Welcome to the Results and Recognition Quality Programs of 2021. This webinar will be a review of the Adult Measures in the R&R program and suggested best practices.
The objectives for this webinar are to: Understand the measure requirements, Understand criteria to meet the measure, Identify possible exclusions, and also, offer best practices that you may want to utilize.
These are the HEDIS measures in the Adult R&R Program.
They are broken down according to the different LOB or the specific populations they apply to: Medicaid, Fully Integrated Duel Eligible Special Needs Plans also referred to as FIDE-SNP and Medicare Advantage. For Medicaid there are 12 measures in that program including the sub-measures. Each sub-measure is independent of one another for the incentives. There are six measures for both the FIDE-SNP and Medicare Advantage.
We will talk about each of these measures in more detail as we move along in the presentation.
Before we go into the measure details I just want to talk a little bit about exclusions. There are some exclusions that may apply to certain measures and some that may apply to every measure. For example, one of the required exclusions pertains to hospice. Members who use hospice services at any time during the measurement year may be excluded from the measure. However, if there’s documentation that a member is nearing the end of life or is receiving palliative care, that would not meet the hospice exclusion. But there are some measures that do have a required exclusion specifically for palliative care. There are also some optional exclusions such as pregnancy, hysterectomy, mastectomy and advanced illness for example that will only apply to a specific measure. If a member is to be excluded from a measure, there has to be clear documentation in the member’s medical record as to the reason why and the date of the occurrence. For example, cervical cancer screening, if we’re looking to possibly exclude a member from this measure based on the fact that she had a hysterectomy, it must be clearly documented that the member had a total, radical and/or vaginal hysterectomy on or before December 31st of the measurement year. As we review the measures we will talk about the measure, the eligible population for each measure, the specific line of business it applies to, what specifically meets the measure for compliance and if any, the possible exclusions that may apply. You will hear the term “Measurement year”, this refers to the year in which we are collecting data from. The measurement year starts January 1st and ends December 31st.
Breast Cancer Screening
Breast Cancer Screening is for the percentage of women 50 to 74 years of age who had a mammogram to screen for breast cancer. The eligible population is for woman 52 to 74 years old by December 31st of the measurement year. This is due to a look back time frame. This is for the Medicaid, FIDE-SNP and Medicare population. For a member to be compliant, a mammogram must be done any time between October 1st, 2 years prior to the measurement year through December 31st of the measurement year 3D mammograms will meet compliance. However, MRIs, US or biopsies will not meet compliance as these tests are usually for diagnostic purposes and not for screenings. A unilateral mastectomy is not an exclusion, it must be a bilateral mastectomy.
So for exclusions, you will see this for a few of the adult measures. Again, for all lines of business, if the member is 66 years of age or older and has a diagnosis of both fragility and advanced illness as noted here the member may be excluded.
Let’s talk about some best practices for Breast Cancer screening. It’s important to educate the members about the importance of early detection and encourage screening. Engage patients to discuss their fears about mammograms and let the women know that the test is less uncomfortable and uses less radiation than it did in the past. You can establish a standing order to obtain annual mammograms for your eligible population. Also important is to document the month and year of most recent mammogram and/or mastectomy status, in the medical record.
Cervical Cancer Screening
Cervical Cancer Screening is for the percentage of woman 25 to 64 years of age who were screened for cervical cancer.
The eligible population is woman ages 24 to 64 years or age by December 31st of the measurement year. This measure also has a look back period. This measure is for the Medicaid population only.
And for a member to be compliant, we look for woman who are 24 to 64 years of age and had a screening done in the measurement or 2 years prior. If one is not found we can look at the measurement year and four years prior for women 30-64 years of age for cervical high-risk HPV testing. However, the age of the member must be 30 years or older on the date the test was performed.
Exclusions can be a total, radical or vaginal hysterectomy with no cervical residual.
Let’s talk for a moment about non-compliance vs optional exclusions. Non-compliance would be if there are no cervical cells present or the sample was inadequate.
Again, biopsies are diagnostic and not considered a screening, so they would not be eligible for this measure. Documentation of hysterectomy alone does not meet the criteria for a possible exclusion and that’s because we need to have significant evidence that the cervix was removed. Any one of these optional exclusions noted here may be used to exclude the member from this measure.
We are going to talk about some best practices.
So average-risk women younger than 21 years of age should not be screened. Cervical cancer is rare in adolescents and screening does not appear to lower that risk. Screening adolescents for cervical cancer can actually do more harm than good because it exposes them to potential harms of tests, biopsies, and procedures, without any real proven benefits. But remember every case may be different so it’s up to the provider and member to make that decision.
Average-risk women younger than 30 years of age should not be tested for HPV. Frequently the test will be positive because it’s spread through sexual contact and is very common in young people, but the infection often clears on its own within a year or two. So a positive result could lead to unnecessary concern and follow-up testing. Other factors may play into this, so again it’s up to the provider & member to discuss this and make a decision. Assess existing barriers to regular cervical cancer screening such as access to care, cost, anxiety, embarrassment or fear and try and implement a policy/procedural change to increase the rate of cervical cancer screenings. Increase community demand to promote cervical cancer screening through patient reminders, group and one on one education. Request to have cervical cytology results sent to you from an OB/GYN office.
So for Chlamydia we look at the percentage of women between 16 to 24 years of age who had at least one chlamydia screening in the measurement year. The eligible population for woman who turn 16 to 24 years of age sby December 31st of the measurement year and who have been identified as being sexually active either by pharmacy data for contraceptive or a claim/encounter for a pregnancy test. So as we all know, contraceptives are prescribed for reasons other than preventing pregnancy. However, whether the member is sexually active or not, if a contraceptive is prescribed, that member may fall in to this measure. This measure is for the Medicaid population only.
For a member to be compliant there must be at least one chlamydia test performed in the measurement year.
This can be done either by a urine test or a swab.
Exclusions - so If the member falls into the measure by just a pregnancy test alone, she may be excluded if she had a prescription for isotretinoin on the date of the pregnancy test or the 6 days after OR had an x-ray performed on the date of the test or 6 days after.
So let’s look at some best practices. Many offices have already adopted a process of universal screening of all girls and boys in this age range through a basic urine test, especially in the pediatric offices starting at their well visits at 16 years of age – so that be something that you want to consider doing.
The screening should occur with or without symptoms, as long as it’s done. Screenings should also occur at any visit where, Oral contraceptives or STDs or urinary symptoms are discussed. Create an environment conducive to sexual history taking and develop a tool for taking this history. Establish a process of obtaining chlamydia-screening results from Ob/GYN providers that are participating in the member’s care.
Adult Access to PCP
This is for the the percentage of members 20 years and older who had an ambulatory or preventative care visit during the measurement year.
The eligible population is for members 20 years and older by December 31st of the measurement year. This is for the Medicaid population only.
For a member to be compliant, they need just one visit with the PCP, sick or well, in the measurement year. There are no applicable exclusions here – it’s very simple and straight-forward.
Some best practices..
Encourage patients to maintain the relationship with a provider to promote consistent and coordinated health care.
Educate patients on the importance of having at least one ambulatory or preventative care visit during each measurement year.
Consider offering extended practice hours to increase care.
Telehealth visits, they will meet compliance. Remind patients of their appointment by making telephone calls or sending texts.
Asthma Medication Ratio
Asthma Medication Ratio – the percentage of members 5 to 64 years of age, who were identified as having persistent asthma and had a ratio of controller medications to total asthma medications of 0.50 or greater during the measurement year.
The eligible population are members who have persistent asthma – a true diagnosis of being asthmatic and not seasonal or allergic asthma. In addition to this, they must meet at least one of the following criteria during both the measurement year AND the year prior: At least one ED visit with a principal diagnosis of asthma OR At least one acute inpatient encounter, with a principal diagnosis of asthma without telehealth, At least one acute inpatient discharge with a principal diagnosis of asthma on the discharge, At least four outpatient visits, observation visits, telehealth visits, or online assessments, on different dates of service, with any diagnosis of asthma and at least two asthma medication dispensing events for any controller or reliever, At least four asthma medication-dispensing events for any controller or reliever.
So members must meet a medication ratio of 0.50 or greater in the measurement year. We’re going to show you how this is calculated in the following slide. This measure is strictly pharmacy driven, however, education from the PCP is the most important aspect of this measure. Educating the members on the importance of staying on their controllers is the key to compliance.
This is for the Medicaid population only. There are some exclusions. Some exclusions cane be emphysema, COPD, chronic respiratory conditions due to fumes or vapes and these just a few. Members who had no asthma controller or reliever medication dispensed during the measurement may also be excluded.
So now we’re going to look at how the calculation is done.
When identifying medication units for this measure, count each individual medication, which is defined as an amount lasting 30 days or less, as one unit. One medication unit equals one inhaler, one injection, one infusion or a 30-day or less supply of an oral medication. So for example, if two inhaler canisters of the same medication dispensed on the same day, they are counted as two medication units and only one dispensing event.
So let’s look at this example that we have here for you. Remember its units of controller medication divided by total asthma medication. In this example, the member filled one-month supply of asthma medications, both controller and a rescuer, and has additional prescriptions for three refills of the controller and three refills of the rescuer medications. Our claim data shows within the measurement year, this member had the controller meds filled twice and the rescue meds filled four times. So the AMR is 2 divided by 6, which gives us a compliance of 0.33. So remember, the AMR is 2, which is the number of controllers in this example and 2 plus 4, 6, which is all the medications, the total medications in this example. So for this example, the member is non-compliant because the AMR is under 0.50 compliant ratio.
Some best practices:
Develop an Asthma Action Plan,
Educate members on the importance of adhering to medications and reducing asthma triggers, Advise members to incorporate inhalers into their daily routine,
Reach out to members to schedule follow-up visits for the condition.
Controlling High Blood Pressure
Controlling High Blood Pressure is the percentage of members 18 to 85 years of age who had a diagnosis of hypertension and have an adequately controlled blood pressure reading of less than 140/90. The eligible population is for member 18 to 85 years of age by December 31st of the measurement year.
This is for Medicaid population only. For a member to be compliant, their last blood pressure reading the measurement year must be below 140/90 and it has to occur on or after the second confirmed diagnosis of hypertension. The diagnosis captured from claims and encounter data. So again, let’s look at some exclusions.
The majority of the exclusions are the same as we have previously seen for all LOB.
The additions specific to this measure are members 81 years of age or older as of December 31 of the measurement year with fragility noted during the measurement. Also members with ESRD, on dialysis or who have had a kidney removed or transplant prior to December 31 of the measurement year may be excluded.
Let’s look at some noncompliance issues for controlling high blood pressure.
So a member is non-compliant if the blood pressure reading was taken during an acute stay or during an emergency room visit. A reading taken by a non-digital device is not compliant. If the member has taken his or her own BP with an electronic device and verbally reports this to the provider, the provider must document this in the medical record - that would be considered acceptable. A blood pressure reading taken of the same day as a test or procedure that required a change in diet or medication on or one day prior, with the exception of fasting blood tests, is not compliant.
So now let’s look at some best practices. Document the blood pressure readings at every visit. If a blood pressure reading is greater than 140/90 at the time of visit, re-take it. Remember, you cannot round up blood pressure values. We do know that some members get a little nervous just walking into a provider’s office. So again, if the reading is greater than 140/90, allow the member to rest or even talk to distract them and then re-take it.
We can take the lowest systolic and diastolic if the reading is done on the same day.
Schedule follow-up visits for blood pressure control after diagnosis or a medication is adjusted. Consider referring to a cardiologist for those blood pressure goals that cannot be attained, or for complicated patients. For patients seen by a specialist, if the Primary Care obtains the visit notes and places them in their medical record and the blood pressure reading <140/90 mmHg, this will count toward compliancy.
Please remember it must be the last blood pressure reading in the measurement year.
Comprehensive Diabetes Care
So for Comprehensive Diabetes Care, there are five sub-measures for this particular measure. We’re are going to review each of these in more detail. Each sub measure is eligible for incentives and are considered separate. The eligible population is the same for all sub measures. This is for members who are 18 to 75 years of age by December 31st of the measurement year with type 1 or type 2 diabetes.
One of the most common questions we have is that the member is not a diabetic, so why are they in this measure. Members are pulled into this measure with a diagnosis of diabetes either by claims or encounter or pharmacy data. So please remember if you are ordering a lab and writing the diagnosis of diabetes, that one diagnosis will stay with the member for 2 years. It is very difficult to exclude a member from this measure due to diagnosis. Members who have a confirmed diagnosis of polycystic ovarian syndrome, gestational diabetes or steroid-induced diabetes may be excluded.
Again, the exclusions that you see here are pretty much the same as the ones we have reviewed in previous slides.
Hemoglobin A1C Testing
This is for the Medicaid, FIDE-SNP and Medicare population.
For the member to be compliant they need at least one A1C test done in the measurement year. The test can be performed either at the lab or in offices with CLIA license who perform the test in offices.
Let’s talk about A1c Control.
So this is for Medicaid, FIDE-SNP and Medicare population.
For Medicaid population to be compliant, the A1C needs to be less than 8. For the FIDE SNP and Medicare population to be compliant, the A1C is poor control of greater than 9. This measure is an inverted measure, meaning the lower your compliance rate is the better you’re doing. When you look at your member gap performance reports, your goal is to see the members as compliant. However for Poor Control >9 you DO NOT want to see them as compliant, because that means the member’s A1c is greater than 9 which is not good. Basically, those members are placed in the measure, you need to take them out. If the A1C is documented in the medical record, it must clearly be noted the date and the result of the test. Ranges and thresholds are not compliant results.
This is for the Medicaid, FIDE-SNP and Medicare population.
We are looking for retinal or dilated eye exam that must be performed by either an optometrist or ophthalmologist in the measurement year or a negative one the previous year.
For members to be compliant, they need to have either a retinal or dilated eye exam that must be performed by either an optometrist or ophthalmologist in the measurement year or again, a negative one in the year prior to the measurement year.
Or clear documentation of bilateral eye enucleation anytime during the member’s history through December 31st of the measurement year.
Here is quick guide of what documentation in the medical record meets compliance.
A Letter or note in the medical record by the PCP, optometrist, or ophthalmologist stating dilated or retinal eye exam was completed, agian by an optometrist or ophthalmologist with both the date and the results. The actual chart or photograph with the date and results. This test does not necessarily have to be done by an eye care professional BUT it must be read and resulted by one OR by a system, that provides artificial intelligence (AI) interpretation.
Bilateral eye enucleation, which is the removal of both eyes.
The exam must be done in an outpatient setting.
Documentation does not have to specifically say no diabetic retinopathy to be considered negative however, it must be clear that the patient had a dilated or retinal eye exam by an optometrist or ophthalmologist and that retinopathy was not present.
A notation limited to a statement that indicates “diabetes without complications” does not meet criteria.
Medical Attention to Nephropathy
This is for the FIDE-SNP and Medicare population only.
For a member to be compliant, they need to have either a nephropathy screening or monitoring or evidence of nephropathy during the measurement year, as documented through either administrative data or medical record review. The next slide will show how the member can meet compliance
The member is compliant if they meet one of the following:
Nephropathy screening test – to meet this criteria, the member needs to have a urine test for albumin or protein in the measurement year. There are several different urine tests that will be accepted for compliance. We need the date of the test or the reported date and the results. The simplest way to meet compliance for a provider’s office is a spot test or a dipstick, which is the urine test done in the office at the time of the visit. Evidence of Nephropathy – to meet this criteria the member needs to have one of the following:
Documentation of a visit to a nephrologist in the measurement year,
Evidence of nephrectomy or kidney transplant,
Documentation of medical attention to any of the following diagnosis noted.
There are not any restrictions on provider type, as far as whose following or monitoring the patient for the illness, it does not have to be the PCP. As long as there is documentation in the medical record stating the member is receiving care for any of these that will meet criteria for this sub-measure. Nephropathy Monitoring – to meet this criteria the member needs to have an ace or an arb prescribed, filled or documented in the measurement year.
Controlling High Blood Pressure
So again, Blood Pressure Control – this sub-measure and criteria is the same as Controlling High Blood Pressure previously discussed.
This, again, is for the Medicaid population only. For members to be compliant, their last blood pressure of the measurement year must be below 140/90.
Some best practices for CDC:
Order labs prior to the members’ appointment.
Coordinate lab testing prior to the office visit so that results can be reviewed and treatment plans adjusted as needed.
Ensure documentation in the medical record includes the date when the HbA1c test was done and/or nephropathy screening was performed, and the results. Document the date of most recent diabetic eye exam, with results, the name and title of eye care provider in the medical record.
Document blood pressure readings at every visit and re-take if greater than 140/90.
As previously discussed, all know some members get a little nervous just walking into a provider’s office. If the first reading is greater than 140/90, allow the member to rest or even talk to them to distract them then re-take it. Just like CBP, we can take the lower of the systolic and diastolic reading on the same day.
Statin Therapy for Patients with Diabetes
Statin Therapy for Patients with Diabetes is the percentage of members ages 40-75 years of age during the measurement year with diabetes, who do not have clinical atherosclerotic cardiovascular disease AND received statin therapy and have a compliance of 80% or greater adherence. The eligible population for members 40-75 years of age as of December 31st of the measurement year.
This, again, is for the Medicaid population only. For a member to be compliant, the member was dispensed at least one statin medication of any intensity during the measurement year and who has remained on the medication for at least 80% of the treatment period. This measure is also pharmacy driven but again education is the key component. Some possible exclusions: Again, members who do not have a diagnosis of diabetes AND who have had a diagnosis of polycystic ovarian syndrome, gestational diabetes or steroid-induced diabetes, in any setting, during the measurement year or the year prior to the measurement year may be excluded.
These are the medications at the different intensity levels that will meet compliance. Please remember this is only a guide as to what is in the NCQA specifications state. We cannot tell you how to treat your patients that would be up to you.
This measure has the same exclusions as the CDC measure with a few additional components. Members with cardiovascular disease identified by either an event or a diagnosis as noted here may be excluded. Some other exclusions that may apply is a diagnosis again of pregnancy, in-vitro fertilization, cirrhosis, palliative care during the measurement year, and these are just to name a few as noted on the bottom of this slide.
Statin Therapy for Patients with Cardiovascular Disease
Statin Therapy for Patients with Cardiovascular Disease is the percentage of males 21-75 years of age and female’s 40-75 years of age during the measurement year, who have clinical atherosclerotic cardiovascular disease AND received statin therapy and an adherence of 80% or greater.
This differs from the previous measure in that the member does not have diabetes but DOES have heart disease.
Also the eligible population differs in ages for males and females. Again, for the males, it’s 21 to 75 years of age by December 31st of the measurement year and for females, it’s ages 40 to 75 years of age by December 31st of the measurement year. This is for the Medicaid population only. For a member to be compliant, it is the same as the previous statin measure for diabetes. The member was dispensed at least one statin medication of any intensity during the measurement year and who has remained on that medication for at least 80% of the treatment period. Again, this measure is pharmacy driven but education is the key component.
Here again, we’re offering you a list of medications at different intensity levels that will meet compliance. Again, please remember this is only a guide as to what is in the NCQA specifications, we cannot tell you how to treat your patients.
Some exclusions, so the exclusions are the same as the one previously discussed with the statin therapy for diabetes.
Let’s talk about some best practices. Educate on the importance of complying with statin therapy during every communication. Simplify the medication regime by using once-daily dosing, if possible.
Listen to the members’ concerns and make them an active part of sharing decision making. Routinely arrange the next appointment for consistent follow-up and monitoring during the current visit.
Colorectal Screening – the percentage of members 50 to 75 years of age who had colorectal screening.
The eligible population is for member’s 50 to 75 years of age by December 31st of the measurement year. This is for the FIDE-SNP and Medicare population only. For a member to be compliant, any of the following screenings completed in the specified time frames are acceptable: A fecal occult blood test during the measurement year, Flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year, A colonoscopy during the measurement year or the nine years prior to the measurement year, CT done during the measurement year or the four years prior to the measurement year, A FIT-DNA test during the measurement year or the two years prior to the measurement year. Please note that a digital rectal exam done in the office for a FOBT test in an office setting or to obtain a sample from any test, or for any test, is not acceptable; the member will be non-compliant.
Again, the exclusions are the same as the CDC exclusions. There is an exceptional exclusion for this specific measure and that would be colorectal cancer or a total colectomy at any time during the member’s history through December 31 of the measurement year.
Let’s talk about some best practices.
Again, ask the member if they’ve had a colorectal screening and update this in their history on an annual basis; document the type and date the test was performed.
Emphasize personal choice and various modalities, especially for those members who may have a fear of having a colonoscopy. You can distribute the FOBT or the FIT test to members who need to be screened. You can also have an FOBT kit on hand to utilize for member teaching. Please remember to act quickly for members who have had a positive stool result. Also, Horizon has partnered with a vendor called BioIQ to send FIT tests to all the non-compliant Medicare members. The vendor will reach out to the PCP first to receive consent to send the members these in-home screenings.
This is the last measure we’re going to review that’s in the Adult R&R Program, Care of Older Adults.
So for Care of Older Adults, we are looking for Medication Review and this is the percentage of adults age 66 years and older who had a medication review completed in the measurement year.
The eligible population are members ages 66 years or older by December 31st of the measurement year. This measure is for the FIDE-SNP population only. So for a member to be compliant there needs to be one medication review in the measurement year. It can be done by either the prescribing physician or a clinical pharmacist. If the medication list is in the progress note and the provider signs the note, this is an indication they have reviewed the list during that visit. Also the member does not need to be physically present when the review is being conducted. So again, if the member is not taking any medications, that will also make the member compliant as long as it’s clearly documented in the medical record. One thing I do need to note, that if the review if for a side effect of a medication at the time it’s being prescribed this is not considered compliant. That is not a medication review.
So let’s just take a look at some best practices. Again, ensure the medication list is in medical record and evidence of the medication review by the prescribing practitioner or clinical pharmacist and the date it was performed. So please remember if the medication list in the in the progress note and the provider signs that note, that is considered a compliant medication review. If the member is not taking any medications clear documentation should be in the medical record with a date of the notation.
Incorporate a standardized template to capture this measure for members 66 years of age or older, if you’re using an EMR system.
That concludes the review of the Adult HEDIS measures for the 2021 Results & Recognition Program. Let’s quickly discuss how you can be successful in closing the gaps. So you can use your gap list, this contains a lot of information to assist you in identifying non-compliant members, it also contains contact information for the members. Calling or mailing to keep in contact with your patients and remind them to schedule their appointments.
Considers some barriers to your patients – offer telehealth visits or even possibly offer extended hours. Utilize your electronic health record – develop standing orders, review your current codes, and also set alerts. You can also refer to the Provider Tips for Optimizing HEDIS Results booklet. If you do not have a copy of that, that can be obtained through your CQIL.
Thank you for listening, if you have any questions, please e-mail them to Quality_RR@HorizonBlue.com.
Review of the Adult HEDIS Measures that includes suggested best practices and appropriate documentation for compliance.