SNP Training Topic 2: SNP Subset of HEDIS Measures

About This Presentation

Title:

SNP Training Topic 2: SNP Subset of HEDIS Measures

Description:

(AMM) Antidepressant Medication Management ... A medication list in the medical record AND ... Medication reviews are often a part of plans' MTM programs ... – PowerPoint PPT presentation

Number of Views:408

Avg rating:3.0/5.0

Slides: 81

Provided by: jeffva

Category:

more less

Transcript and Presenter's Notes

Title: SNP Training Topic 2: SNP Subset of HEDIS Measures

1
SNP Training Topic 2 SNP Subset of HEDIS
Measures

March 3, 11, 16, 26, April 1, 2009

2
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

3
Introduction to SNP AssessmentBrett
KayDirector, SNP Assessment
4
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

5
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 yearrapid turnaround, adapted existing NCQA
measures and processes from voluntary
Accreditation programs
2nd yearfocus on SNP-specific measures
3rd yearRefine measures identify new
SNP-specific measures, where appropriate

6
Three-Year Strategy
7
Project Time Line Phase II

March - Release final SP measures
March 30 - Release ISS Data Collection Tool
S P Measures
April - Release IDSS Data Collection Tool
HEDIS Measures
June 30 - HEDIS submissions and SP measures
submissions due to NCQA
October 30 - NCQA delivers SNP Assessment Report
to CMS

8
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)

9
SNP HEDIS Reporting Requirements Courtney
BreeceSenior Analyst, Licensure Certification
10
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.

11
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.

12
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 CMSs
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.
13
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 Comprehensive do not report HEDIS measures.
14
Audit Requirement

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

15
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.

16
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.)

17
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.

18
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.

19
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.

20
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.

21
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.

22
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.

23
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 measures 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, NCQAs 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.

24
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 plans 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.

25
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.

26
Aisha T. Pittman, MPH

Overview of SNP Subset of HEDIS Measures

27
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

28
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.
29
HEDIS General Guidelines

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

30
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

31
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

32
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

33
New Measures in HEDIS 2009
34
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

35
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

36
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.

37
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

38
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

39
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

40
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 persons 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 patients
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.

41
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

42
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.

43
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

44
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

45
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

46
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.

47
Changes to Measures in HEDIS 2009
48
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

49
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

50
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

51
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

52
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.

53
Measures without Changes in HEDIS 2009
54
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

55
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

56
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

57
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

58
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 1December 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

59
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

60
Controlling High Blood Pressure (CBP)

The percentage of members 1885 years of age who
had a diagnosis of hypertension (HTN) and whose
blood pressure (BP) was adequately controlled
(
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)

61
Controlling High Blood Pressure (CBP)

Numerator criteria
Representative BP is adequately controlled
Adequate control- representative systolic BP140mmHg and representative diastolic BP
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

62
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

63
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

64
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

65
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

66
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 follow-up
within 30 days of discharge
The percentage of members who received follow-up
within 7 days of discharge

67
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

68
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)

69
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

70
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 Cox-2 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

71
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

72
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

73
Use of High Risk Medications in the Elderly (DAE)