.

– –

Currently, the medical record documentation for the pain screening indicator does not specify the type of pain (general or specific) but rather it only requires a notation of the presence or absence of pain. We will consider the wording of the medical record criteria of this indicator during the measure's first-year analysis as it may need to be revised to capture a thorough pain screening. SNP Training #2 – SNP Subset of HEDIS Measures 42

Medication Reconciliation Post Discharge (MRP)

•

The percentage of discharges from January 1 to December 1 of the measurement year for members 65 years of age and older for whom medications were reconciled on or within 30 days of discharge SNP Training #2 – SNP Subset of HEDIS Measures 43

MRP- Eligible Population

• • •

Members 65 years as of 12/31 of the measurement year An acute or nonacute inpatient discharge on or between 1/1 and 12/1 of the measurement year

–

Note: The eligible population for this measure is based on inpatient discharges, not on members. It is possible for the denominator to include multiple events for the same individual

Readmissions/Transfers:

–

If a member has a direct transfer, count the discharge from the facility to which the member was transferred

–

If a member is readmitted within the 30-day follow-up period, count only the readmission discharge SNP Training #2 – SNP Subset of HEDIS Measures 44

MRP- Numerator Criteria

• • •

Medication reconciliation on or within 30 days after discharge

–

Note: only documentation in the outpatient chart meets the intent of the measure; information obtained from the inpatient chart does not count

CPT II code: 1111F Medical record review:

– –

A list of medications that were prescribed or ordered upon discharge Notation that no medications were prescribed or ordered upon discharge SNP Training #2 – SNP Subset of HEDIS Measures 45

MRP FAQs

• •

May a clinical pharmacist consultation be done by phone?

–

Yes, if the information is documented in the medical record. Clinical pharmacists were included so that plans that employ them may get credit. Medication reconciliations are often a part of plans’ MTM programs Does a medication list in the discharge summary for the inpatient discharge meet the numerator criteria?

–

No. The intent of the measure is that the medication list be reviewed by an outpatient provider; therefore, a medication list reviewed in an inpatient setting does not meet the numerator criteria.

–

Documentation of medications in the outpatient setting (e.g., a discharge summary in the outpatient chart) meets the numerator criteria for this measure. SNP Training #2 – SNP Subset of HEDIS Measures 46

Changes to Measures in HEDIS 2009

SNP Training #2 – SNP Subset of HEDIS Measures 47

Colorectal Cancer Screening (COL)

• •

The percentage of members 50 – 80 years of age who had appropriate screening for colorectal cancer Eligible Population:

–

Members 51-80 years as of 12/31 of the measurement year

– – –

Continuously enrolled during the measurement year and the year prior No more than one 45 day gap in enrollment during each year of continuous enrollment Exclude members with diagnosis of colorectal cancer or total colectomy SNP Training #2 – SNP Subset of HEDIS Measures 48

Colorectal Cancer Screening (COL)

• • •

Numerator Criteria:

–

One or more appropriate screenings defined by any one of the following criteria:

•

Fecal occult blood test (FOBT) during the measurement year

• • •

Flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year Double contrast barium enema (DCBE) or air contrast barium enema during the measurement year or the four years prior to the measurement year Colonoscopy during the measurement year or the nine years prior to the measurement year This measure can be collected using the hybrid method New for HEDIS 2009: Documentation in medical record must include a note indicating date the screening was performed in the medical history section. Notations in other sections of the medical record do not distinguish between tests ordered and tests performed SNP Training #2 – SNP Subset of HEDIS Measures 49

•

Antidepressant Medication Management (AMM)

The following components of this measure assess different facets of the successful pharmacological management of major depression.

•

Effective Acute Phase Treatment:

remained on an antidepressant drug during the 84 days/12 weeks following diagnosis percent of members who •

Effective Continuation Phase Treatment:

who remained on an antidepressant drug for at least 180 days/6 months percent of members –

New for HEDIS 2009: Retired Rate

•

Optimal Practitioner Contacts for Medication Management:

Percent of members with at least three follow-up contacts within 12 weeks of diagnosis

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• •

Antidepressant Medication Management (AMM)

Eligible Population:

–

Members 18 years and older as of 4/30 of measurement year

– – – –

Continuously enrolled 120 days prior to IESD through 245 days after IESD Diagnosis of a new episode of major depressive disorder during the intake period No more than one 45-day gap in enrollment Steps to identify eligible population Numerator criteria:

–

Effective acute phase: members who fulfilled a sufficient number of separate prescription/refills of antidepressant medication to have continuous treatment for 84 days

–

Effective continuation phase: a 180-day treatment with antidepressant medication SNP Training #2 – SNP Subset of HEDIS Measures 51

Board Certification (BCR)

•

The percentage of the following physicians whose board certification is active as of December 31 of the measurement year.

•

Family medicine physicians

– • • • • • •

Internal medicine physicians Pediatricians OB/GYN physicians Geriatricians Other physician specialists New for HEDIS 2009: Table BCR-A indicates how to identify physicians Board certification refers to the various specialty certification programs of the American Board of Medical Specialties and the American Osteopathic Association. SNP Training #2 – SNP Subset of HEDIS Measures 52

Measures without Changes in HEDIS 2009

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Glaucoma Screening in Older Adults (GSO)

• •

The percentage of Medicare members 65 years and older who received a glaucoma eye exam Eligible Population:

– – – –

Members 65 years as of 12/31 of the measurement year Continuously enrolled during the measurement year and year prior No more than one 45 day gap in enrollment during each year of continuous enrollment Exclude members with prior diagnosis of glaucoma or glaucoma suspect SNP Training #2 – SNP Subset of HEDIS Measures 54

Glaucoma Screening in Older Adults (GSO)

•

Numerator criteria:

–

One or more eye exams for glaucoma by an eye care professional during the measurement year or the year prior SNP Training #2 – SNP Subset of HEDIS Measures 55

• •

Use of Spirometry Testing in the Assessment and Diagnosis of COPD (SPR)

The percentage of members 40 years of age and older with a new diagnosis or newly active chronic obstructive pulmonary disease (COPD) who received appropriate spirometry testing to confirm the diagnosis Eligible Population:

–

Members 42 years or older as of 12/31 of the measurement year

–

Continuously enrolled two years prior to IESD through 180 days after IESD

–

No more than one 45-day gap in enrollment in each 12-month period before IESD or 6-month period after IESD SNP Training #2 – SNP Subset of HEDIS Measures 56

Use of Spirometry Testing in the Assessment and Diagnosis of COPD (SPR)

•

Steps to Identify Eligible Population:

– – –

Identify all members with diagnosis of COPD during intake period Test for negative diagnosis history, exclude members with prior diagnosis of COPD Calculate continuous enrollment

•

Numerator criteria:

–

At least one claim/encounter with spirometry in the two years before to 180 days after the IESD SNP Training #2 – SNP Subset of HEDIS Measures 57

Pharmacotherapy of COPD Exacerbation (PCE)

•

The percentage of COPD exacerbations for members 40 years of age and older who had an acute inpatient discharge or ED encounter between January 1– December 1 of the measurement year and who were dispensed appropriate medications. Two rates are reported.

•

Dispensed a systemic corticosteroid within 14 days of the event

•

Dispensed a bronchodilator within 30 days of the event SNP Training #2 – SNP Subset of HEDIS Measures 58

• •

Pharmacotherapy of COPD Exacerbation (PCE)

Eligible Population:

–

Members 40 years or older as of 12/1 of the measurement year

– – –

Continuously enrolled Episode Date through 30 days after Episode date, no allowable gaps A COPD exacerbation indicated by acute inpatient discharge or ED encounter

•

Note: The eligible population for this measure is based on acute inpatient discharges and ED visits, not on members. It is possible for the denominator to include multiple events for the same individual

Steps indicated to identify eligible population Numerator Criteria:

–

Rate 1: Prescription for systematic corticosteroid on or 14 days after Episode Date

–

Rate 2: Prescription for bronchodilator on or 30 days after Episode Date SNP Training #2 – SNP Subset of HEDIS Measures 59

Controlling High Blood Pressure (CBP)

• • •

The percentage of members 18–85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled (<140/90) during the measurement year Note: The hybrid method must be used for this measure Eligible population:

–

Members 18-85 years as of 12/31 of the measurement year

– – – –

No more than one 45-day gap in enrollment during the measurement year At least one outpatient encounter with a diagnosis of hypertension in the first six months of the measurement year

Note: Hypertensive diagnosis must be confirmed in the medical record on or before June 30 of the measurement year

Exclude members with ESRD, who are pregnant or were admitted to a non-acute inpatient setting (institutionalized) SNP Training #2 – SNP Subset of HEDIS Measures 60

Controlling High Blood Pressure (CBP)

•

Numerator criteria:

–

Representative BP is adequately controlled

•

Adequate control- representative systolic BP< 140mmHg and representative diastolic BP <90mmHg

•

Representative BP- the most recent BP during the measurement year after the hypertension diagnosis

– –

If there are multiple BPs on the same date use the lowest systolic and lowest diastolic If no BP is recorded assume the member is not controlled SNP Training #2 – SNP Subset of HEDIS Measures 61

Persistence of Beta Blocker Treatment After Heart Attack (PBH)

•

The percentage of members 18 years of age and older during the measurement year who were hospitalized and discharged alive from July 1 of the year prior to the measurement year to June 30 of the measurement year with a diagnosis of acute myocardial infarction (AMI) and who received persistent beta-blocker treatment for six months after discharge SNP Training #2 – SNP Subset of HEDIS Measures 62

• •

Persistence of Beta Blocker Treatment After Heart Attack (PBH)

Eligible population:

–

Members 18 and older as of 12/31 of the measurement year

– – –

Continuously enrolled from discharge to 180 days after discharge Discharged alive from an acute inpatient setting with an AMI Exclude members with a contraindication to beta-blocker therapy or transferred to a nonacute care facility (institutionalized) Numerator Criteria:

–

A 180-day course of treatment of beta blockers

–

Persistence of treatment must be at least 75% or 135 days

–

If members were on beta blockers prior to admission, take into account those prescriptions in determining adherence SNP Training #2 – SNP Subset of HEDIS Measures 63

Osteoporosis Management in Women Who Had a Fracture (OMW)

•

The percentage of women 67 years of age and older who suffered a fracture and who had either a bone mineral density (BMD) test or prescription for a drug to treat or prevent osteoporosis in the six months after the fracture SNP Training #2 – SNP Subset of HEDIS Measures 64

Osteoporosis Management in Women Who Had a Fracture (OMW)

• •

Eligible population:

– –

Women 67 years and older as of 12/31 of the measurement year Continuously enrolled 12 months prior to through 6 months after IESD

– – –

No more than one 45-day gap in enrollment during continuous enrollment period Evidence of a fracture Steps to identify eligible population Numerator Criteria:

– – –

A BMD test on the IESD or in the 180 day period after the IESD A BMD test during the inpatient stay for the fracture A dispensed prescription to treat osteoporosis SNP Training #2 – SNP Subset of HEDIS Measures 65

Follow-Up After Hospitalization for Mental Illness (FUH)

•

The percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental health disorders and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner. Two rates are reported.

•

The percentage of members who received follow up within 30 days of discharge

•

The percentage of members who received follow up within 7 days of discharge SNP Training #2 – SNP Subset of HEDIS Measures 66

• •

Follow-Up After Hospitalization for Mental Illness (FUH)

Eligible Population:

–

Members 6 years and older as of discharge date

– – – – –

Continuously enrolled from discharge date through 30 days after discharge No gaps in enrollment allowed Discharged alive from an acute inpatient setting with a principal mental health diagnosis

Note: The denominator is based on discharges, not members

Exclude members transferred directly to a nonacute facility for a non-mental health principal diagnosis (institutionalized) Numerator Criteria:

–

30 day follow-up: an outpatient visit, intensive outpatient encounter or partial hospitalization with a mental health practitioner within 30 days of discharge

–

7 day follow-up: an outpatient visit, intensive outpatient encounter or partial hospitalization with a mental health practitioner within 7 days of discharge SNP Training #2 – SNP Subset of HEDIS Measures 67

Annual Monitoring for Patients on Persistent Medications (MPM)

•

The percentage of members 18 years of age and older who received at least a 180-day supply of ambulatory 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. For each product line, report each of the four rates separately and as a total rate.

•

Annual monitoring for members on angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB)

• • • •

Annual monitoring for members on digoxin Annual monitoring for members on diuretics Annual monitoring for members on anticonvulsants Total rate (the sum of the four numerators divided by the sum of the four denominators) SNP Training #2 – SNP Subset of HEDIS Measures 68

• •

Annual Monitoring for Patients on Persistent Medications (MPM)

Eligible Population:

–

Members 18 years and older as of 12/31 of the measurement year

– – – – – – –

Continuously enrolled during the measurement year No more than one 45-day gap in enrollment during each year of enrollment 180-day supply of an ambulatory medication of interest Note: Members with more than one persistent medication can appear in the measure multiple times (i.e., in each indicator for which they qualify)

Note: Members may switch therapies with any medication listed during the measurement year and have the days supply for each of those medications count towards the 180-day supply

Exclude members with an inpatient stay in the measurement year Numerator Criteria:

–

ACEI/ARBs, Digoxin, Diuretics: at least one serum potassium and either a serum creatinine or blood urea nitrogen therapeutic monitoring test Anticonvulsants: at least one drug serum concentration level monitoring test for the described drug SNP Training #2 – SNP Subset of HEDIS Measures 69

Potentially Harmful Drug-Disease Interactions in the Elderly (DDE)

•

The percentage of Medicare members 65 years of age and older who have evidence of an underlying disease, condition or health concern and who were dispensed an ambulatory prescription for a contraindicated medication, concurrent with or after the diagnosis

–

Report each of the three rates separately and as a total rate

•

A history of falls and a prescription for tricyclic antidepressants, antipsychotics or sleep agents

– • • •

Dementia and a prescription for tricyclic antidepressants or anticholinergic agents Chronic renal failure and prescription for nonaspirin NSAIDs or Cox 2 Selective NSAIDs Total rate (the sum of the three numerators divided by the sum of the three denominators) For all three rates, a lower rate represents better performance SNP Training #2 – SNP Subset of HEDIS Measures 70

Potentially Harmful Drug-Disease Interactions in the Elderly (DDE)

• •

Eligible population:

–

Members 67 years and older as of 12/31 of the measurement year

– – – –

Continuously enrolled the measurement year and the year prior No more than one 45-day gap in enrollment during each year of continuous enrollment At least one disease or condition or procedure in the measurement year or the year prior

Note: Members with more than one disease or condition can appear in the measure multiple times (i.e., in each indicator for which they qualify)

Numerator criteria:

–

History of falls: dispensed a tricyclic antidepressant

– –

Dementia: dispensed a tricyclic antidepressant Chronic renal failure: dispensed an NSAID or cox-2 selective NSAID SNP Training #2 – SNP Subset of HEDIS Measures 71

Use of High Risk Medications in the Elderly (DAE)

•

The percentage of Medicare members 65 years of age and older who received at least one high risk medication

•

The percentage of Medicare members 65 years of age and older who received at least two different high risk medications

•

For both rates, a lower rate represents better performance

SNP Training #2 – SNP Subset of HEDIS Measures 72

Use of High Risk Medications in the Elderly (DAE)

• •

Eligible population:

–

Members 67 years and older as of 12/31 of the measurement year

– –

Continuously enrolled during the measurement year No more than on 45-day gap in enrollment Numerator Criteria:

–

Rate 1: At least one high risk medication dispensed

–

Rate 2: At least two high risk medications dispensed SNP Training #2 – SNP Subset of HEDIS Measures 73

Future HEDIS Measures for SNPs

• •

HEDIS 2010/2011 Measures

– –

Inpatient Readmissions Potentially Avoidable Hospitalizations Public Comment in June/July SNP Training #2 – SNP Subset of HEDIS Measures 74

Contacts

Brett Kay

Director, SNP Assessment 202-955-1722

[email protected]

Casandra Monroe

Assistant Director, SNP Assessment 202-955-5136

[email protected]

SNP Training #2 – SNP Subset of HEDIS Measures 75

Additional Resources

•

NCQA SNP Website: www.ncqa.org/snp.aspx

–

FAQs (HEDIS)

– –

Training descriptions & schedule Final HEDIS and S&P measures (March 14)

•

NCQA Policy Clarification Support (PCS) http://app04.ncqa.org/pcs/web/asp/TIL_ClientLogin.asp

•

HEDIS Audit information http://www.ncqa.org/tabid/204/Default.aspx

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Policy Clarification Support (PCS)

•

PCS Web address http://app04.ncqa.org/pcs/web/asp/TIL_ClientLogin.asp

•

Link for SNP Web page www.ncqa.org/snp.aspx

SNP Training #2 – SNP Subset of HEDIS Measures 77

Policy Clarification Support (PCS)

• •

Under “Standard Categories/HEDIS Domain,” select one of the following options:

– – – SNP – General Reporting Guidance SNP – HEDIS SNP – Structure & Process Measures

Menu options under “Standard/Measures”

– If “SNP – General Reporting Guidance” was selected: • Not Applicable

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Policy Clarification Support (PCS)

Menu options under “Standard/Measures”

•

If “SNP – HEDIS” was selected:

– (COL) Colorectal Cancer Screening – – (COA) Care for Older Adults – (GSO) Glaucoma Screening in Older Adults (SPR) Use of Spirometry Testing in the Assessment & Diagnosis of COPD – – – – – – – – – – (PCE) Pharmacotherapy Management of COPD Exacerbation (CBP) Controlling High Blood Pressure (PBH) Persistence of Beta Blocker Treatment After a Heart Attack (OMW) Osteoporosis Management in Older Women (AMM) Antidepressant Medication Management (FUH) Follow-Up After Hospitalization for Mental Illness (MPM) Annual Monitoring for Patients on Persistent Medications (DDE) Potentially Harmful Drug-Disease Interactions – – (MRP) Medication Reconciliation Post-Discharge – (DAE) Use of High Risk Medication in the Elderly (BCR) Board Certification (HOS) Medicare Health Outcomes Survey Other

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Policy Clarification Support (PCS)

Menu options under “Standard/Measures”

•

If “SNP – Structure & Process” was selected:

– – – – – – – SNP 1: Complex Case Management SNP 2: Improving Member Satisfaction SNP 3: Clinical Quality Improvements SNP 4: Care Transitions SNP 5: Institutional Relationship with Facilities SNP 6: Coordination of Medicare and Medicaid Services Other

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