Quality measures desktop reference for medicare and medicaid providers

Transcription

1 Quality measus desktop fence for medica and medicaid providers Anthem Blue Cross Cal MediConnect Please note: The information provided is based on HEDIS 2015 Technical Specifications and is subject to change based on guidance given by the National Committee for Quality Assurance, the Centers for Medica & Medicaid Services and state commendations. Please fer to the appropriate agency for additional guidance. Clinical ADULTS ADULTS Measu Source Market Inclusion criteria Occurnce Description of measument, scening, test or tatment needed Access to pventive/ambulatory HEDIS Age 20 and older Members who had an ambulatory or pventive ca visit during the year health services (AAP) Adult body mass index (BMI) HEDIS Ages Biannual Members who had an outpatient visit with documentation of weight and BMI value assessment (ABA) during the year or year prior. Members under age 19 may have a weight and a BMI percentile documented and/or plotted on a BMI chart. monitoring of persistent HEDIS Age 18 and older Members who ceived annual therapeutic testing when pscribed ACEI, ARB, medications (MPM) digoxin, or a diutic Ca for older adults (COA) HEDIS Ages 66 and older Members who had dated evidence of the following during the year: in a Medica Advance ca discussion and planning SNP plan Medication view by a pscribing practitioner or clinical pharmacist to include pscription, over-the-counter, and herbals or supplements A medication list in their medical cord Complete functional status assessment Pain assessment or pain management plan Coloctal cancer scening (COL) HEDIS Ages Varies by test Members who had one or mo of the following coloctal cancer scenings within the appropriate time period: Fecal occult blood test during the year Flexible sigmoidoscopy during the last five years Colonoscopy during the last 10 years Disease-modifying anti-rheumatic HEDIS Age 18 and older Members who we dispensed at least one pscription for a DMARD during the year drug (DMARD) Therapy for with a diagnosis rheumatoid arthritis (RA) (ART) of RA Flu vaccinations for adults (FVO & CAHPS Age 18 and older Members vaccinated for influenza after July 1 FVA) Pneumococcal vaccination for older CAHPS Age 65 and older Once after age Members who have ever ceived a pneumococcal vaccination adults (PNU) Management of urinary incontinence in older adults (MUI) Physical activity in older adults (PAO) HOS Age 65 and older who ported having urine leakage in the past six months HOS Age 65 and older who had a doctor visit in the past 12 months 65 Discussing Urinary Incontinence: Members who discussed their urinary leakage problem with a health ca provider. Discussing Tatment of Urinary Incontinence: Members who discussed tatment options for their curnt urine leakage problem Impact of Urinary Incontinence: Members who ported that urine leakage made them change their daily activities or interfed with their sleep a lot Discussing Physical Activity: Members who spoke with a doctor or other health provider about their level of exercise or physical activity Advising Physical Activity: Members who ceived advice to start, incase or maintain their level of exercise or physical activity ACAPEC Page 1 of 7

2 Measu Source Market Inclusion criteria Occurnce Description of measument, scening, test or tatment needed Medical assistance with smoking CAHPS Age 18 and older Members who ceived the following from a provider during the year: and tobacco use cessation (MSC) who a curnt Cessation advice tobacco users Recommendation for or discussion of cessation medications Recommendation for or discussion of cessation methods or strategies Reducing the risk of falling (FRM) HOS Age 65 and older who we seen by a practitioner in Discussing Fall Risk: Members 75 years of age and older or years of age with balance or walking problems or a fall in the past 12 months who discussed falls or problems with balance or walking with their curnt practitioner the past 12 months Managing Fall Risk: Members 65 years of age and older who had a fall or had problems with balance or walking in the past 12 months who ceived fall risk intervention from their curnt practitioner Use of high-risk medications in the HEDIS Age 66 and older Members who had an evaluation of the use of one or mo high-risk medications elderly (DAE) Potentially harmful drug-disease interactions in the elderly (DDE) HEDIS Age 67 and older who have Members who we dispensed an ambulatory pscription for a potentially harmful medication, concurnt with or after the diagnosis of: evidence of underlying disease, condition History of fall/hip fractu and pscription for anticonvulsants, nonbenzodiazepine hypnotics, SSRIs, antiemetics, s, benzodiazepines, or tricyclic antidepssants or health concern Dementia and a pscription for antiemetics, s, benzodiazepines, tricyclic antidepssants, H2 Receptor Antagonists, nonbenzodiazepine hypnotics, or anticholinergic agents Chronic kidney disease and pscription for Cox-2 Selective NSAIDs or nonaspirin NSAIDs Use of imaging studies for lower back pain (LBP) HEDIS Ages Not applicable Members who had a primary diagnosis of lower back pain and did not have an imaging study (e.g., plain X-ray, MRI or CT scan) within 28 days of the diagnosis Plan all cause admission (PCR) HEDIS Age 18 and older Members who had an acute inpatient stay that was followed by an unplanned acute admission for any diagnosis within 30 days Initiation and engagement of alcohol HEDIS Age 13 and older Members who ceived: and other drug dependence with a new Initiation of AOD Tatment within 14 days of diagnosis tatment (IET) episode of alcohol or other drug dependence (AOD) Engagement of AOD tatment: members who initiated tatment and had two or mo additional services with a diagnosis of AOD within 30 days of the initiation visit MALES Non-commended PSA-based scening in older men (PSA) HEDIS Ages 70 and older Not applicable Men who we scened unnecessarily for prostate cancer using prostate-specific antigen (PSA)-based scening FEMALES Pnatal and postpartum ca (PPC) HEDIS Live birth First trimester and days Members who had a pnatal visit within the first trimester or within 42 days of enrollment in the plan postpartum Members who had a postpartum visit on or between 21 and 56 days after delivery FEMALES Fquency of ongoing pnatal ca HEDIS Live birth At least 14 Members who had appropriate pnatal visits throughout the pgnancy: (FPC) visits for a 40- Every 4 weeks for the first 28 weeks of pgnancy week pgnancy Every 2-3 weeks for weeks of pgnancy Weekly for 37 weeks of pgnancy through delivery Bast cancer scening (BCS) HEDIS Ages Every two years Members who had one or mo scening mammograms during the year or year prior Page 2 of 7

3 Measu Source Market Inclusion criteria Occurnce Description of measument, scening, test or tatment needed Cervical cancer scening (CCS) HEDIS Ages Varies by age Women who we scened for cervical cancer using the following criteria: Ages 21-64: At least one cervical cytology (PAP) test every the years Ages 30-64: Cervical cytology (PAP) test/human papillomavirus (HPV) co-testing every five years Non-commended cervical cancer scening in adolescent females (NCS) HEDIS Ages Not applicable Adolescent females who we scened unnecessarily for cervical cancer Note: Cervical cancer scening should begin at age 21 Chlamydia scening in women (CHL) HEDIS Ages and sexually active Members who had at least one scening test for chlamydia during the year Osteoporosis testing (OTO) HOS Ages Members who have ever had a bone density test to check for osteoporosis Osteoporosis management with a fractu (OMW) Human papillomavirus (HPV) vaccine for female adolescents HOS Ages who had a fractu As diagnosed Members who had either a bone mineral density test or a pscription for drugs to tat osteoporosis within 6 months HEDIS Ages 9-13 Multiple doses Members who had the doses of the HPV vaccine on or between their 9th and 13th birthdays CARDIOVASCU LAR CONDITIONS Controlling high blood pssu (CBP) Persistence of beta-blocker tatment after a heart attack (PBH) HEDIS Ages with a diagnosis of hypertension HEDIS Ages 18 and older with an inpatient discharge for AMI Aspirin use and discussion (ASP) CAHPS Men ages Women ages DIABETES Comphensive diabetes ca (CDC) HEDIS Ages with diagnosis of type I OR type II diabetes After discharge Members whose blood pssu (BP) was adequately controlled: Ages 18-59: <140/90 mm Hg Ages with Diabetes: BP <140/90 mm Hg Ages Non-diabetics: BP <150/90 mm Hg Note: BOTH systolic and diastolic values must be below stated value. Only the most cent measument during the year counts towards compliance. Members who ceived beta-blocker tatment for six months after a hospital discharge for AMI Aspirin Use: Members at risk for cardiovascular disease who a curntly taking aspirin Discussing Aspirin Risks and Benefits: Members who discussed the risks and benefits of using aspirin with a doctor or other health ca provider Each year, members with type I or type II diabetes should have: HbA1c testing Blood pssu monitoring Nephropathy scening and tatment, if indicated Dilated eye exam in curnt year or negative exam in pvious year Diabetes control is determined by: HbA1c below 9 percent (actual goal depends on age and comorbidities) Blood pssu <140/90 Only the most cent scening sult during the year counts towards compliance Page 3 of 7

4 RESPIRATORY CONDITIONS BEHAVIORAL HEALTH BEHAVIORAL HEALTH Measu Source Market Inclusion criteria Occurnce Description of measument, scening, test or tatment needed Use of appropriate medications for HEDIS Ages 5-64 who Members who we dispensed at least one pscription for an asthma controller. people with asthma (ASM) have persistent Note: Persistent asthma is defined as having one or mo of the following both this year asthma and last year: One ED visit for asthma One inpatient visit for asthma Four outpatient or observation visits on diffent dates with asthma as part of diagnosis, along with at least two asthma medication dispensing events Medication management for people with asthma (MMA) HEDIS Ages 5-64 who have persistent asthma Asthma medication ratio (AMR) HEDIS Ages 5-64 who have persistent asthma Avoidance of antibiotic tatment in adults with acute bronchitis (AAB) Pharmacotherapy management of chronic obstructive pulmonary disease (COPD) exacerbation (PCE) Spirometry testing in assessment/diagnosis of COPD (SPR) Antidepssant medication management (AMM) Follow-up ca for childn pscribed attention deficit hyperactivity disorder (ADHD) medications (ADD) Follow-up after hospitalization for mental illness (FUH) Four asthma medication dispensing events Members who mained on an asthma controller medication: 50 percent of time from the pscription start to end of the year 75 percent of time from the pscription start to end of the year Members who had a ratio of controller medications to total asthma medications of 0.50 or gater HEDIS Ages Members who did not ceive an antibiotic pscription after a diagnosis of acute bronchitis HEDIS Age 40 and older Inpatient Members who we dispensed appropriate medications: who had an acute discharge or Systemic corticosteroid within 14 days of the event inpatient Emergency Bronchodilator within 30 days of the event discharge or ED Department visit for COPD (ED) event HEDIS Age 40 and older who had a new diagnosis of COPD or newly active COPD HEDIS Age 18 and older who had a diagnosis of a new episode of major depssion As newly diagnosed/ newly active Members who ceived spirometry testing to confirm the COPD diagnosis Members who we tated with antidepssant medications and mained on for: At least 84 days At least 180 days HEDIS Ages 6-12 Varies by phase Members who we newly pscribed medications or started ADHD medications after a 120-day bak with at least the follow-up visits in a 10-month period: Initiation phase: follow-up visit with pscriber within 30 days of pscription Continuation and maintenance phase: mained on medication and had two mo visits within nine months HEDIS Age 6 and older Within 7 and/or Members who had an outpatient visit, intensive outpatient visit or partial hospitalization who we 30 days after with a mental health practitioner, pferably within seven days of discharge but no later discharged from discharge than 30 days after discharge. an inpatient mental health hospitalization Page 4 of 7

5 PATIENT EXPERIENCE Measu Source Market Inclusion criteria Occurnce Description of measument, scening, test or tatment needed HEDIS Ages with Members who had a glucose test or HbA1c during the year schizophnia or Note: Measu applies to members who a using medications and do not bipolar disorder have a diagnosis of diabetes and a not taking any antihyperglycemic or hypoglycemic and who a not medications diabetic Diabetes scening for people with schizophnia or bipolar disorder and use medications (SSD) Diabetes monitoring for people with diabetes and schizophnia (SMD) Cardiovascular monitoring for people with cardiovascular disease and schizophnia (SMC) Adhence to medications for individuals with schizophnia (SAA) Use of multiple concurnt s in childn and adolescents (APC) Metabolic monitoring for childn and adolescents on s (APM) Use of first-line psychosocial ca for childn and adolescents on s (APP) HEDIS Ages with schizophnia and diabetes HEDIS Ages with schizophnia and cardiovascular disease HEDIS Ages with schizophnia who we dispensed an medication HEDIS Ages 1-17 with 90 days of continuous medication tatment HEDIS Ages 1-17 who had two or mo pscriptions HEDIS Ages 1-17 who had a new pscription for an medication CAHPS Members who have been with the plan through the year Members who had both an LDL-C and an HbA1c test during the year Members who had an LDL test during the year Note: Indicators of cardiovascular disease include: Inpatient discharge for AMI or CABG during the year Diagnosis of PCI in any setting during the year Diagnosis of IVD during an inpatient or outpatient visit in both the curnt year and the year prior Members who mained on the medication for at least 80 percent of time between the pscription date and December 31 Members who we on two or mo concurnt medications Members who had metabolic testing during the year Members who had documentation of psychosocial ca as first-line tatment Ease of getting needed ca and seeing specialists In the last six months, how often was it easy to get appointments with specialists? In the last six months, how often was it easy to get the ca, tests or tatment you needed through your health plan? Rating of specialist CAHPS In the last six months, rate the specialist you saw most often using any number from 0 to 10, whe 0 is the worst specialist possible and 10 is the best specialist possible? Rating of personal doctor CAHPS Using a number from 0 to 10, whe 0 is the worst personal doctor and 10 is the best personal doctor, what number would you use to rate your personal doctor? Page 5 of 7

6 Measu Source Market Inclusion criteria Occurnce Description of measument, scening, test or tatment needed Getting appointments and ca quickly CAHPS In the last six months, when you needed ca right away, how often did you get ca as soon as you thought you needed it? In the last six months, not counting the times when you needed health ca right away, how often did you get an appointment for yourself at a doctor s office or clinic as soon as you thought you needed it? Overall rating of health ca quality CAHPS Using a number from 0 to 10, whe 0 is the worst health ca possible and 10 is the best health ca possible, what number would you use to rate all your health ca in the last six months? Overall rating of health plan CAHPS Using a number from 0 to 10, whe 0 is the worst health plan possible and 10 is the best health plan possible, what number would you use to rate your health plan? HEDIS is a gisted trademark of the National Committee for Quality Assurance (NCQA). HEDIS Healthca Effectiveness Data and Information Set HOS Medica Health Outcomes Survey CAHPS Consumer Assessment of Healthca Providers and Systems survey Anthem Blue Cross Cal MediConnect Plan is a health plan that contracts with both Medica and Medi-Cal to provide benefits of both programs to enrollees. Anthem Blue Cross is the trade name of Blue Cross of California and Anthem Blue Cross Partnership Plan is the trade name of Blue Cross of California Partnership Plan, Inc., independent licensees of the Blue Cross Association. ANTHEM is a gisted trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol a gisted marks of the Blue Cross Association. Page 6 of 7