NCQA Supports Medicaid Behavioral Measure Reporting

NCQA supports draft legislation to require state reporting of Medicaid Adult Core Set behavioral measures to help fight opioids.

April 18, 2018

Dear Chairman Burgess, Ranking Member Green, and House Energy & Commerce Health Subcommittee Members:

The National Committee for Quality Assurance (NCQA) strongly supports the discussion draft bill for “Mandatory Reporting with Respect to Adult Behavioral Health Measures.”

This legislation requires states to report all Medicaid adult behavioral quality core set measures starting in 2024.The core set includes behavioral health measures NCQA stewards, including:

  • Antidepressant Medication Management;
  • Follow-Up After Hospitalization for Mental Illness;
  • Follow-Up After Emergency Department Visit for Mental Illness or Alcohol and Other Drug Abuse or Dependence;
  • Initiation and Engagement of Alcohol and Drug Treatment;
  • Medical Assistance with Smoking and Tobacco Use Cessation;
  • Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications
  • Diabetes Care for People with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control (>9.0%)
  • Adherence to Antipsychotic Medications for Individuals with Schizophrenia; and

Requiring states to report these measures will help address the opioid crisis and make behavioral health the priority for Medicaid that beneficiaries need. Behavioral and mental health conditions are substantially undertreated and strongly associated with higher overall utilization and cost. Many behavioral health treatments also have significant side effects that require careful monitoring and often further treatment.

In fact, given the opioid crisis’ urgency, we urge you to require reporting as soon as is feasible in 2021 rather than 2024.

NCQA has additional measures to help address the opioid crisis, including:

  • Use of Opioids at High Dosage.
  • Use of Opioids from Multiple Providers.

Please see Appendix A for a list of additional behavioral measures we have or are developing.

Thank you for your leadership in addressing the opioid crisis and the opportunity to support your work on this important issue. If you have any questions please contact our Director of Federal Affairs, Paul Cotton, at (202) 955-5162 or cotton@ncqa.org.

Sincerely,

 

Margaret O’Kane,
President
1100 13th Street NW, Third Floor
Washington, DC 20005
phone 202.955.3500
fax 202.955.3599

Appendix A:

Healthcare Effectiveness Data and Information Set (HEDIS) Mental Health & Behavioral Measures

DomainMeasureStatusData SourceDenominatorNumerator
Screening Depression screening and follow up In HEDIS Electronic Clinical Data Source (ECDS) Members 12 years of age and older. Members who were screened for clinical depression using a standardized tool and received appropriat
Symptom Monitoring Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults In HEDIS ECDS Members 12 years of age and older with a diagnosis of major depression or dysthymia. Members who had a PHQ-9 tool administered at least once during a four-month period.
Medication adherence Adherence to antipsychotic medications for individuals with schizophrenia In HEDIS Claims Members 19–64 years of age with schizophrenia. Members who achieved a PDC of at least 80% for their antipsychotic medications.
Antidepressant medication management In HEDIS Claims Members 18 years of age and older who were treated with antidepressant medication and had a diagnosis of major • Initiation Phase. Members who had at least 84 days of continuous treatment with antidepressant medication beginning on the index prescription start date (IPSD) through 114 days after the IPSD.
• Continuation Phase. Members who had at least 180 days of continuous treatment with antidepressant medication beginning on the IPSD through 231 days after the IPSD.
Medication management Follow-up care for children prescribed ADHD medication In HEDIS Claims Children 6–12 years of age who were newly prescribed ADHD medication. • Initiation Phase. Members who had an outpatient, intensive outpatient or partial hospitalization follow-up visit with a practitioner with prescribing authority within 30 days after the IPSD.
• Continuation and Maintenance Phase. Members with a prescription dispensed for ADHD medication, who remained on the medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two follow-up visits with a practitioner within 270 days after the Initiation Phase ended.
Access to care Initiation and engagement of alcohol and other drug dependence (AOD) treatment In HEDIS Claims Members 13 years of age and older with a new episode of AOD during the first 10 and ½ months of the measurement year. • Initiation of AOD Treatment. The percentage of members who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of the diagnosis.
• Engagement of AOD Treatment. The percentage of members who initiated treatment and who had two or more additional services with a diagnosis of AOD within 30 days of the initiation visit.
Coordination Follow-up after hospitalization for mental illness In HEDIS Claims Members 6 years of age and older who were hospitalized for treatment of mental • 30-day Follow-up. Discharges for which the member received follow-up within 30 days of discharge.
• 7-day Follow-up. Discharges for which the member received follow-up within 7 days of discharge.
Follow-up after hospitalization for mental illness In HEDIS Claims Members who had an ED visit with a primary mental health diagnosis Members who received an outpatient or partial hospitalization visit with a primary diagnosis of mental health.
Follow-up after ED visit for AOD In HEDIS Claims Members who had an ED visit for two or more serious chronic conditions, including depression as well as Alzheimer’s, atrial fibrillation, chronic kidney disease, COPD/asthma, cardiovascular (heart failure, heart attack, stroke) Percentage of emergency department visits for members who have high-risk multiple chronic conditions and had a follow-up service within 7 days of the ED visit.
“Integration” of medical needs Diabetes screening for people with schizophrenia or bipolar disorder who are using antipsychotic medications In HEDIS Claims Members 18-64 years of age with schizophrenia or bipolar disorder and dispensed an antipsychotic medication. Members who had a glucose test or HbA1c test during the measurement year.
Diabetes monitoring for people with diabetes and schizophrenia In HEDIS Claims Members 18-64 years of age with schizophrenia and diabetes. Members who had an HbA1c test and an LDL- C during the measurement year.
Cardiovascular monitoring for people with cardiovascular disease and schizophrenia In HEDIS Claims Members 18–64 years of age with schizophrenia and cardiovascular disease. Members who had an LDL-C test performed during the measurement year.
Metabolic monitoring for children and adolescent on antipsychotics In HEDIS Claims Members 1–17 years of age who had two or more antipsychotic prescriptions. Members who had both of the following during the measurement year.
• At least 1 blood glucose/HbA1c test.
• At least 1 LDL-C or cholesterol test.
Overuse/ Appropriateness Use of multiple concurrent antipsychotics in children and adolescents In HEDIS Claims Children and adolescents 1–17 years of age who were dispensed an antipsychotic medication. Members who were on two or more concurrent antipsychotic medications for at least 90 consecutive days during the measurement year.
Opioid overuse In HEDIS Claims Members 18 years of age and older receiving prescription opioids for > 15 days during the measurement year. • High Dosage. Members who received a daily dosage of opioids greater than 120 mg morphine equivalent dose (MED) for 90 consecutive days or longer.
• Multiple Prescribers and Multiple Pharmacies. Members who received prescriptions for opioids from four (4) or more prescribers AND four (4) or more pharmacies.
• Multi-Provider, High Dosage: Members who had prescriptions for opioids greater than 120mg morphine equivalent dose (MED) for 90 consecutive days or longer, AND who received opioid prescriptions from four (4) or more prescribers AND four (4) or more pharmacies.
Utilization Identification of alcohol and other drug services In HEDIS Claims All members Members who received the following chemical dependency services during the measurement year:
• Any service.
• Inpatient.
Mental health utilization In HEDIS Claims All members Members who received the following mental health services during the measurement year:
• Any service.
• Inpatient.
• Intensive outpatient or partial hospitalization.
• Outpatient or ED.
Use of first-line psychosocial care for children and adolescent on antipsychotics In HEDIS Claims Children and adolescents 1–17 years of age who had a new prescription for an antipsychotic medication. Members who had documentation of psychosocial care in the 121-day period from 90 days prior to the IPSD through 30 days after the IPSD.
Outcomes Depression remission/response Under development ECDS Member 12 years of age and older with a diagnosis of major depression or dysthymia and an elevated PHQ-9 score. Members who had evidence of response or remission within 5–7 months of the elevated PHQ-9 score.

Additional NCQA measures address “integrated care” for behavioral health conditions (not in HEDIS)

MeasureData SourceDenominatorNumerator
Alcohol Screening and Follow-up for People with Serious Mental Illness (SMI) Claims Members 18 years of age and older with at least one inpatient visit or two outpatient visits for schizophrenia or bipolar I disorder, or at least one inpatient visit for major depression during the measurement year. Members who were screened for unhealthy alcohol use and received two events of counseling if identified as an unhealthy alcohol user.
Tobacco Use Screening and Follow-up for People with Serious Mental Illness or Alcohol and Other Drug Dependence Claims • SMI: Members 18 years of age and older with at least one inpatient visit or two outpatient visits for schizophrenia or bipolar I disorder, or at least one inpatient visit for major depression during the measurement year.
• AOD: All members 18 years of age or older as of December 31 of the measurement year with any diagnosis of alcohol or other drug dependence during the measurement year.
• AOD: Members who were screened for tobacco use and received follow-up care if identified as a current tobacco user.
Body Mass Index Screening and Follow-up for People with Serious Mental Illness Claims Members 18 years of age and older with at least one inpatient visit or two outpatient visits for schizophrenia or bipolar I disorder, or at least one inpatient visit for major depression during the measurement year. Members who had calculated body mass index documented and were provided two events of follow-up care if body mass index was greater than or equal to 30 kg/m2. Follow-up includes:
• Two events of counseling, on different dates, for weight management (such as nutrition or exercise counseling) or
• One event of counseling and one fill of medication (Orlistat) for weight management.
Controlling High Blood Pressure for People with Serious Mental Illness Claims Members 18-85 years of age with at least one acute inpatient visit or two outpatient visits for schizophrenia or bipolar I disorder, or at least one inpatient visit for major depression during the measurement year AND a diagnosis of hypertension. Members whose most recent blood pressure (BP) was adequately controlled (after the diagnosis of hypertension) based on the following criteria: • Members 18-59 years of age whose BP was <140/90 mm Hg.
• Members 60-85 years of age and flagged with a diagnosis of diabetes whose BP was <140/90 mm Hg.
• Members 60-85 years of age and flagged as not having a diagnosis of diabetes whose BP was <150/90 mm Hg.
Comprehensive Diabetes Care for People with Serious Mental Illness: Hemoglobin A1c (HbA1c) Testing Claims Members 18-75 years of age with at least one acute inpatient visit or two outpatient visits for schizophrenia or bipolar I disorder, or at least one inpatient visit for major depression during the measurement year AND diabetes (type 1 and type 2). Members who had an HbA1c test performed.
Comprehensive Diabetes Care for People with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) Claims Members 18-75 years of age with at least one acute inpatient visit or two outpatient visits for schizophrenia or bipolar I disorder, or at least one inpatient visit for major depression during the measurement year AND diabetes (type 1 and type 2). Members whose most recent HbA1c level was greater than 9.0% or was missing a result, or for whom an HbA1c test was not done.
Comprehensive Diabetes Care for People with Serious Mental Illness: Medical Attention to Nephropathy Claims Members 18-75 years of age with at least one acute inpatient visit or two outpatient visits for schizophrenia or bipolar I disorder, or at least one inpatient visit for major depression during the measurement year AND diabetes (type 1 and type 2). Members who received a nephropathy screening test or had evidence of nephropathy.
Comprehensive Diabetes Care for People with Serious Mental Illness: Blood Pressure Control (<140/90 mm Hg) Claims Members 18-75 years of age with at least one acute inpatient visit or two outpatient visits for schizophrenia or bipolar I disorder, or at least one inpatient visit for major depression during the measurement year AND diabetes (type 1 and type 2). Members whose most recent blood pressure screening result was <140/90mm Hg.
Comprehensive Diabetes Care for People with Serious Mental Illness: Hemoglobin A1c (HbA1c) Control (<8.0%) Claims Members 18-75 years of age with at least one acute inpatient visit or two outpatient visits for schizophrenia or bipolar I disorder, or at least one inpatient visit for major depression during the measurement year AND diabetes (type 1 and type 2). Members whose most recent HbA1c level was less than 8.0%.
Comprehensive Diabetes Care for People with Serious Mental Illness: Eye Exam Claims Members 18-75 with at least 1 acute inpatient visit or 2 outpatient visits for schizophrenia or bipolar disorder, or at least 1 inpatient visit for major depression during the measurement year AND diabetes (type 1 and type 2). Members who received an eye exam.
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