2016 HEDIS Measures and Specifications

Transcription

1 2016 HEDIS Measures and Specifications Measure Reported Data Line of Business Children and Adolescents Adolescent immunizations (IMA) On or before age 13 Adolescent well care visits (AWC) Ages Appropriate testing for children with pharyngitis (CWP) Ages 3-18 Appropriate treatment for children with upper respiratory infection (URI) Ages 3 months 18 years Asthma medication ratio (AMR) Ages 5-85 Childhood immunizations (CIS) Younger than age 2 Percentage who received meningococcal vaccine on or between 11 th to 13 th birthdays Percentage who received tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) or tetanus, diphtheria toxoids vaccine (Td) on or between 10 th to 13 th birthdays Percentage who had one well care visit per calendar year Documentation must include a visit with a PCP or OB/GYN, date of the visit and all of the following: A health and developmental history (physical and mental) A physical exam Health education/anticipatory guidance Percentage diagnosed with pharyngitis, dispensed an antibiotic and received a group A streptococcus (strep) test for the episode Percentage given a diagnosis of URI and NOT dispensed an antibiotic prescription Percentage identified as having persistent asthma who had a ratio of controller medications to total asthma medications of 0.50 or greater during the measurement year Percentage who completed vaccines: 4 Diphtheria, tetanus and acellular pertussis (DTaP) 3 Polio (IPV) 1 Measles, mumps and rubella (MMR) 3 H influenza type B (HiB) 3 Hepatitis B (HepB) 1 Chicken pox (VZV) 4 Pneumococcal conjugate (PCV) 1 Hepatitis A (HepA) 2 or 3 Rotavirus (RV) 2 Influenza (flu),

2 Children and adolescents access to primary care practitioners (CAP) Ages 12 months 19 years Chlamydia screening (CHL) Women ages with documentation of being sexually active Follow-up after hospitalization for mental illness (FUH) Ages 6 and older Follow-up for children with attention deficit hyperactivity disorder (ADHD) (ADD) Ages 6 (as of March 1 of the year prior to the measurement year) to 12 (as of Feb. 28 of the measurement year) Human papillomavirus (HPV) for female adolescents On or between 9 th and 13 th birthdays Lead screening (LSC) Younger than age 2 Medication management for people with asthma (MMA) Ages 5-85 Ages months and 25 months 6 years: Percentage who had a yearly visit with a PCP Ages 7-19 years: Percentage who had a visit with a PCP during the measurement year or the year prior to the measurement year Percentage who had at least one test for chlamydia during the measurement year Percentage hospitalized for treatment of selected mental health disorders and had an outpatient visit, intensive outpatient encounter or partial hospitalization with a mental health practitioner Two rates are reported: Percentage who received follow-up within 30 days of discharge Percentage who received follow-up within seven days of discharge Initiation phase of medication management percentage who had one visit within 30 calendar days of an ADHD script Continuation and maintenance phase percentage who remained on the medication for at least 210 days and, in addition to the visit in the initiation phase, had a least two follow-up visits with a practitioner within 270 days (9 months) after the initiation phase ended Percentage who had at least three doses HPV vaccination with different dates of service, on or between the 9 th and 13 th birthday Percentage who had one or more capillary or venous lead blood tests prior to 2 nd birthday Percentage identified as having persistent asthma and dispensed appropriate medications that they remained on during the treatment period Two rates are reported: Percentage who remained on medication for 50 percent of the treatment period Percentage who remained on medication for 75 percent of the treatment period, Medicaid,

3 Metabolic monitoring for children and adolescents on antipsychotics (APM) Ages 1-17 Use of first-line psychosocial care for children and adolescents on antipsychotics (APP) Ages 1-17 Use of multiple concurrent antipsychotics in children and adolescents (APC) Ages 1-17 Weight assessment and counseling for physical activity and nutrition for children/adolescents (WCC) Ages 3-17 Well-child care visits (W15) Ages 0-15 months Well-child care visits (W34) Ages 3-6 Women Breast cancer screening (BCS) Ages Percentage who had two or more antipsychotic prescriptions and had metabolic testing Percentage who had a new prescription for an antipsychotic medication and had documentation of psychosocial care as first-line treatment Percentage who were on two or more concurrent antipsychotic medications; a lower rate indicates better performance Percentage who had an outpatient visit during the calendar year with documented evidence of height, weight and body mass index (BMI) percentile (ranking based on CDC BMI-forage growth chart), and counseling for nutrition and physical activity Percentage who had the recommended minimum of six well child visits by the age of 15 months Documentation must include a visit with the primary care physician (PCP), date of the visit and all of the following: A health and developmental history (physical and mental) A physical exam Health education/anticipatory guidance Percentage who had one or more well care visits per calendar year Documentation must include a visit with a PCP, date of the visit and all of the following: A health and developmental history (physical and mental) A physical exam Health education/anticipatory guidance Percentage who had at least one mammogram on or between Oct. 1 two years prior to the measurement year and Dec. 31 of the measurement year,

4 Cervical cancer screening (CCS) Ages Chlamydia screening (CHL) Women ages with documentation of being sexually active Frequency of ongoing prenatal care (FPC) Non-recommended cervical cancer screening in adolescent females (NCS) Ages Osteoporosis management in women who had a fracture (OMW) Ages Osteoporosis testing in older women (OTO) Ages Prenatal and postpartum care (PPC) Percentage of women who were appropriately screened for cervical cancer using either of the following criteria: Women ages who had a pap smear every three years Women ages who had pap smear/hpv co-testing on the same date of service performed every five years Percentage who had at least one test for chlamydia during the measurement year Percentage who delivered a live birth on or between Nov. 6 of the year prior to the measurement year and Nov. 5 of the measurement year, and who received the expected number of prenatal care visits; rates are reported by the percentage of expected visits American Congress of Obstetricians and Gynecologists (ACOG) recommends that women with an uncomplicated pregnancy receive visits every four weeks for the first 28 weeks of pregnancy, every two to three weeks until 36 weeks of pregnancy, and weekly thereafter Percentage who were screened unnecessarily for cervical cancer; a lower compliance rate for this measure indicates better performance Percentage who suffered a fracture and 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 Percentage of Medicare members who report ever having received a bone density test to check for osteoporosis Percentage who had delivered a live birth on or between Nov. 6 of the year prior to the measurement year and Nov. 5 of the measurement year and: Had one prenatal visit in first 12 weeks or 42 days of joining UnitedHealthcare Community Plan Had one visit between 21 and 56 days after delivery Commercial, Medicaid Medicaid Admin.

5 Adult Adherence to antipsychotic medications for individuals with schizophrenia (SAA) Ages during the measurement year Adult BMI assessment (ABA) Ages Adults access to preventive/ambulatory health services (AAP) Ages 20 and older Antidepressant medication management (AMM) Ages 18 and older Annual monitoring for patients on persistent medication (MPM) Ages 18 and older Percentage with schizophrenia who were dispensed and remained on an antipsychotic medication for at least 80 percent of their treatment period Percentage who had an outpatient visit during the calendar year or year prior Documentation must indicate the dated weight and BMI value. For members younger than age 20 on the date of service, BMI must be recorded in percentile. Percentage of Medicaid and Medicare members who had an ambulatory or preventive care visit in the measurement year Percentage of Commercial members who had an ambulatory or preventive care visit during the measurement year or the two years prior to the measurement year Percentage diagnosed with major depression and newly treated with antidepressant medication, and remained on an antidepressant medication treatment Two rates are reported: Effective Acute Phase Treatment percentage who remained on an antidepressant medication for at least 84 days (12 weeks) Effective Continuation Phase Treatment Percentage who remained on an antidepressant medication for at least 180 days (six months) Percentage who received at least 180 treatment days of ambulatory medication therapy for a select therapeutic agent during the measurement year, and had at least one therapeutic monitoring event for the therapeutic agent during the measurement year Three separate rates and a total rate are reported: Angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB) Digoxin Diuretics Total rate (the sum of the three numerators divided by the sum of the three denominators) Medicaid, Medicare,,,

6 Asthma medication ratio (AMR) Ages 5-85 Avoidance of antibiotic treatment in adults with acute bronchitis (AAB) Ages Cardiovascular monitoring for people with cardiovascular disease and schizophrenia (SMC) Ages Care for older adults (COA) Ages 66 or older Colorectal cancer screening (COL) Ages Comprehensive diabetes care (CDC) Ages Controlling high blood pressure (CBP) Ages Diabetes monitoring for people with diabetes and schizophrenia (SMD) Ages Percentage identified as having persistent asthma who had a ratio of controller medications to total asthma medications of 0.50 or greater during the measurement year Percentage with a diagnosis of acute bronchitis who were NOT dispensed an antibiotic prescription Percentage with schizophrenia and cardiovascular disease who had an LDL-C test during the measurement year Percentage who had each of the following during the measurement year: Advance care planning Medication review Functional status assessment Pain screening Percentage who had: Yearly fecal occult blood test (FOBT) Flexible sigmoidoscopy every five years Colonoscopy every 10 years Percentage ages with diabetes (Type I and Type 2) who had each of the following on a yearly basis: Hemoglobin A1c (HbA1c) testing HbA1c poor control (greater than 9.0 percent) HbA1c control (less than 8.0 percent) HbA1c control (less than 7.0 percent) Retinal eye exam Medical attention for nephropathy BP control (less than 140/90 mm Hg) Percentage who had a diagnosis of hypertension, and blood pressure was adequately controlled during the measurement year based on the following criteria: Ages 18-59: Less than 140/90 mm Hg Ages with diabetes: Less than 140/90 mm Hg Ages without diabetes: Less than mm Hg Percentage with schizophrenia and diabetes who had both an LDL-C test and an HbA1c test during the measurement year, Medicaid SNP Commercial, Medicare, Medicare, Medicare Medicaid

7 Diabetes screening for people with schizophrenia or bipolar disorder who are using antipsychotic medications (SSD) Ages Disease-modifying anti-rheumatic drug therapy for rheumatoid arthritis (DMAR) (ART) Ages 18 and older Follow-up after hospitalization for mental illness (FUH) Ages 6 and older Initiation and engagement of alcohol and other drug dependence treatment (IET) Medication management for people with asthma (MMA) Ages 5-85 Medication reconciliation post-discharge (MRP) Ages 18 or older Percentage with schizophrenia or bipolar disorder, who were dispensed an antipsychotic medication and had a diabetes screening test during the measurement year Percentage diagnosed with rheumatoid arthritis who were dispensed at least one ambulatory prescription for a disease modifying anti-rheumatic drug (DMARD) Percentage hospitalized for treatment of selected mental health disorders and had an outpatient visit, intensive outpatient encounter or partial hospitalization with a mental health practitioner Two rates are reported: Percentage who received follow-up within 30 days of discharge Percentage who received follow-up within seven days of discharge Percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) dependence who received the following: Initiation of AOD treatment Initiated treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of the diagnosis Engagement of AOD Treatment Initiated treatment and had two or more additional services with an AOD diagnosis within 30 days of the initiation visit Percentage identified as having persistent asthma and dispensed appropriate medications that they remained on during the treatment period Two rates are reported: Percentage who remained on medication for 50 percent of the treatment period Percentage who remained on medication for 75 percent of the treatment period Percentage for whom medications were reconciled on or within 30 days of an acute or non-acute hospital discharge Medicaid,,,, Medicare, SNP

8 Non-recommended PSA-based screening in older men (PSA) Ages 70 and older Persistence of beta-blocker treatment after a heart attack (PBH) Ages 18 and older Pharmacotherapy management of COPD exacerbation (PCE) Ages 40 and older Potentially harmful drug-disease interactions in the elderly (DDE) Ages 65 or older Statin Therapy for Patients with Cardiovascular Disease (SPC) Men ages and women ages Percentage who are screened unnecessarily for prostate cancer using prostate-specific antigen (PSA)-based screening; a lower compliance rate for this measure indicates better performance Percentage who were hospitalized and discharged with a diagnosis of AMI from July 1 of the year prior to the measurement year to June 30 of the measurement year, and who received persistent beta-blocker treatment for six months after discharge Percentage who had an acute inpatient discharge or emergency room encounter between Jan. 1 and Nov. 30 of the measurement year, and were dispensed appropriate medications Two rates are reported: Percentage dispensed a systemic corticosteroid within 14 days of the event Percentage dispensed a bronchodilator within 30 days of the event Percentage with evidence of an underlying disease, condition or health concern and dispensed an ambulatory prescription for a contraindicated medication, concurrent with or after the diagnosis Diseases, conditions or health concerns include: 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 (CRF) and prescription for non-aspirin NSAIDs or Cox-2 selective NSAIDs Percentage identified as having clinical atherosclerotic disease (ASCVD) and met the following criteria. The following rates were reported: Received statin therapy Members who were dispensed at least one high or moderate-intensity statin medication during the measurement year 80 percent statin adherence Members who remained on a high- or moderateintensity statin medication for at least 80 percent of the treatment period.,, Admin., and Medicare

9 Statin Therapy for Patients with Diabetes (SPD) Ages Use of high-risk medications in the elderly (DAE) Ages 66 or older Use of imaging studies for low back pain (LBP) Ages Use of spirometry testing in the assessment and diagnosis of chronic obstructive pulmonary disease (COPD) (SPR) Ages 40 and older Survey Measures Aspirin use and discussion for members who are currently taking aspirin (ASP) Percentage of members with diabetes who do not have clinical ASCVD who met the following criteria. Two rates are reported: Received statin therapy Members who were dispensed at least one statin medication of any intensity during the measurement year 80 percent statin adherence Members who remained on a statin medication of any intensity for at least 80 percent of the treatment period Percentage who received at least one high risk medication Percentage who received at least two different high risk medications Percentage with a primary diagnosis of low back pain who did NOT have an imaging study (plain X-ray, Magnetic Resonance Imaging (MRI) or CT scan) within 28 days of the diagnosis Percentage with a new diagnosis or newly active COPD and received appropriate spirometry testing to confirm the diagnosis Aspirin Use: Percentage of women ages with at least two risk factors for heart disease Percentage of men ages with at least one risk factor for heart disease Percentage of men ages regardless of risk factors Discussing Aspirin Risks and Benefits: Percentage of women ages and men ages who discussed the risk/benefits of using aspirin with a doctor or health provider, and Medicare Admin.,

10 CAHPS Health Plan Survey 5.0H, Adult Version (CPA) CAHPS Health Plan Survey 5.0H, Child Version (CPC) Four global rating questions reflect overall satisfaction: Rating of all health care Rating of health plan Rating of personal doctor Rating of specialist seen most often Seven composite scores summarize responses in key areas: Claims processing (Commercial only) Customer service Getting care quickly Getting needed care How well doctors communicate Shared decision making Plan information on costs (Commercial only) Question Summary Rates: Health promotion and education Coordination of care Four global rating questions reflect overall satisfaction: Rating of all health care Rating of health plan Rating of personal doctor Rating of specialist seen most often Five composite scores summarize responses in key areas: Customer service Getting care quickly Getting needed care How well doctors communicate Shared decision making Question Summary Rates: Health promotion and education Coordination of care Children with chronic conditions (CCC) Access to prescription medicines Access to specialized services Family centered care: Getting needed information Family centered care: Personal doctor who knows child Coordination of care for children with chronic conditions

11 Fall risk management (FRM) Discussion of Fall Risks: Percentage of Medicare members ages 75 and older, or ages with balance or walking problems or a fall in the past 12 months, who were seen by a practitioner in the past 12 months and who discussed falls or problems with balance or walking with their current practitioner Managing Falls Risks: Percentage of Medicare members ages 65 and older who had a fall or had problems with balance or walking in the past 12 months, who were seen by a practitioner in the past 12 months and who received fall risk intervention from their current practitioner Flu vaccinations for adults (FVA) Ages Percentage who received an influenza vaccination between July 1 of the measurement year and the date on which the CAHPS 5.0H survey was completed Flu vaccinations for older adults (FVO) Ages 65 and older Percentage who received an influenza vaccination between July 1 of the measurement year and the date on which the Medicare CAHPS survey was completed Medicare Management of urinary incontinence in older adults (MUI) Ages 65 and older Medical assistance with smoking and tobacco use cessation (MSC) Osteoporosis testing in older women (OTO) Ages Discussing: Percentage who reported having a problem with urine leakage in the past six months and discussed their urine leakage problem with their current practitioner Receiving Treatment: Percentage who reported having a urine leakage problem in the past six months and who received treatment for their current urine leakage problem Percentage of adults ages 18 and older who are current smokers or tobacco users who received cessation advice during the measurement year on the following: Advising smokers and tobacco users to quit Discussing cessation medications Discussing cessation strategies Percentage of Medicare members who report ever having received a bone density test to check for osteoporosis

12 Physical activity in older adults (PAO) Ages 65 and older Discussing Physical Activity: Percentage who had a doctor s visit in the past 12 months and spoke with a doctor or other health provider about their level of exercise or physical activity Advising Physical Activity: Percentage who had a doctor s visit in the past 12 months and received advice to start, increase or maintain their level of exercise or physical activity Pneumonia vaccine (PNU) Percentage of Medicare members ages 65 Ages 65 and older and older, as of Jan. 1 of the measurement year, who have ever received a pneumococcal vaccine HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).