SNP Training – Topic 2: SNP Subset of HEDIS Measures

March 3, 11, 16, 26, April 1, 2009 SNP Training – Topic 2: SNP Subset of HEDIS Measures

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

Introduction to SNP AssessmentBrett KayDirector, 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

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 SNP-specific measures, where appropriate

Three-Year Strategy

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

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)

SNP HEDIS Reporting Requirements Courtney BreeceSenior 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.

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.

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.

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. * Organizations with SNP benefit packages that have an enrollment of <29 as of the Feb 2008 Comprehensive do not report HEDIS measures.

Audit Requirement • Question: Does every submission require an audit? • Response: Yes, every SNP benefit package level submission must undergo a HEDIS Compliance Audit™.

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.

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.)

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.

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 SNP-specific submission.

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.

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.

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.

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.

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.

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.

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. • *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.

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

HEDIS 2009 Measures * 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.

HEDIS General Guidelines • HEDIS 2009, Volume 2: Technical Specifications • General Guidelines for Data Collection and Reporting (p. 9) apply to SNP reporting

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

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

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

New Measures in HEDIS 2009

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

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

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.

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

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

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

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.

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

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.

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

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

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

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.

Changes to Measures in HEDIS 2009

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

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

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

SNP Training – Topic 2: SNP Subset of HEDIS Measures