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SNP Training – Topic 2:
SNP Subset of HEDIS Measures
March 3, 11, 16, 26, April 1, 2009
Overview
• Describe the SNP assessment project
NCQA is executing on behalf of CMS
• Review the SNP HEDIS reporting
requirements
– Which measures do SNPs have to report?
– Who has to report?
• Overview of individual measures
– Descriptions
– Eligible population
– Numerator criteria
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Introduction to SNP Assessment
Brett Kay
Director, SNP Assessment
Objectives of SNP Assessment Program
• Develop a robust and comprehensive
assessment strategy
• Evaluate the quality of care SNPs provide
• Evaluate how SNPs address the special
needs of their beneficiaries
• Provide data to CMS to allow plan-plan
and year-year comparisons
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SNP Assessment: How did we get here?
• Existing contract with CMS to develop
measures focusing on vulnerable elderly
• Revised contract to address SNP
assessment
– 1st year—rapid turnaround, adapted existing
NCQA measures and processes from
voluntary Accreditation programs
– 2nd year—focus on SNP-specific measures
– 3rd year—Refine measures; identify new SNPspecific measures, where appropriate
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Three-Year Strategy
Phase 1 - FY 2008
SNPs Effective as of
January 2007
Phase 2 - FY 2009
SNPs Effective as of
January 2008
HEDIS 2009
(15 measures)
HEDIS 2008
(13 measures)
•Addition of two 1st year
measures: Care for Older
Adults; Medication
Reconciliation PostDischarge
Structure & Process
Measures
Structure & Process
Measures
• SNP 1: Complex Case
Management
• SNP 2: Improving
Member Satisfaction
• SNP 3: Clinical Quality
Improvements
• SNP1 – 3
• SNP 4: Care Transitions
• SNP 5: Institutional SNP
Relationship with Facility
• SNP6: Coordination of
Medicare & Medicaid
Phase 3 - FY 2010
SNPs Effective as of January
2008
HEDIS 2010
• Measure development:
–Potentially Avoidable
Hospitalizations
–Inpatient Readmissions
–MDS measures (I-SNPs)
–Disease-specific measures (CSNPs)
Structure & Process
Measures
•Refinement of existing S&P
measures, includes the
potential development of
new elements
•Potential development of new
measures
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Project Time Line – Phase II
• March - Release final S&P measures
• March 30 - Release ISS Data Collection
Tool
– S & P Measures
• April - Release IDSS Data Collection Tool
– HEDIS Measures
• June 30 - HEDIS submissions and S&P
measures submissions due to NCQA
• October 30 - NCQA delivers SNP
Assessment Report to CMS
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Training & Education
• Five training topic areas, focus is on
content and data submission
– Introduction to NCQA & SNP Assessment
Program
– SNP Subset of HEDIS Measures
– Interactive Data Submission System (IDSS)
– Structure & Process Measures
• Phase I (SNP 1-3)
• Phase II (SNP 4-6)
– Interactive Survey System (ISS)
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SNP HEDIS Reporting Requirements
Courtney Breece
Senior Analyst, Licensure & Certification
SNP HEDIS Reporting Requirements
• Required Measures
(COL) Colorectal Cancer Screening*
(GSO) Glaucoma Screening in Older Adults
(COA) Care for Older Adults*
(SPR) Use of Spirometry Testing in the Assessment & Diagnosis of COPD
(PCE) Pharmacotherapy of COPD Exacerbation
(CBP) Controlling High Blood Pressure*
(PBH) Persistence of Beta Blocker Treatment After a Heart Attack
(OMW) Osteoporosis Management in Older Women
(AMM) Antidepressant Medication Management
(FUH) Follow-Up After Hospitalization for Mental Illness
(MPM) Annual Monitoring for Patients on Persistent Medications
(DDE) Potentially Harmful Drug-Disease Interactions
(DAE) Use of High Risk Medication in the Elderly
(MRP) Medication Reconciliation Post-Discharge*
(BCR) Board Certification
(HOS) Medicare Health Outcomes Survey
* SNP benefit packages under PPO Contracts do not have to report these measures because
these measures rely on medical record review.
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New SNP-only Measures
• Question: Are the two new SNP-only measures
(Care for Older Adults and Medication
Reconciliation Post-Discharge) optional
because they are 1st year measures?
• Response: These measures are not optional for
reporting in HEDIS 2009. They are required.
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General Reporting Requirements
• Who reports & what is the level of
reporting?
– Every SNP benefit package (identified by the
CMS Plan ID)
– Enrollment of 30 or more members as of
CMS’s February 2008 Comprehensive Report
If a SNP benefit package is listed in the February 2008 SNP
Comprehensive Report, but had 29 or fewer members, a HEDIS report is
not required; however, CMS requires that the organization report the
Structure & Process measures regardless of enrollment size.
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Reporting Structure
• Question: What are the HEDIS reporting requirements for MA plans
and SNP benefit packages?
• Response: See the chart below for details about the reporting
requirements.
MA HEDIS Reporting
Requirements
SNP HEDIS Reporting
Requirements
Summary Level
Reporting
Patient Level
Reporting
Summary Level
Reporting
Patient Level
Reporting
≥ 1,000 members including no SNP benefit packages
Yes
Yes
No
Not applicable
< 1,000 members including no SNP benefit packages
No
No
No
Not applicable
≥ 1,000 members including SNP benefit packages
Yes
Yes
Yes*
Not applicable
<1,000 members including SNP benefit packages
No
No
Yes*
Not applicable
SNP-only benefit packages with ≥ 1,000 SNP members
Yes
Yes
Yes*
Not applicable
SNP-only benefit packages with < 1,000 SNP members
No
No
Yes*
Not applicable
≥ 1,000 Medicaid members with <1,000 in a SNP DualEligible benefit package
No
No
Yes*
Not applicable
MA Contract
* Organizations with SNP benefit packages that have an enrollment of <29 as of the Feb 2008
Comprehensive do not report HEDIS measures.
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Audit Requirement
• Question: Does every submission require an
audit?
• Response: Yes, every SNP benefit package level
submission must undergo a HEDIS Compliance
Audit™.
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Medicare Specifications
• Question: Does the SNP submission use
Medicare specifications for the measures?
• Response: Yes, for the required HEDIS measures
use the specifications in Volume 2, HEDIS
Specifications.
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Patient-Level Detail File
• Question: Does CMS require a Patient Level
Detail File for each SNP benefit package
submission?
• Response: No, the plan does not need to
create a separate patient-level file for each
SNP submission. However, the patient-level data
submitted for the larger Contract-level must
include all MA members, including members
enrolled in its SNP benefit packages. (See the
Reporting Structure Chart above.)
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Medicare Advantage
• Question: If an MA plan has a SNP benefit
package, does it report the members in the
Medicare Contract submission AND the SNP
submission?
• Response: Yes, SNP members will be reported in
two submissions – the full Medicare submission
at the Contract-level and the SNP benefit
package in which they receive benefits.
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Dual-Eligible SNP
• Question: For Dual-Eligible SNP benefit
packages, is a member reported to NCQA in
the Medicare, Medicaid, and SNP submissions?
• Response: Yes, in all three. All HEDIS guidelines
about dual eligible members still apply, and
these members are also included in the SNPspecific submission.
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SNP-only Plan
• Question: If a Medicare Advantage organization, which
offers only SNP benefit packages, meets the threshold
for reporting HEDIS at the Contract level do they report
all HEDIS measures required for Contract-level reporting
or only the SNP subset measures?
• Response: If a Medicare Advantage organization with
only SNP benefit packages had 1,000 members listed on
July 2008 Monthly Enrollment by Contract Report, the
plan must report the SNP subset of measures and the
other Medicare measures as well. See the memo from
CMS dated December 9, 2008 for the complete list of
HEDIS measures required for Contract-level reporting.
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Medicare Advantage & Hybrid Method
• Question: If an MA plan uses the hybrid method
to report any measure, must they draw a
separate sample for the SNP benefit packages?
• Response: Yes, every submission is treated
separately; for example, if a plan reports
Colorectal Cancer Screening for the full MA
plan population and a SNP benefit package,
two distinct samples must be drawn.
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Hybrid Methodology – Substituting Records
• Question: If an MA plan draws a sample for the
Controlling High Blood Pressure measure for the MA
population and a separate sample for the same
measure for the SNP benefit package, what does the
plan do with the overlapping members?
• Response: If there are SNP members in the sample for
the full MA plan (main sample), the plan may use them
for the SNP sample. For example, the main sample of
411 has 5 SNP members. The SNP sample has 250.
Randomly select 5 members from the SNP sample and
replace them with 5 SNP members in the main sample.
The 5 SNP members are evaluated in both samples. If
the plan chooses to use the option to substitute records,
all SNP members in the main sample must be used for
the SNP sample, the members pulled from the SNP
sample must be chosen at random, and the auditor
must approve the process.
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Continuous Enrollment
• Question: How is continuous enrollment
calculated for the SNP benefit packages?
• Response: Calculate continuous enrollment for
SNP members according to the standard HEDIS
requirement for Medicare products. Members
should be reported in the SNP they are enrolled
in at the end of the continuous enrollment
period. For measures with no continuous
enrollment requirement, report members in the
SNP they were in at the time of service.
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Small Denominators
• Question: How are small denominators handled?
• Response: To understand the performance of the entire
SNP program, it is important that SNPs report a measure
even when there are fewer than 30 members in the
measure’s denominator. Each SNP benefit package
must collect data and report the required measures
according to the specifications regardless of the
denominator size.
• It is important to note, NCQA’s Interactive Data
Submission System (IDSS) will not calculate a rate for
measures where the denominator is fewer than 30, but
NCQA will use the reported measure numerators and
denominators for aggregated reporting purposes.
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Institutional SNPs & Contract Level Reporting
• Question: If a Medicare Advantage organization, which
offers only Institutional SNP benefit packages, meets the
threshold for reporting HEDIS at the Contract level
(>1,000 members), are they required to report all MA
measures?
• Response: Yes, reporting at the Contract Level is
required. In some cases, Institutional SNPs may have no
members that meet the denominator criteria for some
measures because of the required exclusions; however,
the plan’s auditor must determine for each measure
that the plan calculated the denominator, the
exclusions and the measure result. Additionally, the plan
must report all counts for the denominators, numerators
and exclusions even when they are zeros.
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Medicare Health Outcomes Survey
• Question: Is a Medicare Advantage organization, which offers only SNP
benefit packages, required to report HOS and what are the
requirements?
• Response: Yes, reporting HOS at the Contract Level is required for
Medicare contracts with exclusively SNP packages in effect on or before
January 1, 2008. See the chart below for details about the reporting
requirements. To report HOS data, SNPs must contract with a certified
HOS survey vendor and notify NCQA of their survey vendor choice no
later than February 2, 2009.
Plan Type
Survey
Type
Contract Date
Enrollment Criteria
2009 Reporting
SNP
Medicare HOS
Contracts in effect on or before
January 1, 2008
Minimum of 500
members*
Required
• *Generally, enrollment size is verified in the fall to determine eligibility and
analyzed again prior to sampling to ensure the plan did not drop below
the required membership.
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Overview of SNP Subset of HEDIS Measures
Aisha T. Pittman, MPH
HEDIS Measures for SNPs
• Selected in collaboration with SNP
Technical Panel
– Excluded measures with upper age limit
below 75
– Excluded measures focusing on
management of one chronic condition
• Collected by SNP benefit package,
regardless of size
– Will be reported in aggregate
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HEDIS 2009 Measures
Effectiveness of Care Measures
Colorectal Cancer Screening*
Glaucoma Screening in Older Adults
Use of Spirometry Testing in the Assessment and Diagnosis of COPD
Pharmacotherapy of COPD Exacerbation
Controlling High Blood Pressure*
Persistence of Beta Blocker Treatment After Heart Attack
Osteoporosis Management in Older Women
Antidepressant Medication Management
Follow-Up After Hospitalization for Mental Illness
Annual Monitoring for Patients on Persistent Medications
Potentially Harmful Drug-Disease Interactions in the Elderly
Use of High Risk Medications in the Elderly
Care for Older Adults*
Medication Reconciliation Post-Discharge*
Health Plan Descriptive Information Measures
Board Certification
* SNP benefit packages under PPO Contracts do not have to report these measures because these measures rely on medical record review.
** This first-year measure is optional for all MA reporting, including the SNP benefit packages.
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HEDIS General Guidelines
• HEDIS 2009, Volume 2: Technical
Specifications
• General Guidelines for Data Collection
and Reporting (p. 9) apply to SNP
reporting
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Components of HEDIS Measures
• Measure Description
– Explains what the rate is capturing
• Definitions
– Intake Period- time period to identify eligible
episodes
– Episode Date- date of event or service
– Index Episode Start Date (IESD)- the earliest
episode date during the intake period
• Eligible Population
– The total population that meets the measure
specifications -also referred to as the denominator
– Exclusions can be applied to the denominator if
applicable
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Components of HEDIS Measures
• Rate
– The rate is the numerator/eligible population
•The numerator is comprised of those people
who received the treatment or service
indicated in the measure
• Data Collection Methodology
– There are three possible methods:
• Administrative
• Medical Record or Hybrid
• Survey
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Eligible Population
• Product lines
– Commercial, Medicare, Medicaid
• Ages
• Continuous enrollment
– The time period during which a member must be
continuously enrolled in the plan
• Allowable gap
– Gaps allowed during the continuous enrollment period
• Anchor date
– Enrollment date criteria for the eligible population
• Benefit
– The type of benefits the member must have to be included
in the measure
• Event/diagnosis
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New Measures in HEDIS 2009
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Care for Older Adults (COA)
• The percentage of adults 65 years and older
who had each of the following during the
measurement year.
–
–
–
–
Advance care planning
Medication review
Functional status assessment
Pain screening
• This measure is collected using the hybrid
method or CPT Category II codes
• Eligible population: Members 65 years and older
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COA- Advance Care Planning FAQs
• Evidence of an advance care plan during the
measurement year
• CPT II code: 1157F or 1158F
• Medical record review:
– Presence of an advanced care plan in the medical
record
• Advance directives, actionable medical orders, living wills,
surrogate decision makers
– Documentation of and care planning discussion with
a provider and the date on which it was discussed
• Notation in the medical record
• Oral statements
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COA- Advance Care Planning
• Can a health plan find an advance care plan executed
in 2005 in the medical record and consider the member
numerator compliant, even if it is clear that the plan is
no longer in force?
– No. The advance care plan does not have to be executed
during the measurement year but it must be active during the
measurement year to be compliant. A member would not be
compliant if the advance care plan was executed in 2005 and it
is clearly no longer active during the measurement year. The
intent was for plans to be able to use advance care plans that
were executed several years ago that were still active.
• Is evidence of advanced care planning done by a
licensed social worker or nurse case manager
acceptable for this measure?
– Yes. The measure does not specify the type of visit or physician
type for the Advance care planning numerator; thus, Advance
care planning performed by a licensed social worker or nurse
case manager would be compliant.
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COA- Medication Review
• At least one medication review conducted by a
prescribing practitioner or clinical pharmacist
during the measurement year AND the
presence of a medication list in the medical
record
• CPT II Code: 1160F (review) AND 1159F (list)
• Medical Record Review:
– A medication list in the medical record AND
– Evidence of a medication review and the date on
which it was performed
• Documentation that a practitioner has reviewed all
medications that the member is taking
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COA- Medication Review FAQs
• May a clinical pharmacist consultation be done
by phone?
– Yes, if the information is documented in the medical
record. Clinical pharmacists were included so that
plans that employ them may get credit. Medication
reviews are often a part of plans’ MTM programs
• Is the date and initials of the provider on a
medication list sufficient evidence that the
medication list was reviewed?
– Yes, the initials of the provider on the medication list
along with the date of the review would be compliant
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COA- Functional Status Assessment
• At least one functional status assessment
during the measurement year
• CPT II code: 1170F
• Medical record review:
• Notation of functional independence,
• Notation of loss of independence, ADLs
• Notation of level of assistance needed to
accomplish tasks
• Results of assessment using standardized
functional status assessment tool
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COA- Functional Status Assessment FAQs
• If a patient has lost the ability to walk unassisted, and that is noted
in the patients chart, could this notation be used as a loss of
independent performance?
– Yes. If the documentation in the medical record states that the
"member has lost the ability to walk" and has a date on which the
assessment was performed, does meet numerator criteria for loss of
independent performance.
• Would notation of a person’s use of cane or walker meet the
criteria?
– No. These notations are not specific enough to be considered an
assessment of functional status
• Is there criteria around which or how many ADL's, IADL's, etc, need
to be notated in the patient’s chart in order for that to be counted
toward functional status assessment?
– No. There is not specific number of ADLs or IADLs that should be
assessed in order to meet the functional status assessment. However, a
date on which the assessment was performed should be noted.
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COA- Pain Screening
• At least one pain screening or
development of a pain management
plan during the measurement year
• CPT II code: 1125F, 1126F, 0521F
• Medical record review:
– Notation of presence or absence of pain
– Results of a screening using a standardized
pain screening tool
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COA- Pain Screening FAQs
• How detailed does a pain screen have to be? For
example, would a notation in a chart indicating the
patient was not experiencing chest pain be considered
evidence of Absence of Pain and be counted?
– Yes. Notation in a chart indicating the patient was not
experiencing chest pain would be considered evidence of the
absence of pain and would be compliant for the pain screening
component of the measure.
– Currently, the medical record documentation for the pain
screening indicator does not specify the type of pain (general
or specific) but rather it only requires a notation of the presence
or absence of pain.
– We will consider the wording of the medical record criteria of
this indicator during the measure's first-year analysis as it may
need to be revised to capture a thorough pain screening.
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Medication Reconciliation Post Discharge
(MRP)
• The percentage of discharges from
January 1 to December 1 of the
measurement year for members 65 years
of age and older for whom medications
were reconciled on or within 30 days of
discharge
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MRP- Eligible Population
• Members 65 years as of 12/31 of the
measurement year
• An acute or nonacute inpatient discharge on or
between 1/1 and 12/1 of the measurement year
– Note: The eligible population for this measure is
based on inpatient discharges, not on members. It is
possible for the denominator to include multiple
events for the same individual
• Readmissions/Transfers:
– If a member has a direct transfer, count the
discharge from the facility to which the member was
transferred
– If a member is readmitted within the 30-day follow-up
period, count only the readmission discharge
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MRP- Numerator Criteria
• Medication reconciliation on or within 30 days
after discharge
– Note: only documentation in the outpatient chart
meets the intent of the measure; information
obtained from the inpatient chart does not count
• CPT II code: 1111F
• Medical record review:
– A list of medications that were prescribed or ordered
upon discharge
– Notation that no medications were prescribed or
ordered upon discharge
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MRP FAQs
• May a clinical pharmacist consultation be done by
phone?
– Yes, if the information is documented in the medical record.
Clinical pharmacists were included so that plans that employ
them may get credit. Medication reconciliations are often a part
of plans’ MTM programs
• Does a medication list in the discharge summary for the
inpatient discharge meet the numerator criteria?
– No. The intent of the measure is that the medication list be
reviewed by an outpatient provider; therefore, a medication list
reviewed in an inpatient setting does not meet the numerator
criteria.
– Documentation of medications in the outpatient setting (e.g., a
discharge summary in the outpatient chart) meets the
numerator criteria for this measure.
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Changes to Measures in HEDIS 2009
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Colorectal Cancer Screening (COL)
• The percentage of members 50 – 80 years of
age who had appropriate screening for
colorectal cancer
• Eligible Population:
– Members 51-80 years as of 12/31 of the
measurement year
– Continuously enrolled during the measurement year
and the year prior
– No more than one 45 day gap in enrollment during
each year of continuous enrollment
– Exclude members with diagnosis of colorectal
cancer or total colectomy
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Colorectal Cancer Screening (COL)
• Numerator Criteria:
– One or more appropriate screenings defined by any one of the
following criteria:
• Fecal occult blood test (FOBT) during the measurement year
• Flexible sigmoidoscopy during the measurement year or the four
years prior to the measurement year
• Double contrast barium enema (DCBE) or air contrast barium
enema during the measurement year or the four years prior to the
measurement year
• Colonoscopy during the measurement year or the nine years prior
to the measurement year
• This measure can be collected using the hybrid method
• New for HEDIS 2009: Documentation in medical record
must include a note indicating date the screening was
performed in the medical history section. Notations in
other sections of the medical record do not distinguish
between tests ordered and tests performed
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Antidepressant Medication Management
(AMM)
• The following components of this measure
assess different facets of the successful
pharmacological management of major
depression.
• Effective Acute Phase Treatment: percent of members who
remained on an antidepressant drug during the 84 days/12 weeks
following diagnosis
• Effective Continuation Phase Treatment: percent of members
who remained on an antidepressant drug for at least 180 days/6
months
– New for HEDIS 2009: Retired Rate
• Optimal Practitioner Contacts for Medication Management:
Percent of members with at least three follow-up contacts within
12 weeks of diagnosis
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Antidepressant Medication Management
(AMM)
• Eligible Population:
– Members 18 years and older as of 4/30 of measurement year
– Continuously enrolled 120 days prior to IESD through 245 days
after IESD
– Diagnosis of a new episode of major depressive disorder during
the intake period
– No more than one 45-day gap in enrollment
– Steps to identify eligible population
• Numerator criteria:
– Effective acute phase: members who fulfilled a sufficient number
of separate prescription/refills of antidepressant medication to
have continuous treatment for 84 days
– Effective continuation phase: a 180-day treatment with
antidepressant medication
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Board Certification (BCR)
• The percentage of the following physicians
whose board certification is active as of
December 31 of the measurement year.
• Family medicine physicians
• Internal medicine physicians
• Pediatricians
• OB/GYN physicians
• Geriatricians
• Other physician specialists
• New for HEDIS 2009: Table BCR-A indicates how to identify
physicians
– Board certification refers to the various specialty
certification programs of the American Board of
Medical Specialties and the American Osteopathic
Association.
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Measures without Changes in HEDIS 2009
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Glaucoma Screening in Older Adults (GSO)
• The percentage of Medicare members 65 years
and older who received a glaucoma eye exam
• Eligible Population:
– Members 65 years as of 12/31 of the measurement
year
– Continuously enrolled during the measurement year
and year prior
– No more than one 45 day gap in enrollment during
each year of continuous enrollment
– Exclude members with prior diagnosis of glaucoma
or glaucoma suspect
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Glaucoma Screening in Older Adults (GSO)
• Numerator criteria:
– One or more eye exams for glaucoma by an
eye care professional during the
measurement year or the year prior
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Use of Spirometry Testing in the Assessment
and Diagnosis of COPD (SPR)
• The percentage of members 40 years of age
and older with a new diagnosis or newly active
chronic obstructive pulmonary disease (COPD)
who received appropriate spirometry testing to
confirm the diagnosis
• Eligible Population:
– Members 42 years or older as of 12/31 of the
measurement year
– Continuously enrolled two years prior to IESD through
180 days after IESD
– No more than one 45-day gap in enrollment in each
12-month period before IESD or 6-month period after
IESD
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Use of Spirometry Testing in the Assessment
and Diagnosis of COPD (SPR)
• Steps to Identify Eligible Population:
– Identify all members with diagnosis of COPD
during intake period
– Test for negative diagnosis history, exclude
members with prior diagnosis of COPD
– Calculate continuous enrollment
• Numerator criteria:
– At least one claim/encounter with spirometry
in the two years before to 180 days after the
IESD
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Pharmacotherapy of COPD Exacerbation
(PCE)
• The percentage of COPD exacerbations
for members 40 years of age and older
who had an acute inpatient discharge or
ED encounter between January 1–
December 1 of the measurement year
and who were dispensed appropriate
medications. Two rates are reported.
• Dispensed a systemic corticosteroid within 14 days
of the event
• Dispensed a bronchodilator within 30 days of the
event
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Pharmacotherapy of COPD Exacerbation
(PCE)
• Eligible Population:
– Members 40 years or older as of 12/1 of the measurement year
– Continuously enrolled Episode Date through 30 days after
Episode date, no allowable gaps
– A COPD exacerbation indicated by acute inpatient discharge
or ED encounter
• Note: The eligible population for this measure is based on acute
inpatient discharges and ED visits, not on members. It is possible for
the denominator to include multiple events for the same individual
– Steps indicated to identify eligible population
• Numerator Criteria:
– Rate 1: Prescription for systematic corticosteroid on or 14 days
after Episode Date
– Rate 2: Prescription for bronchodilator on or 30 days after
Episode Date
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Controlling High Blood Pressure (CBP)
• The percentage of members 18–85 years of age who
had a diagnosis of hypertension (HTN) and whose blood
pressure (BP) was adequately controlled (<140/90)
during the measurement year
• Note: The hybrid method must be used for this measure
• Eligible population:
– Members 18-85 years as of 12/31 of the measurement year
– No more than one 45-day gap in enrollment during the
measurement year
– At least one outpatient encounter with a diagnosis of
hypertension in the first six months of the measurement year
– Note: Hypertensive diagnosis must be confirmed in the medical
record on or before June 30 of the measurement year
– Exclude members with ESRD, who are pregnant or were
admitted to a non-acute inpatient setting (institutionalized)
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Controlling High Blood Pressure (CBP)
• Numerator criteria:
– Representative BP is adequately controlled
• Adequate control- representative systolic BP<
140mmHg and representative diastolic BP
<90mmHg
• Representative BP- the most recent BP during the
measurement year after the hypertension
diagnosis
– If there are multiple BPs on the same date use the lowest
systolic and lowest diastolic
– If no BP is recorded assume the member is not controlled
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Persistence of Beta Blocker Treatment After
Heart Attack (PBH)
• The percentage of members 18 years of age
and older during the measurement year who
were hospitalized and discharged alive from
July 1 of the year prior to the measurement year
to June 30 of the measurement year with a
diagnosis of acute myocardial infarction (AMI)
and who received persistent beta-blocker
treatment for six months after discharge
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Persistence of Beta Blocker Treatment After
Heart Attack (PBH)
• Eligible population:
– Members 18 and older as of 12/31 of the measurement year
– Continuously enrolled from discharge to 180 days after
discharge
– Discharged alive from an acute inpatient setting with an AMI
– Exclude members with a contraindication to beta-blocker
therapy or transferred to a nonacute care facility
(institutionalized)
• Numerator Criteria:
– A 180-day course of treatment of beta blockers
– Persistence of treatment must be at least 75% or 135 days
– If members were on beta blockers prior to admission, take into
account those prescriptions in determining adherence
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Osteoporosis Management in Women Who
Had a Fracture (OMW)
• The percentage of women 67 years of
age and older who suffered a fracture
and who had either a bone mineral
density (BMD) test or prescription for a
drug to treat or prevent osteoporosis in
the six months after the fracture
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Osteoporosis Management in Women Who
Had a Fracture (OMW)
• Eligible population:
– Women 67 years and older as of 12/31 of the measurement year
– Continuously enrolled 12 months prior to through 6 months after
IESD
– No more than one 45-day gap in enrollment during continuous
enrollment period
– Evidence of a fracture
– Steps to identify eligible population
• Numerator Criteria:
– A BMD test on the IESD or in the 180 day period after the IESD
– A BMD test during the inpatient stay for the fracture
– A dispensed prescription to treat osteoporosis
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Follow-Up After Hospitalization for Mental
Illness (FUH)
• The percentage of discharges for
members 6 years of age and older who
were hospitalized for treatment of
selected mental health disorders and who
had an outpatient visit, an intensive
outpatient encounter or partial
hospitalization with a mental health
practitioner. Two rates are reported.
• The percentage of members who received followup within 30 days of discharge
• The percentage of members who received followup within 7 days of discharge
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Follow-Up After Hospitalization for Mental
Illness (FUH)
• Eligible Population:
– Members 6 years and older as of discharge date
– Continuously enrolled from discharge date through 30 days after
discharge
– No gaps in enrollment allowed
– Discharged alive from an acute inpatient setting with a principal
mental health diagnosis
– Note: The denominator is based on discharges, not members
– Exclude members transferred directly to a nonacute facility for a
non-mental health principal diagnosis (institutionalized)
• Numerator Criteria:
– 30 day follow-up: an outpatient visit, intensive outpatient
encounter or partial hospitalization with a mental health
practitioner within 30 days of discharge
– 7 day follow-up: an outpatient visit, intensive outpatient
encounter or partial hospitalization with a mental health
practitioner within 7 days of discharge
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Annual Monitoring for Patients on Persistent
Medications (MPM)
• The percentage of members 18 years of age and older
who received at least a 180-day supply of ambulatory
medication therapy for a select therapeutic agent
during the measurement year and at least one
therapeutic monitoring event for the therapeutic agent
in the measurement year. For each product line, report
each of the four rates separately and as a total rate.
• Annual monitoring for members on angiotensin converting enzyme
(ACE) inhibitors or angiotensin receptor blockers (ARB)
• Annual monitoring for members on digoxin
• Annual monitoring for members on diuretics
• Annual monitoring for members on anticonvulsants
• Total rate (the sum of the four numerators divided by the sum of the
four denominators)
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Annual Monitoring for Patients on Persistent
Medications (MPM)
• Eligible Population:
– Members 18 years and older as of 12/31 of the measurement year
– Continuously enrolled during the measurement year
– No more than one 45-day gap in enrollment during each year of
enrollment
– 180-day supply of an ambulatory medication of interest
– Note: Members with more than one persistent medication can appear
in the measure multiple times (i.e., in each indicator for which they
qualify)
– Note: Members may switch therapies with any medication listed during
the measurement year and have the days supply for each of those
medications count towards the 180-day supply
– Exclude members with an inpatient stay in the measurement year
• Numerator Criteria:
– ACEI/ARBs, Digoxin, Diuretics: at least one serum potassium and either
a serum creatinine or blood urea nitrogen therapeutic monitoring test
– Anticonvulsants: at least one drug serum concentration level
monitoring test for the described drug
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Potentially Harmful Drug-Disease Interactions
in the Elderly (DDE)
• The percentage of Medicare members 65 years of age
and older who have evidence of an underlying disease,
condition or health concern and who were dispensed
an ambulatory prescription for a contraindicated
medication, concurrent with or after the diagnosis
– Report each of the three rates separately and as a total rate
• A history of falls and a prescription for tricyclic antidepressants,
antipsychotics or sleep agents
• Dementia and a prescription for tricyclic antidepressants or
anticholinergic agents
• Chronic renal failure and prescription for nonaspirin NSAIDs or Cox2 Selective NSAIDs
• Total rate (the sum of the three numerators divided by the sum of
the three denominators)
– For all three rates, a lower rate represents better performance
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Potentially Harmful Drug-Disease Interactions
in the Elderly (DDE)
• Eligible population:
– Members 67 years and older as of 12/31 of the measurement
year
– Continuously enrolled the measurement year and the year prior
– No more than one 45-day gap in enrollment during each year
of continuous enrollment
– At least one disease or condition or procedure in the
measurement year or the year prior
– Note: Members with more than one disease or condition can
appear in the measure multiple times (i.e., in each indicator for
which they qualify)
• Numerator criteria:
– History of falls: dispensed a tricyclic antidepressant
– Dementia: dispensed a tricyclic antidepressant
– Chronic renal failure: dispensed an NSAID or cox-2 selective
NSAID
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Use of High Risk Medications in the Elderly
(DAE)
• The percentage of Medicare members 65
years of age and older who received at
least one high risk medication
• The percentage of Medicare members 65
years of age and older who received at
least two different high risk medications
• For both rates, a lower rate represents better
performance
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Use of High Risk Medications in the Elderly
(DAE)
• Eligible population:
– Members 67 years and older as of 12/31 of
the measurement year
– Continuously enrolled during the
measurement year
– No more than on 45-day gap in enrollment
• Numerator Criteria:
– Rate 1: At least one high risk medication
dispensed
– Rate 2: At least two high risk medications
dispensed
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Future HEDIS Measures for SNPs
• HEDIS 2010/2011 Measures
– Inpatient Readmissions
– Potentially Avoidable Hospitalizations
• Public Comment in June/July
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Contacts
Brett Kay
Director, SNP Assessment
202-955-1722
[email protected]
Casandra Monroe
Assistant Director, SNP Assessment
202-955-5136
[email protected]
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Additional Resources
• NCQA SNP Website:
www.ncqa.org/snp.aspx
– FAQs (HEDIS)
– Training descriptions & schedule
– Final HEDIS and S&P measures (March 14)
• NCQA Policy Clarification Support (PCS)
http://app04.ncqa.org/pcs/web/asp/TIL_ClientLogin.asp
• HEDIS Audit information
http://www.ncqa.org/tabid/204/Default.aspx
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Policy Clarification Support (PCS)
• PCS Web address
http://app04.ncqa.org/pcs/web/asp/TIL_ClientLogin.asp
• Link for SNP Web page
www.ncqa.org/snp.aspx
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Policy Clarification Support (PCS)
• Under “Standard Categories/HEDIS
Domain,” select one of the following
options:
– SNP – General Reporting Guidance
– SNP – HEDIS
– SNP – Structure & Process Measures
• Menu options under “Standard/Measures”
– If “SNP – General Reporting Guidance” was
selected:
• Not Applicable
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Policy Clarification Support (PCS)
Menu options under “Standard/Measures”
• If “SNP – HEDIS” was selected:
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
(COL) Colorectal Cancer Screening
(GSO) Glaucoma Screening in Older Adults
(COA) Care for Older Adults
(SPR) Use of Spirometry Testing in the Assessment & Diagnosis of COPD
(PCE) Pharmacotherapy Management of COPD Exacerbation
(CBP) Controlling High Blood Pressure
(PBH) Persistence of Beta Blocker Treatment After a Heart Attack
(OMW) Osteoporosis Management in Older Women
(AMM) Antidepressant Medication Management
(FUH) Follow-Up After Hospitalization for Mental Illness
(MPM) Annual Monitoring for Patients on Persistent Medications
(DDE) Potentially Harmful Drug-Disease Interactions
(DAE) Use of High Risk Medication in the Elderly
(MRP) Medication Reconciliation Post-Discharge
(BCR) Board Certification
(HOS) Medicare Health Outcomes Survey
Other
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Policy Clarification Support (PCS)
Menu options under “Standard/Measures”
• If “SNP – Structure & Process” was selected:
–
–
–
–
–
–
SNP 1: Complex Case Management
SNP 2: Improving Member Satisfaction
SNP 3: Clinical Quality Improvements
SNP 4: Care Transitions
SNP 5: Institutional Relationship with Facilities
SNP 6: Coordination of Medicare and Medicaid
Services
– Other
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