Adult Measures

Hello and welcome to the Results and Recognition Program’s presentation on the HEDIS Adult Measures.

Results and Recognition is also referred to as R&R.

This webinar will review the adult measures in the R&R program, the criteria to meet compliance for those measures, possible exclusions, and also some suggested best practices that can help you be successful in closing those gaps in care.

These are the HEDIS measures in the Adult R&R program.

They are broken down according to the different lines of business, or the specific populations they apply to, which is Medicaid, Fully Integrated Dual Eligible Special Needs Plan, also referred to as FIDE-SNP, Medicare Advantage, and Braven.

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 members medical record as to the reason why and the date of the occurrence.

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.

Our first measure is Adults' Access to Preventive Ambulatory Health Services.

For a member to be compliant, they need just one visit with the PCP and it can be sick or well, in the measurement year.

There are no applicable exclusions here. It's very simple and straightforward and is the easiest measure to meet compliancy.

Some best practices for that measure, encourage patients to maintain the relationship with a provider to promote consistent and coordinated healthcare.

Educate patients on the importance of having at least one ambulatory or preventive care visit during each measurement year.

Consider offering extended practice hours to increase care.

Telehealth visits will meet compliance for this measure.

Also, reminding patients of their appointments by making calls and sending texts.

The next measure is Asthma Medication Ratio.

For this, we're looking at the percentage of members 5 to 64 years of age who are 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, of members who have persistent asthma, which is 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, which is noted with these bullet points. Some exclusions for this measure can be emphysema, COPD, chronic respiratory conditions due to fumes or vapes and these are just a few.

Members who had no asthma controller or reliever medication dispensed during the measurement year may also be excluded.

Some best practices for the measure, develop an asthma action plan.

Educate members on the importance of sticking to those medications and reducing asthma triggers.

Advise members to incorporate inhalers into their daily routine, and reach out to members to schedule follow up visits for the condition.

The next measure is Breast Cancer Screening.

The eligible population for this measure is for women, 52 to 74 years old by December 31st of the measurement year, and this is the population that we're focusing on who had a mammogram to screen for breast cancer.

For a member to be compliant, a mammogram must be done anytime between October 1st, 2 years prior to the measurement year, through December 31st of the measurement year. 3D mammograms will meet compliance.

However, MRIs, ultrasounds 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.

However, a bilateral mastectomy may be an exclusion at any time during the member's history through December 31st of the measurement year.

And for the population for women of 52 to 74 years old, this is due to a look back timeframe.

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 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 the members, most recent mammogram and or mastectomy status in the medical record.

The next measure is Cervical Cancer Screening.

So, for this, we're focusing on the percentage of women, 21 to 64 years of age who was screened for cervical cancer.

For a member to be compliant we look for women who are 24 to 64 years of age who had the screening done in the measurement year or 2 years prior.

This measure also has a look back period. If one is not found, we can look at the measurement year and 4 years prior for women 30 to 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.

Possible exclusions include hysterectomy with no residual cervix, cervical agenesis, or acquired absence of cervix anytime during the members' history through December 31st of the measurement year. Let's talk a moment about noncompliance versus optional exclusions.

Noncompliance 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 a 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.

And just to note, lab results that indicate the sample contained no endocervical cells may be used if a valid result was reported for the test. Let's look at some best practices.

Average risk women younger than 21 years of age should not be screened.

Cervical cancer is rare in adolescence and screening does not appear to lower that risk.

Average risk women younger than 30 years of age should not be tested for HPV.

Frequently the test will be positive because it is spread through sexual contact and it's very common in young people, but the infection often clears on its own within a year or two.

Assess existing barriers to regular cervical cancer screening, such as access to care, cost, anxiety, embarrassment or fear, and try to implement a policy or procedural change to increase the rate of cervical cancer screenings.

Increase community demand to promote cervical cancer screening through patient reminders, group, and 1 on 1 education.

Also request to have cervical cytology results sent to you from an OB/GYN office, if that is where the member was seen.

The next measure is Chlamydia Screening in Women.

For this measure, 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 are those women who turn 16 to 24 years of age by December 31^st of the measurement year, and who have been identified as being sexually active, either by pharmacy data for a contraceptive or a claim, or an 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 into this measure.

A possible exclusion are for those members who qualify for the measure based on a pregnancy test alone and who either had a prescription for isotretinoin on the date of the pregnancy test or the 6 days after the test or had an X Ray on the date of the pregnancy test or 6 days afterwards.

Some best practices for this measure, adopt urine screening of all women in this age range to eliminate the need for a pelvic exam.

Screening should occur with or without symptoms screening should also occur at any visit where oral contraceptives, 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 for obtaining chlamydia screening results from OB/GYN providers participating in the members care.

The next measure is Care for Older Adults.

We're looking at the percentage of adults, 66 years of age and older, who had a medication review, a functional status assessment and pain assessment during the measurement year.

The member must be compliant for all 3 sub-measures to close this gap.

Let's take a look at each of these sub-measures.

The first is medication review. Documentation must come from the same medical record and include one of the following, which is a medication list in the record and evidence of a medication review by a prescribing practitioner or clinical pharmacist, and the date, when that was performed, or notation that the member is not taking any medication and the date when it was noted.

A review of side effects for a single medication at the time of the prescription alone, is not sufficient, and an outpatient visit is not required to meet this criteria.

Do not include medication lists, or medication reviews performed in an acute inpatient setting.

For functional status assessment, at least one of the following must be assessed and noted, and that's either a notation of activities of daily living, a notation of instrumental activities of daily living, or a result of an assessment using a standardized functional status assessment tool.

A functional status assessment limited to an acute or single condition event or body system does not meet criteria for a comprehensive functional status assessment.

The components of the functional status assessment numerator may take place during separate visits within the measurement year.

Do not include comprehensive functional status assessments, performed in an acute inpatient setting.

For pain assessment, documentation in the medical record, must include evidence of a pain assessment and the date when it was performed.

Notation for a pain assessment must include one of the following, which is documentation that the patient was assessed for pain and that may include positive or negative findings or a result of an assessment using a standardized pain assessment tool.

Do not include pain assessments, performed in an acute inpatient setting.

Notation alone of a pain management or pain treatment plan does not meet the criteria for this sub-measure, and also, notation alone of screening for chest pain, or documentation alone of chest pain, should not be included.

Some best practices for this measure, complete the medication review, functional status assessment and pain assessment during the same visit.

Ensure a medication list is present in the medical record.

Document in the medical record, if the member is not taking any medications.

Incorporate a standardized template to capture these measures for members 66 years of age and older.

Complete a functional status assessment and pain assessment at every face-to-face visit or during every telehealth visit.

Colorectal Cancer Screening. For this measure we are looking at the percentage of members 50 to 75 years of age who had appropriate screening for colorectal cancer.

There are a few ways to meet compliance for this measure.

And those are by a fecal occult blood test during the measurement year, a flexible sigmoidoscopy during the measurement year or the 4 years prior, a colonoscopy during the measurement year or 9 years prior, a CT colonography also known as a virtual colonoscopy done during the measurement year or 4 years prior.

And lastly, a FIT-DNA test during the measurement year, or the 2 years prior, digital rectal exams, and FOBT tests performed in an office setting or performed on a sample collected via a DRE is not counted towards compliance.

Possible exclusions include colorectal cancer and or a total colectomy anytime during the member's history through December 31st 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.

Also document the type and the date that the test was performed.

Emphasize personal choice in various modalities, especially for those members who may fear having a colonoscopy.

You can distribute the FOBT or the FIT tests to members who need to be screened and can also have an FOBT kit on hand to utilize from member teaching.

Please remember to act quickly for members who have had a positive stool result.

Also, Horizon has partnered with a vendor called BIO IQ to send FIT tests to all the noncompliant Medicare members. The vendor will reach out to the PCP first to receive consent to send the members these in-home screenings.

Controlling High Blood Pressure. For this we're looking at the percentage of members 18 to 85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled during the measurement year. Adequately controlled means less than 140 over 90.

The BP reading must occur on or after the date of the 2nd diagnosis of hypertension.

Possible exclusions include a diagnosis of pregnancy, end stage renal disease and other conditions on or prior to December 31st of the measurement year.

So, let's look at some noncompliance issues for controlling high blood pressure.

The member is not compliant if the blood pressure is greater than 140 over 90, if there is no BP reading during the measurement year, or if the reading is incomplete. A member is non-compliant if the blood pressure reading was taken during an acute stay, or during an emergency room visit.

If the reading is taken by a non-digital device that is non-compliant.

If the member has taken his or her own blood pressure with an electronic device and verbally reports this to the provider, the provider must document this in the medical record and that would be considered acceptable.

A blood pressure reading, taken on the same day as a test, or for a procedure that required a change in diet or medication on or one day prior, with the exception of fasting blood tests is non-compliant.

Some best practices for this measure, document the blood pressure readings at every visit.

If a blood pressure reading is greater than 140 over 90 at the time of the visit retake it.

Remember you cannot round up blood pressure values.

If the reading is greater than 140 over 90, allow the member to rest or even talk to distract them and then retake it.

If two blood pressures are taken on the same day.

We can take the lowest systolic and diastolic from both readings to meet compliancy, if they're under 140 over 90.

Next, 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 provider obtains the visit notes, and places them in their medical record, and the blood pressure reading is less than 140 over 90, this will count towards compliancy. Also keep in mind that it must be the last blood pressure reading in the measurement year that will determine compliance for this measure.

The next few measures focus on diabetes.

They were previously grouped together as the Comprehensive Diabetes Care measure, which was known as CDC. However, the sub-measures of CDC are now independent of one another and have different acronyms.

So, the first measure here is Blood Pressure Control for Patients with Diabetes.

For this measure, the criteria is identical to Controlling High Blood Pressure.

The difference is that this one focuses on diabetics and CBP focuses on those with hypertension.

The possible exclusions for both measures are also different.

Hemoglobin A1C Control for Patients with Diabetes.

We are looking at the percentage of members, 18 to 75 years of age with type 1 or type 2 diabetes, who had A1C control of less than 8% for Medicaid members and A1C poor control of greater than 9% for FIDE-SNP, Medicare and Braven members.

The latter, which is A1C poor control of greater than 9% is known as an inverted measure, which means a lower rate indicates better performance for this indicator.

A member's diabetic status is determined by claims or pharmacy data.

Some possible exclusions include members who do not have diabetes, those who had a diagnosis of polycystic ovarian syndrome, gestational, or steroid induced diabetes during the measurement year or the year prior. Eye Exam for Patients with Diabetes.

We are looking at the percentage of members, 18 to 75 years of age with type 1 or type 2 diabetes who had a retinal eye exam.

There are 3 ways to meet compliance for this measure.

Either by a retinal or dilated eye exam by an eye care professional in the measurement year, and an eye care professional means either an optometrist or an ophthalmologist.

A negative retinal or dilated eye exam negative for retinopathy by an eye care professional in the year prior to the measurement year, or a bilateral eye enucleation, anytime during the member's history through December 31st of the measurement year.

Possible exclusions here are the same as the ones we just discussed for A1C control for patients with diabetes.

Here is a quick guide of what documentation in the medical record meets compliance.

The first is a letter or note in the medical record by the PCP, optometrist or ophthalmologist stating dilated or retinal exam was completed, again, by an eye care professional with both the date and the results.

The actual chart or photograph with the date and results will meet compliance as well. 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 interpretation.

Next is 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 eye care professional and that retinopathy was not present. A notation limited to a statement that indicates diabetes without complications, does not meet criteria.

Next is Kidney Health Evaluation for Patients with Diabetes.

For this, we're focusing on the percentage of members 18 to 85 years of age with either type 1 or type 2 diabetes who received a kidney health evaluation, defined by an estimated glomerular filtration rate and a urine albumin creatinine ratio, during the measurement year.

Members must have both tests to meet compliancy regardless of the result.

For the uACR, we can take, excuse me, either this ratio or both a quantitative urine albumin and a urine creatinine if those service dates are four days or less apart.

For example, if the service date for the quantitative urine albumin test was December 1st of the measurement year then the urine creatinine test must have a service date on, or between November 27th and December 5th of the measurement year.

Possible exclusions include the ones that we discussed for the last two measures with an additional component of evidence of end stage renal disease or dialysis any time during the members history on, or prior to December 31st of the measurement year.

Statin Therapy for Patients with Diabetes.

We're focusing on the percentage of members, 40 to 75 years of age during the measurement year with diabetes who do not have clinical atherosclerotic, cardiovascular disease and met the following criteria, which is having received statin therapy and statin adherence of 80%. Receiving statin therapy refers to those members who were dispensed at least one statin medication of any intensity during the measurement year, and statin adherence of 80% for those members who remained on a statin medication of any intensity for at least 80% of the treatment period.

Possible exclusions are the same as for the previous measures related to diabetes.

These are the medications at the different intensity levels that will meet compliance.

Please remember, this is only a guide as to what the NCQA specifications state.

We cannot tell you how to treat your patients. That would be up to you.

Some best practices for the diabetic measures.

Order labs prior to the members' appointment and ensure documentation in the medical record includes the date when the A1C test was done and the results.

Ensure documentation in the medical record includes a kidney health evaluation.

Document the date of the most recent diabetic eye exam with results as well as the name and title of the eye care provider.

Document blood pressure readings at every visit and retake is greater than 140 over 90.

Also, educate on the importance of complying with statin therapy during every communication.

The last measure that will be discussed is Statin Therapy for Patients with Cardiovascular Disease, and for this measure, we're looking at the percentage of males, 21 to 75 years of age and females, 40 to 75 years of age, during the measurement year who were identified as having clinical atherosclerotic cardiovascular disease and received statin therapy and maintained statin adherence of 80%.

The difference between this measure, and the SPD measure, which was just discussed, is that SPD focuses on members who do not have these conditions and this measure focuses on those who do.

There are 2 eligible categories for this measure, and those are males between the ages of 21 to 75, and women between the ages of 40 to 75.

Receiving statin therapy, refers to those members who were dispensed at least one high intensity or moderate intensity statin medication during the measurement year.

And statin adherence refers to members who remained on that high or moderate intensity, statin med, for at least 80% of the treatment period.

Possible exclusions are the same as those for the diabetic measures.

Here again, we're offering you a list of medications at the different intensity levels that will meet compliance.

Again, please remember, this is only a guide as to what is in the NCQA specifications.

Another difference between this measure and SPD is that SPD includes low intensity statin meds, and this measure only includes high and moderate intensity statins.

Some best practices for the SPD and SPC measures include, educating 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 member's concerns and make them an active part of shared decision making.

And then routinely arrange the next appointment for consistent follow up and monitoring.

So, that concludes the review of the Adult HEDIS measures. Let's quickly discuss how you can be successful in closing the gaps.

Make sure your EMR is updated to reflect the members’ specialists and other providers on the patient care team.

Utilize your electronic health record and develop standing orders. Review your current codes and also set alerts and reminders of HEDIS recommended screenings.

Submit your claims data for every service rendered, making sure that the medical record documentation supports all billed services.

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.

Consider some barriers as to why members may not be compliant with their care and offer telehealth visits or possibly extended hours.

Calling or mailing to keep in contact with your patients and remind them to schedule their appointments is always a good thing.

And lastly access the Quality Resource Center for strategies and tools to providing quality service to your patients.

Thank you for listening to this presentation on the HEDIS Adult Measures.

If you have any questions, please send them to the email noted here.

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