ABCBS PCMH Specifications. ARKANSAS BLUE CROSS and BLUE SHIELD An Independent Licensee of the Blue Cross and Blue Shield Association

Transcription

1 ABCBS PCMH 2016 Specifications An Independent Licensee of the Blue Cross and Blue Shield Association

2 Table of Contents I. Terminology 3 II. Transformation Activities 2016 List of Activities 4 3 month month month month 12 III. Quality Metrics 2016 List of Quality Metrics and Targets Facts 15 Exceptions 16 Specifications IV. Summary of changes from V. Resources 35 2

3 Terminology Attest/ Attestation: Verifies that the information provided is truthful and can be supported Numerator: The number of patients affected by the measure; the top number in a fraction; the number of incidences (example on page 9) Denominator: The total number of patients in the population being analyzed; shows how many total parts/patients you have; the bottom number in a fraction (example on page 9) Domain: The grouping of measures by initiatives or organizations Exclusion: Information that should be separated from the measure (not included) High Priority Members: Members that are considered high risk by the clinic or Blue Cross Blue Shield; Patients that require attention soon Inclusion: Information to specifically include in the measure Measurement Number: The specific identifying information for a measure in a program. A measure that s used in multiple programs may have several measure numbers. 3

4 2016 Activities Date extended to 04/30/16 4

5 3 Month Activities Activity A: Identify the top 10% of High Priority Arkansas Blue Cross and Blue Shield members using: 1. Arkansas Blue Cross and Blue Shield and its family of companies patient panel data that ranks members by risk at beginning of performance period OR 2. The clinic s patient-centered assessment to determine which members on this list are high priority Submit this list to the PCMH Provider Portal Note: At this time, you may use a combination of both options listed above; however, make note that the BCBS risk score tool includes many details about the patient and may contain medical history that the clinic may not be aware of. 5

6 3 Month Activities Activity B: Report Clinical Quality Measure Data for calendar year 2015 for: Controlling High Blood Pressure, Diabetes: Hemoglobin A1c Poor Control, and Weight Assessment for Children and Adolescents (BMI). Note: This activity is currently for informational purposes. There are no set targets or goals at this time. This measure should reflect the whole patient empanelment and NOT just BCBS members. This is an e-measure for Meaningful Use. Measure Numerator Denominator Controlling High Blood Pressure Coding The number of patients in the denominator whose most recent BP is adequately controlled (<140/90) during the measurement year. Total number of patients age who had at least one outpatient encounter with a diagnosis of hypertension (HTN) during the first six months of the measurement year. ICD-10 I10- hypertension, R03.0 -elevated blood pressure w/o dx of HTN Measure Description: Percentage of patients years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90) during the measurement period. Domain: Clinical Process/Effectiveness Measure Number: CMS 165v4, NQF 0018, PQRS 236/GPRO HTN-2 Exclusions: (1) All patients with evidence of end-stage renal disease (ESRD) or chronic kidney disease, stage 5, on or prior to the end of the measurement year. Documentation in the medical record must include a related note indicating evidence of ESRD. Documentation of dialysis or renal transplant also meets the criteria for evidence of ESRD. (2) All patients with a diagnosis of pregnancy during the measurement year. (3) All patients who had an admission to a nonacute inpatient setting during the measurement year. 6

7 3 Month Activities Activity B: Report Clinical Quality Measure Data for calendar year 2015 for: Controlling High Blood Pressure, Diabetes: Hemoglobin A1c Poor Control, and Weight Assessment for Children and Adolescents (BMI) Note: This activity is currently for informational purposes. There are no set targets or goals at this time. This measure should reflect the whole patient empanelment and NOT just BCBS members. This is an e-measure for Meaningful Use Measure Numerator Denominator Diabetes: Hemoglobin A1c Poor Control Codes Patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or for whom an HbA1c test was not done during the measurement year. CPT A1c Patients years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year. ICD10: E11.65 type 2 with hyperglycemia E10.65 type 1 with hyperglycemia Measure Description: Percentage of patients years of age with diabetes who had hemoglobin A1c> 9% (poor control) during the measurement period. Domain: Clinical Process/Effectiveness Measure Number: CMS 122v4, NQF 0059, PQRS 001 GPRO DM-2 Exclusions: (1) Patients with a diagnosis of polycystic ovaries, in any setting, any time in their history through December 31 of the measurement year. (2) Patients with a diagnosis of gestational or steroid-induced diabetes, in any setting, during the measurement year or the year prior to the measurement year. 7

8 Measure Numerator Denominator Weight Assessment and Counseling for Children and Adolescents 3 Month Activities Activity B: Report Clinical Quality Measure Data for calendar year 2015 for: Controlling High Blood Pressure, Diabetes: Hemoglobin A1c Poor Control, and Weight Assessment for Children and Adolescents (BMI) Note: This activity is currently for informational purposes. There are no set targets or goals at this time. This measure should reflect the whole patient empanelment and NOT just BCBS members. This is an e-measure for Meaningful Use. The percentage of patients in the denominator who had evidence of Body mass index (BMI) percentile documentation during the measurement year *NQF 0024 also includes counseling for nutrition and physical activity Patients 3-17 years of age with at least one outpatient visit with a primary care physician (PCP) or OB- GYN during the measurement year Codes HCPCS- BMI=G8418 CPT: 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, , Measure Description: Percentage of patients 3-17 years of age who had an outpatient visit with a PCP or OB/GYN and who had evidence of BMI percentile documentation during the measurement year. *We are only capturing the BMI documentation at this time, not data on nutrition and physical activity counseling. The target age range is 3-17 years; however, 2-17 years is also acceptable based on EHR reporting capabilities. Domain: Population Health/ Effectiveness of Care Measure Number: CMS 155v4, NQF 0024, PQRS 239 Exclusion(s): (1) Patients who have a diagnosis of pregnancy during the measurement year. 8

9 Example: For Assistance on Activity B Measure: Diabetes: Hemoglobin A1c Poor Control Clinic population: 5,000 patients Your report in your EHR shows that you have 300 patients that were seen during the measurement period (last year)with a diagnosis of Diabetes. Your A1c report shows 22 of the 300 patients had an A1c >9 or didn t have an A1c drawn/recorded Numerator=22 Denominator=300 Divide 22/300 and x 100 to get a % (the portal will do the math for you) 7.3% of your patients with Diabetes were uncontrolled *Note: Don t forget to add the exclusions into your reports. For example, did any of the 300 patients with Diabetes have Gestational Diabetes? If the answer is yes, you subtract them from the 300. Most EHRs will allow you to add exclusions when you run the report. 9

10 6 Month Activities Activities C-G: Answer the questions that accompany each activity on the portal. Activity Topics C: Assess operations of practice and opportunities to improve D: Develop strategy to implement care coordination and practice transformation E: Identify and address medical neighborhood barriers to coordinated care (including BH professionals and facilities) F: Provide 24/7 access to care Tips 1. Some questions require a single answer, while others allow for multiple answers. 2. If you select other for any question, you must give a detailed explanation. 3. Each activity requires an attestation before submitting and completing. G: Document approach to expanding access to same-day appointments 10

11 12 Month Activities Activities H-M: Answer the questions that accompany each activity on the portal. Activity Topics H. Identify Childhood/Adult Vaccination Practice Strategy I. Establish processes that result in contact with patients who have not received preventative care J. Describe patients' ability to receive timely care, appointments, and information from specialists (including BH specialists) K. Incorporate e-prescribing into practice workflows L. Integrate EHR into practice workflows M. Complete care plans for High- Priority patients Tips 1. Some questions require a single answer, while others allow for multiple answers. 2. If you select other for any question, you must give a detailed explanation. 3. Each activity requires an attestation before submitting and completing. 11

12 13 Month Activities This activity is the same as the 3 month Activity B EXCEPT the 13 month CQM reports should reflect your 2016 patient data as opposed to the 2015 data reported for the 3 month Activity. Activity N: Report Clinical Quality Measure Data for calendar year 2016 for: Controlling High Blood Pressure, Diabetes: Hemoglobin A1c Poor Control, and Weight Assessment for Children and Adolescents (BMI). These measures should reflect the whole patient empanelment and NOT just BCBS members. On the portal, you will be directed to Activity N. There you will be able to view your 2015 data and input your 2016 data. For more details, refer to pages 6-9 Example: 12

13 2016 Quality Metrics Targets 1. Percentage of patients who turned 15 months old during the performance period who received at least four wellness visits in the first 15 months At least 70% 2. Percentage of patients 3-6 years of age who had one or more well-child visits during the measurement year At least 67% 3. Percentage of patients years of age who had one or more well- care visits during the measurement year 4. Percentage of patients 6-12 years of age with an ambulatory prescription dispensed for ADHD medication that was prescribed by their PCMH, who had a follow-up visit within 30 days by any practitioner with prescribing authority At least 45% At least 36% 5. Percentage of patients prescribed appropriate asthma medications At least 85% 6. Percentage of CHF patients age 18 and over on beta blockers At least 49% 7. Percentage of children who received appropriate treatment for an Upper Respiratory Infection (URI) No more than 65% 8. Percentage of diabetes patients who complete annual HbA1C, between years of age At least 78% 13

14 2016 Quality Metrics Targets 9. Percentage of patients with Diabetes and CAD that are currently taking a statin At least 70% 10. Percentage of a clinic s high priority patients seen by a member of the PCP s care management team at least twice in the past 12 months 11. Percentage of patients who had an acute inpatient hospital stay who were seen by a health-care provider within 10 days of discharge 12. Percentage of patients age 18 years and older who were prescribed chronic Alprazolam (Xanax) during the measurement period 13. Percentage of patients years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90mmHg) during the measurement period (All payer source) 14. Percentage of patients years of age with diabetes (type 1 or type 2) whose most recent HbA1C level during the measurement period was greater than 9.0% (poor control), was missing the most recent result, or was not done during the measurement period (All payer source) 15. Percentage of patients 3-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had evidence of height, weight, and body mass index (BMI) percentile documentation during the measurement period (All payer source) At least 76% At least 40% No more than 12% At least 55% No more than 35% At least 45% 14

15 Quality Metrics Facts WHAT: There are a total of 15 Quality Metrics for These metrics were developed to assist practices with improving patient care. They are based on quality metrics that are currently used in many initiatives. WHERE: Clinics will not be responsible for collecting the data needed for Quality Metrics This data will be retrieved through the claims process and will be presented to the clinics quarterly. We do recommend that you build similar reports/registries in your EHR to assist with practice transformation, but this is not required. WHEN: The targets for the metrics are 12 month goals, allowing clinics to work on improving their quality of care throughout the year. WHY: These metrics can provide insight to the clinic regarding possible areas of strengths and weaknesses; therefore, initiating planning and implementation of population management techniques, programs, and policies. HOW: Due to the quantity of measures currently being used to improve quality in the primary care setting across the U.S., BCBS selected measures that are similar or currently used throughout the state of Arkansas. The measures may vary in detail, so the numerator and denominator used by Arkansas Blue Cross Blue Shield is listed for each metric. 15

16 Quality Metrics- Exceptions Clinics will NOT be responsible for meeting the target for BCBS on the following Quality Metric until notified. BCBS will provide data when available. Metric 12 (Xanax prescriptions) Metrics that vary from the Arkansas State PCMH Metric 6 (CHF on beta blockers) Metric 7 (Antibiotic treatment for URI) Metric 9 (Diabetes and statin medications) Metrics that are reported under Activities Metrics 13-15: These metrics are included on the portal under 3 month activities and 13 month activities. Clinics are required to collect and report their own data. These metrics are for informational purposes and may be used as a reference point. 16

17 Quality Metrics Quality Metric 1: Percentage of patients who turned 15 months old during the performance period who received at least four wellness visits in their first 15 months Numerator Denominator Codes Children in the denominator who received four or more well-child visits during their first 15 months of life All children that are 15 months during the measurement year (age 15 months through 26 months on the report end date) and have continuous medical coverage CPT: 99381, 99382, 99391, 99392, Diagnosis codes: ICD-9: V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 ICD-10: Z00.10, Z00.111, Z00.121, Z00.129, Z76.2, Z00.8, Z23 Target: At least 70% Domain: Use of Services Measures: NQF 1392, HEDIS, PQRS, Arkansas State PCMH 17

18 Quality Metrics Quality Metric 2: Percentage of patients 3-6 years of age who had one or more well-child visits during the measurement year Numerator Denominator Codes Children who received at least one well-child visit with a PCP in the last reported 12 months All children that are 3-6 years old during the measurement year and have continuous medical coverage CPT: 99382, 99383, 99392, Diagnosis codes: ICD-9: V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 ICD-10: Z & Z00.129, Target: At least 67% Domain: Use of Services Measures: NQF 1516, HEDIS, PQRS, Arkansas State PCMH 18

19 Quality Metrics Quality Metric 3: Percentage of patients years of age who had one or more well-care visits during the measurement year Numerator Denominator Codes Members who had at least one comprehensive well-care visit with a primary care practitioner (PCP) or an obstetrics and gynecology (OB/GYN) practitioner in the last reported 12 months All males and females that are years old at the end of the reporting period and have continuous medical coverage CPT: , Diagnosis codes: ICD-9:V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 ICD-10: Z00.00, Z00.01, Z00.121, Z00.129, Z01.411, Z Target: At least 45% Domain: Use of Services Measures: HEDIS, Arkansas State PCMH 19

20 Quality Metrics Quality Metric 4: Percentage of patients 6-12 years of age with an ambulatory prescription dispensed for ADHD medication that was prescribed by their PCMH, who had a follow-up visit within 30 days by any practitioner with prescribing authority Numerator Includes the ADHD patients who had an outpatient, intensive outpatient or partial hospitalization followup visit with prescribing provider during the 30 days after the initial ADHD prescription. * This is not a medication adherence measure; therefore, we are only looking at the initial prescription fill and follow up appointment. Denominator All children 6 years of age at the start of the measurement period and 12 years of age as of 10 months prior to end of measurement period. Building events for ADHD prescriptions (with pre and post script windows). See page 21 for more details. 20

21 ADHD Follow Up Quality Metrics ADHD Medications: (HEDIS) Reference by NCQA Description Prescription CNS stimulants amphetamine-dextroamphetamine atomoxetine dexmethylphenidate dextroamphetamine lisdexamfetamine methamphetamine methylphenidate ICD-9: ICD-10: F90.1, F90.2, F90.9 Other Codes: 90791, 90792, 90801, 90802, , , 90826, , , , 90845, 90847, 90849, 90853, 90857, 90862, 90875, 90876, , , 99078, , , , , 99238, 99239, , , , , 99383, 99384, 99393, 99394, , 99411, 99412, / G0155, G0176,G0177,G0409-G0411/ H0002, H0004, H0031,H0034-H0037, H0039, H0040, H2000, H2001, H2010, H2011-H2020 / M0064 / S0201, S9480, S9484, S9485 Target: At least 36% Domain: Process/ Effective Communication Measures: CMS 136v5, NQF# 0108, HEDIS, PQRS 366, Arkansas State PCMH 21

22 Quality Metrics Quality Metric 5: Percentage of patients prescribed appropriate asthma medications Numerator Denominator Codes The number of patients in the denominator who were dispensed at least one prescription for an asthma controller medication during the measurement year Patients who were identified as having *persistent asthma with a visit during the measurement period, who also had medical benefits throughout 24 months before the measurement end date and pharmacy benefits 12 months before the measurement end date ICD-9: ICD-10: J45.3-J45.52 *Persistent asthma-at least four asthma medication dispensing events where leukotriene modifiers or antibody inhibitors were the sole asthma medication dispensed in that year. The patient must also have at least one diagnosis of asthma during the same year. Exclusion(s): (1)Exclude patients who had any diagnosis of Emphysema, COPD, Chronic Bronchitis (Obstructive Chronic Bronchitis Value Set, Chronic Respiratory Conditions Due To Fumes/Vapors Value Set), Cystic Fibrosis or Acute Respiratory Failure any time during the patient s history through the end of the measurement year (e.g., December 31). Target: At least 85%. Domain: Effectiveness of Care Measure Number: CMS 126v4, HEDIS, NQF 0036 (retired measure), PQRS 311, Arkansas State PCMH 22

23 Asthma Controller Medications Quality Metrics Description Prescriptions Antiasthmatic combinations Antibody inhibitor * Inhaled steroid combinations Inhaled corticosteroids Leukotriene modifiers* Long-acting, inhaled beta-2 agonists Mast cell stabilizers Methylxanthines Short-acting, inhaled beta-2 Agonists (This is a quick reliever medication class, not controllers. These should not be used for this metric.) Dyphylline-guaifenesin Guaifenesin-theophylline Omalizumab Budesonide-formoterol Fluticasone- salmeterol Mometasone-formoterol Beclomethasone Budesonide Ciclesonide Flunisolide Fluticasone CFC free Mometasone Triamcinolone Montelukast Zafirlukast Zileuton Arformoterol Salmeterol Formoterol Cromolyn Aminophylline Dyphylline Theophylline Albuterol Levalbuterol Metaproterenol Note: 1. For Antibody inhibitors or Leukotriene modifiers to be considered a controller medication, there has to be a prescription dispensed at least 4 times during the measurement year. 2. Also, there would need to be no other asthma medications prescribed along with either of those two medication classes for them to count as the sole controller medication. 23

24 Quality Metrics Quality Metric 6: Percentage of CHF patients age 18 and over on beta blockers specifically recommended for CHF management * Numerator Denominator Codes Includes the CHF patients in the denominator who filled a betablocker-containing prescription for CHF during the last 120 days of the report period. *Beta blockers to include for CHF: Bisoprolol fumarate Metoprolol tartrate Metoprolol succinate Carvedilol Bisoprolol & hydrochlorothiazide Metoprolol tartrate & hydrochlorothiazide Metoprolol succinate & hydrochlorothiazide All males and females that are 18 years or older at the end of the report period, with medical benefits throughout the 12 months prior to end of report period and pharmacy benefits for 6 months prior to end of report period. Also, during the 24 months prior to end of report period, patient has two or more encounters that are at least 14 days apart, where CHF is the diagnosis* (encounters can be office visit, ER visit, Inpatient or Outpatient) ICD- 9: , , , , , , 428.0, 428.1, , ,428.30, , , , ICD- 10: I11.0, I13.0, I50.1, I50.20, I50.22, I50.30, I50.32, I50.40, I50.42, I50.9 * Not only as a primary diagnosis Exclusions and other measure details can be found on pg

25 Quality Metric 6 Quality Metrics Exclusions: 1. Documentation of medical reason(s) for not prescribing beta-blocker therapy (e.g., low blood pressure, fluid overload, asthma, patients recently treated with an intravenous positive inotropic agent, allergy, intolerance, other medical reasons) 2. Documentation of patient reason(s) for not prescribing beta-blocker therapy (e.g., patient declined, other patient reasons) 3. Documentation of system reason(s) for not prescribing beta-blocker therapy (e.g., other reasons attributable to the healthcare system) These exclusions are noted in the NQF standards. Target: At least 49% Domain: Effectiveness of Care/Prevention and Treatment Measure Number: CMS 144v4, NQF 0083, HEDIS, PQRS 008 GPRO HF-6, Arkansas State PCMH 25

26 Quality Metrics Quality Metric 7: Percentage of children who received appropriate treatment for an Upper Respiratory Infection (URI) Numerator Patients who were dispensed antibiotic medication on or within 3 days after an outpatient or ED encounter for upper respiratory infection (URI) during the intake period (a higher rate is better). The measure is reported as an inverted rate *The measure is reported as an inverted rate (e.g. 1- numerator/denominator) to reflect the number of children that were not dispensed an antibiotic Denominator All children age 3 months as of July 1 of the year prior to the measurement year to 18 years as of June 30 of the measurement year who had an ED or outpatient visit with only a diagnosis of nonspecific upper respiratory infection (URI) during the intake period (July 1st of the year prior to the measurement year to June 30th of the measurement year). Refer to pg. 27 for codes, exclusions, and other metric detail. 26

27 Quality Metric 7 Quality Metrics AHFS ICD CPT HCPCS with Modifiers , , , , , , , , , Primary or secondary diagnosis codes: ICD-9: 460xx, 4640x, 46410, 46420, 4650x, 4658x, 4659x ICD-10: J00, J04.0, J04.10, J04.2, J06.0, J , 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241,99242, 99243, 99244, 99245, 99281, 99282, 99283, 99284, T1015 with modifier 1 = U1, T1015 with modifier 1 = U2, T1015 with modifier 1 = U5, T1015 with modifier 2 = U1, T1015 with modifier 2 = U2, T1015 with modifier 2 = U5, T1015 with modifier 3 = U1, T1015 with modifier 3 = U2, T1015 with modifier 3 = U5, T1015 with modifier 4 = U1, T1015 with modifier 4 = U2, T1015 with modifier 4 = U5, T1015 with modifiers 1-4 = 00 Exclusion(s): (1) ED visits that result in inpatient admission, (2) Episode Dates where a new or refill prescription for an antibiotic medication was filled 30 days prior to the Episode Date or was active on the Episode Date, (3) Episode Dates where the member had a claim/encounter with a competing diagnosis on or 3 days after the Episode Date, (4) Exclude all events after the first eligible event Target: No more than 65%. Domain: Effectiveness of Care Measure Number: CMS 154v4, NQF 0069, HEDIS, PQRS 065, Arkansas State PCMH 27

28 Quality Metrics Quality Metric 8: Percentage of Diabetes patients who complete annual HbA1C, between years of age Numerator Denominator Codes Patients included in the denominator who had an HbA1c test performed during the measurement year Patients years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) Diagnosis codes: ICD-9: ICD-10z: E08 - E13 CPT Codes: (A1c) CPT II codes: 3044F HbA1c <7 3045F HbA1c F HbA1c >9 Exclusion(s): (1) A diagnosis of polycystic ovaries, in any setting, any time in the patient s history through December 31 of the measurement year. (2) A diagnosis of gestational or steroid-induced diabetes, in any setting, during the measurement year or the year prior to the measurement year Target: At least 78% Domain: Effectiveness of Care: Comprehensive Diabetes Care Measure Number: NQF 0057, HEDIS, Arkansas State PCMH 28

29 Quality Metrics Quality Metric 9: Percentage of patients with Diabetes and Coronary Artery Disease that are currently taking a statin Numerator Denominator Codes Individuals in the denominator with at least one prescription for a statin or one or more claims with a procedure code for lipid-lowering therapy and no claim with a code for exclusions due to medical reasons, patient reasons, or system reasons All patients at the end of the report period with medical benefits throughout the 12 months prior to the end of the report period and 6 months of pharmacy coverage, who have a diagnosis of DM and CAD (Acute myocardial infarction or Ischemic heart disease) and had a professional encounter or facility event during the measurement period NDC code-michigan Quality Improvement Consortium 2012 Statin Drug List: ( MQIC_Statins_2015.pdf) Diagnosis codes for DM(see previous page) Diagnosis codes for CAD: ICD-9: , ICD-10: I25.10 Exclusion(s): (1) Individuals with a diagnosis of polycystic ovaries who do not have a visit with a diagnosis of diabetes in any setting during the measurement period. (2) Individuals with a diagnosis of gestational diabetes or steroid-induced diabetes who do not have a visit with a diagnosis of diabetes mellitus in any setting during the measurement period (these are exclusions due to medical reasons) Target: At least 70% Domain: Effectiveness of Care: Comprehensive Diabetes Care Measure Number: NQF 2712, HEDIS, Arkansas State PCMH 29

30 Quality Metrics Quality Metric 10: Percentage of a practice s high priority patients who have been seen by any PCP within their PCMH at least twice in the past 12 months Numerator The number of those high priority patients with 2 of the required visit types and criteria with their attributed PCMH Denominator Patients designated as high priority by practices according to Activity A Codes: CPT Other-Place of Service = 11 Count each distinct visit with attributed PCMH as one visit Visits occurring on the same day do not count as multiple visits Provider specialty must be either 001, 008, 011, 037, or 038 Target: At least 76% Domain: Utilization Measure Number: Arkansas State PCMH 30

31 Quality Metrics Quality Metric 11: Percentage of patients who had an acute inpatient hospital stay who were seen by a health-care provider within 10 days of discharge Numerator Patients with inpatient stays who meet the criteria below with any provider, within 10 days of discharge CPT: Place of Service = 11 Denominator Patients with an inpatient stay during the measurement period Defined as patient with a DRG assigned on the claim Logic takes into account transfers and does not count them as a separate inpatient stay from the original event Inclusion(s): Hospitalizations with a discharge date that occur within the start of the performance period and 10 days before the end of the performance period are included in the denominator Exclusion(s): Excludes stays with the following DRGs for childbirth: 0765, 0766, 0767, 0768, 0774, 0775 Target: At least 40% Domain: Care Coordination Measure Number: Arkansas State PCMH 31

32 Quality Metrics Quality Metric 12: Percentage of patients age18 years and older who were prescribed chronic Alprazolam (Xanax) during the measurement period Numerator Denominator Codes The number of patients in the denominator who had a minimum of 4 pharmacy claims (minimum drug quantity of 15 mg or more) for a drug with Alprazolam (Xanax) description (per HIC3 code) during the measurement year. Patients 18 years of age or older, for whom prescriptions were written during the measurement period HIC3: H2F and contains the description of Alprazolam Target: No more than12%. (Clinics will NOT be responsible until notified. See pg. 15 for details) Domain: Effectiveness of Care Measure Number: Arkansas State PCMH 32

33 Quality Metrics The following Quality Metrics are reported under Activity B on the PCMH portal. (Refer to pages 6-8 for details.) Quality Metric 13: Percentage of patients years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90mmHg) during the measurement period. Quality Metric 14: Percentage of patients years of age with diabetes (type 1 or type 2) whose most recent HbA1C level during the measurement period was greater than 9.0% (poor control) or was missing the most recent result, or an HbA1C test was not done during the measurement period. Quality Metric 15: Percentage of patients 3-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had evidence of height, weight, and body mass index (BMI) percentile documentation during the measurement period. 33

34 2016 Summary of Changes New Activities New Quality Metrics 3 month- Quarterly CQM reports Metric 7: Antibiotics and URI 12 month-vaccination practice Metric 10: PCP visit for high priority* 12 month-care plans for high priority patients * Metric 11: Hospital discharge follow up* 13 month- Quarterly CQM reports Metric 12: Xanax prescriptions Metric 13: Hypertension-controlled Metric 14: Diabetes-poor control Metric 15: BMI *Measures that were listed under Practice Support in the PCMH 2015 year 34

35 Resources Agency for Healthcare Research and Quality (AHRQ) The Healthcare Effectiveness Data and Information Set (HEDIS) Healthcare Common Procedure Coding System (HCPCS) CodeSets/HCPCS-Quarterly-Update.html National Quality Forum (NQF) National Drug Code Directory (NDC) htm Disclosure: This resource focuses exclusively on Arkansas Blue Cross Blue Shield 2016 PCMH and may not include information included in other programs. This is meant to be an instrument to clinics and is not all-inclusive of every code or circumstance. 35