HEDIS 1 2016 Table of Contents HEDIS Overview... 1 The HEDIS Measure Development Process... 1 Submitting Comments... 1 NCQA Review of Public Comments... 2 Value Set Directory... 2 Items for Public Comment... 2 Questions... 3 Proposed New Measures... Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults... 6 Depression Remission, Response or Treatment Adjustment for Adolescents and Adults... 12 Depression Screening and Follow-up for Adolescents and Adults... 19 Inpatient Hospital Utilization... 35 Emergency Department Utilization... 44 Statin Therapy for Patients with Cardiovascular Disease... 52 Statin Therapy for Patients with Diabetes... 65 Hospitalization for Potentially Preventable Complications... 81 Proposed Changes to Existing Measures... Asthma Medication Ratio... 97 Medication Management for People with Asthma... 101 Medication Reconciliation Post-Discharge... 123 Proposed Measures to Retire... Use of Appropriate Medications for People with Asthma... 133 Guideline Updates... General Guideline 28: Members who Switch Products... 138 Guidelines for Relative Resource Use Measures... 139 Guideline Announcement... General Guidelines 12 16: Retirement of the Measure Rotation Strategy... 142 1 HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).
Draft Document for HEDIS 2016 Public Comment Obsolete After March 18, 2015 1 HEDIS 1 2016 Public Comment Overview HEDIS Overview HEDIS is a set of standardized performance measures designed to ensure that purchasers and consumers can reliably compare the performance of health plans. It also serves as a model for emerging systems of performance measurement in other areas of health care delivery. HEDIS is maintained by NCQA, a not-for-profit organization committed to evaluating and publicly reporting on the quality of physicians, HMOs, PPOs, ACOs and other organizations. The HEDIS measurement set consists of 83 measures across five domains of care. Items available for Public Comment are proposed changes to HEDIS 2016, which will be published in July 2015 and reported in June 2016, based on activity that occurred during the 2015 measurement year. HEDIS Measure Development Process The NCQA Committee on Performance Measurement (CPM) oversees the evolution of the measurement set. Several Measurement Advisory Panels (MAP) provide clinical and technical knowledge required to develop the measures. Additional HEDIS Expert Panels and the Technical Measurement Advisory Panel (TMAP) provide invaluable assistance by identifying methodological issues and providing feedback on new and existing measures. Synopsis NCQA seeks feedback on proposed new measures and changes to specifications and guidelines for HEDIS 2016. Reviewers are asked to submit their comments to NCQA in writing via the Public Comment Web site by 5:00 PM (EST) Wednesday, March 18. Submitting Comments Submit all comments via NCQA s Public Comment Web site, using the following link: www.ncqa.org/publiccomment.aspx Note: NCQA does not accept comments via mail, e-mail or fax. How to Submit a Comment 1. Enter the following information: Your e-mail address. Your contact information. 2. Choose from the following options: Select HEDIS 2016 Public Comment. Select the measure on which you would like to comment. Select your support option (e.g., Support, Do not support, Support with modifications). Note: If you choose Do not support, include your rationale in the text box. If you choose Support with modifications, enter the suggested modification in the text box.
Draft Document for HEDIS 2016 Public Comment Obsolete After March 18, 2015 2 3. Enter your comment into the text box. There is a 2,500 character limit. If you exceed the limit, your comment will be cut off at 2,500 characters. Note: We suggest that you develop your comment in Word, in order to check your character limit, and save a copy for reference. Use the cut and paste function to copy your comment into the text box. 4. Submit additional comments using the same process. NCQA must receive your comments by 5:00 PM (EST) Wednesday, March 18. Note: For more detailed information on posting a comment, please see Posting a Comment Instructions document. NCQA Review of Public Comments NCQA appreciates the time and effort required to submit comments, and reviews all feedback submitted within the Public Comment period. Due to the high volume of comments received, NCQA cannot respond to individual comments; however, NCQA MAPs and Expert Panels will consider all comments and advise NCQA staff. Based on the review, NCQA staff will bring recommendations to the CPM, a committee of representatives from purchasers, consumers, health plans, health care providers and policy makers that oversees the evolution of the measurement set. The CPM also reviews all comments before making final decisions for HEDIS 2016. Value Set Directory Effective with HEDIS 2014, code tables are not included in measure specifications; they are included in a separate Excel workbook called the Value Set Directory. Measure specifications reference value sets that must be used for HEDIS reporting. A value set contains the complete set of codes used to identify the service or condition included in the measure. All codes for all measures listed below are in the HEDIS 2016 Public Comment Value Set Directory, which is included with the measure materials on the NCQA Public Comment Web page. Items for Public Comment Refer to the NCQA Public Comment page for detailed documentation (e.g., memos, specifications, workups, performance data, guidelines, value sets) on the items described below. Proposed New Measures NCQA proposes the following new measures: 1. Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults. 2. Depression Remission, Response or Treatment Adjustment for Adolescents and Adults. 3. Depression Screening and Follow-up for Adolescents and Adults. 4. Inpatient Hospital Utilization. 5. Emergency Department Utilization. 6. Statin Therapy for Patients with Cardiovascular Disease. 7. Statin Therapy for Patients with Diabetes. 8. Hospitalization for Potentially Preventable Complications.
Draft Document for HEDIS 2016 Public Comment Obsolete After March 18, 2015 3 Proposed Changes to Existing Measures NCQA proposes changes to the following measures: 1. Asthma Medication Ratio. 2. Medication Management for People with Asthma. 3. Medication Reconciliation Post-Discharge. Proposed Measures to Retire NCQA proposes retiring the following measures: 1. Use of Appropriate Medications for People with Asthma. Guideline Updates NCQA would like feedback on the following guideline updates: 1. General Guideline 28: Members who Switch Products. 2. Guidelines for Relative Resource Use Measures Guideline Announcement NCQA would like to announce the following guideline retirement: 1. General Guidelines 12 16: Retirement of the Measure Rotation Strategy. Questions? Contact NCQA Customer Support at 888-275-7585, Monday Friday, 8:30 a.m. 5:00p.m. (EST). 1 HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).
Draft Document for HEDIS 2016 Public Comment Obsolete After March 18, 2015 4 Proposed New Measures for HEDIS 1 Learning Collaborative: Depression Care Measures Set NCQA s theme for 2015 our 25th anniversary is Looking Forward. As part of planning for NCQA s future, we propose new HEDIS measures that address patient-reported outcomes and utilize electronic clinical data. The measures are proposed for phased implementation through a learning collaborative, with voluntary reporting using a new data collection method. We have been encouraged by stakeholders to explore measures that assess depression care; specifically, do health plan members get screened for depression appropriately and do they receive care that leads to improved outcomes? Throughout the development process, NCQA focused on specifications assessing the quality of patient management and ones that encourage collaborative care by utilizing technology in an efficient and effective manner. To achieve these goals, detailed electronic clinical data, such as electronic health records (EHRs) and clinical registries, were required in order to provide valid and reliable health plan HEDIS measures. NCQA seeks comments on the proposed measure set, Depression Care for Adolescents and Adults, which will require a new data collection method using electronic clinical data sources: 1. Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults. The percentage of members 12 years of age and older with a diagnosis of major depression or dysthymia who have a PHQ-9 or PHQ-A tool administered at least once during a four-month period. 2. Depression Remission, Response or Treatment Adjustment for Adolescents and Adults. The percentage of members 12 years of age and older with a diagnosis of depression and an elevated PHQ-9 or PHQ-A score, who had evidence of response or remission within 5 7 months of the elevated PHQ-9 score or an indication of treatment adjustment within 30 days of the PHQ-9 score that showed no evidence of response or remission. 3. Depression Screening and Follow-up for Adolescents and Adults. The percentage of members 12 years of age and older who were screened for clinical depression using a standardized tool and, if screened positive, who received appropriate follow-up care. The new measures are adapted from existing NQF-endorsed provider-level measures, developed by Minnesota Community Measurement and the Centers for Medicare & Medicaid, and used in various federal quality reporting programs. They assess care for depression along the continuum of care and will be included in a new HEDIS domain. In recognition of the unique challenges and opportunities new data sources present, we propose to phase-in voluntary reporting through a learning collaborative, beginning with Utilization of the PHQ-9 for HEDIS 2016. NCQA will work with health plans to refine data collection and reporting guidelines. We expect to identify several innovative solutions and better understand the role of health plans in aggregating electronic data for quality improvement. Although we expect limited ability to report these measures initially, this will be a large step forward in adapting HEDIS to efficient use of health information technology. The new data collection method introduces possibilities for future HEDIS measures that let plans track meaningful outcomes and earn recognition for investing in innovative quality improvement strategies. NCQA field-tested the measures using different data sources (e.g., EHRs, a statewide database for quality reporting, administrative claims, medical records). Performance results were generated for Medicare, Medicaid and commercial plans using 2012 and 2013 data. They demonstrate low performance, suggesting that gaps in care exist for all three measures, independent of data source. Testing also demonstrated the feasibility of calculating and reporting the measures at the health plan level, using EHR and other electronic 1 HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).
Draft Document for HEDIS 2016 Public Comment Obsolete After March 18, 2015 5 clinical data. Supporting documents for the proposed measures include the draft measure specifications and associated measure rationale work-up. NCQA would like to hear from health plans who are interested in participating in a learning collaborative for further testing of these measures in 2015. Please send inquiries to Learningcollaborative@ncqa.org. NCQA acknowledges the contributions of the Geriatric Measurement Advisory Panel, the Behavioral Health Measurement Advisory Panel and the Technical Measurement Advisory Panel. This project was supported by grant number U18HS020503 (PI: Scholle) from the Agency for Healthcare Research and Quality (AHRQ) and contract number HHSM-500-2011-00079C from the Centers for Medicare and Medicaid Services (CMS). The content is solely the responsibility of the authors and does not necessarily represent the official views of AHRQ or CMS.
Draft Document for HEDIS 2016 Public Comment Obsolete After March 18, 2015 6 Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults SUMMARY OF CHANGES TO HEDIS 2016 This is a first year measure for HEDIS 2016 using a new reporting methodology for electronic clinical data. Description The percentage of members 12 years of age and older with a diagnosis of major depression or dysthymia who have a PHQ-9 or PHQ-A tool administered at least once during a four-month period. Two rates are reported. 1. ECDS Data Coverage Rate. The percentage of members 12 and older with a diagnosis of major depression or dysthymia who are covered by an electronic clinical data system (ECDS). 2. PHQ Utilization Rate. The percentage of PHQ utilization. Members with a diagnosis of major depression or dysthymia who are covered by an ECDS and, if they had an outpatient encounter, have either a PHQ-9 or PHQ-A Score present in their record. Definitions ECDS Electronic clinical data system. An electronic version of a patient s comprehensive medical experiences, maintained over time. May include some or all of the key administrative clinical data relevant to the patient s care (e.g., demographics, progress notes, problems, medications, vital signs, past medical history, social history, immunizations, laboratory data, radiology reports). The ECDS provides automated access to the patient s comprehensive information and has the ability to create data files to be used for quality reporting (e.g., QRDA 1, C-CDA, CCD) and may also support other care-related activities through various interfaces, including evidence-based decision support, quality management and outcomes reporting. To qualify for this measure, ECDS data must be automated and accessible to the care team at the point of care (e.g., EHRs, registries and case management or disease management systems that the provider has access to during a patient interaction). Measurement period The measurement year is segmented to establish regular utilization of the PHQ assessment tool in the management of depression. The first qualifying encounter in each period determines the denominator events for the performance measure. The measurement year is divided into three periods: Assessment Period One. Dates of service January 1 through April 30 of the measurement year. Assessment Period Two. Dates of service May 1 through August 31 of the measurement year. Assessment Period Three. Dates of service September 1 through December 31 of the measurement year.
Draft Document for HEDIS 2016 Public Comment Obsolete After March 18, 2015 7 Eligible Population Product line Ages Commercial, Medicare, Medicaid (report each product line separately). 12 years and older as of January 1 of the measurement year. Report four age stratifications and a total rate. 12 17 years. 65+ years. 18 44 years. Total. 45 64 years. Continuous enrollment Allowable gap Anchor date Benefit Event/ diagnosis Step 1 Step 2 Step 3 The measurement year. No more than one gap in enrollment up to 45 days during the measurement year. To determine continuous enrollment for a Medicaid beneficiary for whom enrollment is verified monthly, the member may not have more than a 1-month gap in coverage (i.e. a member whose coverage lapses for 2 months [60 days] is not considered continuously enrolled.) December 31 of the measurement year. Medical Follow the steps below to identify the eligible population. Identify all members with an active diagnosis of major depression or dysthymia (Major Depression and Dysthymia Value Set) that starts before the beginning of the measurement year or during the measurement year. Identify all members in step 1 with an active diagnosis of depression that starts before or during an outpatient encounter (Depression Encounter Value Set) that occurs in the measurement year. Determine continuous enrollment. For all members identified in step 2, identify members continuously enrolled in the health plan for the measurement year, with no more than a 45-day gap in enrolment. Electronic Specification ECDS data coverage denominator ECDS data coverage numerator The eligible population. Identify all members for whom the plan has access to the electronic clinical data. This includes any provider or provider groups that can submit clinical data to the health plan via electronic file transfer (e.g., QRDA 1, C-CDA, CCD) or through third-party aggregator applications for purposes of quality reporting. Include members only if the electronic clinical interface is accessible by health care providers at the point of care.
Draft Document for HEDIS 2016 Public Comment Obsolete After March 18, 2015 8 Utilization of PHQ-9 denominator Step 1 Step 2 Step 3 Step 4 Utilization of PHQ-9 numerator Step 1 Step 2 Step 3 Step 4 Step 5 Total performance Rate Count the first outpatient encounter in any or all of the three assessment periods. Members need only have one event in any measurement period to be counted. Follow the steps below to determine denominator events. For all members from the ECDS data coverage numerator identify all outpatient encounters (Depression Encounter Value Set) during the measurement year where an active diagnosis of depression starts before or during the encounter. For each outpatient encounter in step 1, identify the date of service and classify each encounter in one of the three assessment periods. For each assessment period, count only the first qualifying encounter for each member. Each member may have up to three qualifying encounters (one from each assessment period) for the measurement year. Count the number of qualifying encounters for each member. The denominator is the sum of the member s first qualifying encounter for each assessment period. A PHQ-9 or PHQ-A total score in the patient s record during the assessment period in which a qualifying encounter occurred. Follow the steps below to determine numerator events. For each member, identify PHQ questionnaires completed during the measurement year. The presence of a PHQ total score indicates completion of a PHQ assessment tool. Assign a date to each PHQ score. Use the date when the PHQ total score was recorded, not the date when the assessment was performed. Classify each PHQ score in an assessment period. For each assessment period, count only the first qualifying PHQ total score for each member. Each member may have up to three qualifying PHQ total scores (one from each assessment period) for the measurement year. Sum the qualifying PHQ events across the three periods to report the total PHQ utilization numerator. To calculate the performance rate, divide the sum of the qualifying PHQ events across the three assessment periods (step 5) by the sum of the qualifying encounters across the three assessment periods. Exclusions (Required) Any member with an active diagnosis of any of the following at any time during the measurement year: Bipolar disorder (Bipolar Disorder Value Set; Bipolar Disorder ECDS Value Set). Personality disorder (Personality Disorder Value Set; Personality Disorder ECDS Value Set). Psychotic disorder (Psychotic Disorders Value Set). Autism spectrum disorder (Pervasive Developmental Disorder Value Set). Also exclude: Members admitted to hospice during the measurement year or with permanent residence in a nursing home. Note: Value Sets will contain all applicable SNOMED codes.
Draft Document for HEDIS 2016 Public Comment Obsolete After March 18, 2015 9 Data Elements for Reporting Organizations that submit HEDIS data to NCQA must provide the following data elements. Table XXX-1/2/3: Data Elements for Utilization of the PHQ-9 to Monitor Depression Symptoms Measurement year Data collection methodology (Electronic Clinical Data) Eligible population ECDS denominator ECDS numerator Required exclusions Numerator total rate Lower 95% confidence interval Upper 95% confidence interval Electronic Clinical Data For each age stratification and total For each age stratification and total Each rate, for each age stratification and total Each rate, for each age stratification and total Each rate, for each age stratification and total Each rate, for each age stratification and total Each rate, for each age stratification and total
Draft Document for HEDIS 2016 Public Comment Obsolete After March 18, 2015 10 Measure Flow Diagrams Figure 1: Electronic Data Capture Rate for Depression Care Eligible Population Is the member aged 12 or older? YES Did the member NO Not included in eligible population Have an active diagnosis of MDD or dysthymia starting before the start of the measurement year or during the measurement year? YES Have an outpatient encounter preceded by an active diagnosis of depression during the measurement year? YES YES Have continuous enrollment in the health plan for the measurement year, with medical benefits? NO Not included in eligible population Exclusions Did the member have an active diagnosis of bipolar disorder, personality disorder, schizophrenia, psychotic disorder or pervasive developmental disorder anytime during the measurement year? OR Was the member in hospice or a permanent resident in a nursing home during the measurement year? YES Not included in denominator NO Does the health plan have direct access to the electronic clinical data as required by the measure specification? This includes any submission of clinical data directly to the health plan via electronic file transfer (e.g. QRDA 1, C-CDA, or CCD) for purposes of quality reporting. NO Not numerator compliant Numerator YES Are these data also directly accessible at the point of care by the reporting provider? NO Not numerator compliant YES Numerator compliant
Draft Document for HEDIS 2016 Public Comment Obsolete After March 18, 2015 11 Figure 2: Measure Performance Eligible Population Is the member aged 12 or older? YES Did the member NO Not included in eligible population Have an active diagnosis of MDD or dysthymia starting before the start of the measurement year or during the measurement year? YES Have an outpatient encounter preceded by an active diagnosis of depression during the measurement year? YES YES Have continuous enrollment in the health plan for the measurement year, with medical benefits? NO Not included in eligible population Exclusions Did the member have an active diagnosis of bipolar disorder, personality disorder, schizophrenia, psychotic disorder or pervasive developmental disorder anytime during the measurement year? OR Was the member in hospice or have permanent residence in a nursing facility during the measurement year? YES Not included in denominator NO Did the member have a qualifying encounter in Assessment Period 1? (January 1 through April 30) YES Count in denominator Denominator Did the member have a qualifying encounter in Assessment Period 2? (May 1 through August 31) YES Count in denominator Did the member have a qualifying encounter in Assessment Period 3? (September 1 through December 31) YES Count in denominator Numerator Does the member have a PHQ total score in Assessment Period 3? (September 1 through December 31) Does the member have a PHQ total score in Assessment Period 2? (May 1 through August 31) Does the member have a PHQ total score in Assessment Period 1? (January 1 through April 30) YES YES YES Numerator compliant
Draft Document for HEDIS 2016 Public Comment Obsolete After March 18, 2015 12 Depression Remission, Response or Treatment Adjustment for Adolescents and Adults SUMMARY OF CHANGES TO HEDIS This is a new measure for HEDIS, using a new reporting methodology for electronic clinical data. Description The percentage of members 12 years of age and older with a diagnosis of depression and an elevated PHQ-9 or PHQ-A score, who had evidence of response or remission within 5 7 months of the elevated PHQ-9 score or an indication of treatment adjustment within 30 days of the PHQ-9 score, that showed no evidence of response or remission. Five rates are reported: 1. ECDS Data Coverage Rate. The percentage of members 12 years of age and older whose health information is accessible in an electronic clinical data system (ECDS). 2. Depression Remission Rate. The percentage of members who achieved remission (PHQ score <5) within five seven months after the initial elevated PHQ-9 score. 3. Depression Response Rate. The percentage of members who were not in remission and showed response within five seven months after the initial elevated PHQ-9 score. 4. Depression Treatment Adjustment Rate. The percentage of members who have an indication of treatment adjustment within 30 days of the PHQ-9 score that showed no response or remission. 5. Remission, Response and Treatment Adjustment Total Rate. The sum of the Remission, Response and Treatment Adjustment performance rates. Definitions ECDS Electronic clinical data system. An electronic version of a patient s comprehensive medical experiences, maintained over time. May include some or all of the key administrative clinical data relevant to the patient s care (e.g., demographics, progress notes, problems, medications, vital signs, past medical history, social history, immunizations, laboratory data, radiology reports). The ECDS provides automated access to the patient s comprehensive information and has the ability to create data files to be used for quality reporting (e.g., QRDA 1, C-CDA, CCD) and may also support other care-related activities through various interfaces, including evidence-based decision support, quality management and outcomes reporting. To qualify for this measure, ECDS data must be automated and accessible to the care team at the point of care (e.g., EHRs, registries and case management or disease management systems that the provider has access to during a patient interaction). Intake period IESD May 1 of the year prior to the measurement year through April 30 of the measurement year. Index Episode Start Date. The earliest date during the intake period where either a PHQ-9 or a PHQ-A score >9 is documented in the ECDS within 30 days of an interactive encounter between the member and a provider. An interactive encounter can be face-to-face, phone-based or via secure messaging (e.g., e-mail or patient portal).
Draft Document for HEDIS 2016 Public Comment Obsolete After March 18, 2015 13 Depression reevaluation period Treatment remission Treatment response Treatment adjustment Depression response score The 150 210-day (inclusive) period following the IESD, during which depression symptoms are reevaluated using the PHQ-9 or PHQ-A tool. Members who achieve remission from depression, as demonstrated by a PHQ-9 or PHQ-A score of <5 recorded in the ECDS during the Depression Reevaluation Period. Members with indication of response to treatment for depression, as demonstrated by a PHQ-9 total score or PHQ-A total score reduction of at least 50 percent during the Depression Reevaluation Period. Members with no indication of remission or response on a follow-up PHQ-9 or PHQ-A score during the Depression Reevaluation Period, but who have evidence that treatment was adjusted (i.e., dispensed a new antidepressant or non-antidepressant psychotropic medication, had increased dosage of an antidepressant, switched antidepressants, were delivered a new therapy or changed therapy type) within 30 days of the follow-up PHQ-9 or PHQ-A score that showed no remission or response. PHQ-9 or PHQ-A score indicating a member s depression symptom level. The PHQ score must be the last noted in the member s record during the Depression Reevaluation Period (i.e., if multiple PHQ scores are present in the member record, choose the score closest to the end of the Depression Reevaluation Period). Eligible Population Product lines Ages Commercial, Medicaid, Medicare (report each product line separately). 12 years and older as of May 1 of the year prior to the measurement year. Report four age stratifications and a total rate. 12 17 years. 18 44 years. 45 64 years. 65+ years. Total. The total is the sum of the age stratifications. Continuous enrollment Allowable gap Anchor date Benefit May 1 of the year prior to the measurement year through December 31 of the measurement year. No more than one gap in continuous enrollment of up to 45 days during each year of continuous enrollment. To determine continuous enrollment for a Medicaid beneficiary for whom enrollment is verified monthly, the member may not have more than a 1-month gap in coverage (i.e., a member whose coverage lapses for 2 months [60 days] is not considered continuously enrolled). IESD. Medical.
Draft Document for HEDIS 2016 Public Comment Obsolete After March 18, 2015 14 Event/diagnosis Step 1 Step 2 Step 3 Follow the steps below to identify the eligible population. Identify members in the specified age range with at least one interactive outpatient encounter (Depression Encounter Value Set) during the Intake Period, with an active diagnosis of major depressive disorder or dysthymia (Major Depression and Dysthymia Value Set). Identify all eligible episode dates. For each member in step 1, identify the dates for each interactive outpatient encounter (Depression Encounter Value Set) occurring during the Intake Period. Identify the IESD. For each member in step 2, identify the first date during the Intake Period where an elevated PHQ-9 or PHQ-A score (>9) was recorded in the ECDS 15 days prior to the eligible episode through 15 days after the eligible episode. Electronic Specification ECDS data coverage denominator ECDS data coverage numerator Denominator: Depression rate Numerator: Depression remission Numerator: Depression response The eligible population. Identify all members for whom the plan has access to the electronic clinical data. This includes any provider or provider groups that can submit clinical data to the health plan via electronic file transfer (e.g., QRDA 1, C-CDA, CCD) or through thirdparty aggregator applications for quality reporting. Include members only if the electronic clinical interface is accessible by health care providers at the point of care. The eligible population: all members who meet the eligibility criteria for the ECDS data coverage numerator. Identify all members who achieve remission of depression symptoms as demonstrated by a PHQ-9 or PHQ-A Depression Response Score of <5 recorded in the ECDS during the Depression Reevaluation Period. From the group of members who do not meet depression remission numerator criteria, identify members who indicate a response to treatment for depression as demonstrated by a PHQ-9 or PHQ-A Depression Response Score at least 50 percent lower than the PHQ score associated with the IESD, recorded in the ECDS during the Depression Reevaluation Period. The condition of PHQ-9 or PHQ-A score response is met when the following is true: Numerator: Depression Treatment adjustment PPPPPP DDDDDDDDDDDDDDDDDDDD RRRRRRRRRRRRRRRR SSSSSSSSSS PPPPPP tttttttttt ssssssssss ffffffff IIIIIIII 22 From the group of members who do not meet the Depression Response or Remission Numerator criteria, identify members who have evidence of treatment adjustment within 30 days of the Depression Response Score indicating no remission or response during the Depression Reevaluation Period. Documentation of any of the following indicate treatment adjustment: New antidepressant. Dispensed an antidepressant medication (Table AMM-C), where the member had no pharmacy claims for the same medication during the period between the IESD and the Depression Response Score. This includes starting an antidepressant medication, adding a new antidepressant medication to existing medications or switching antidepressants.
Draft Document for HEDIS 2016 Public Comment Obsolete After March 18, 2015 15 Note: Switching between a generic and a brand name medication does not count as treatment adjustment. Adjusting the dose of the same medication counts as treatment adjustment. New Non-Antidepressant. Dispensed a non-antidepressant psychotropic medication (Table XXX-X), where the member had no pharmacy claims for the same medication during the period between the IESD and the Depression Response Score. New Therapy. Any service for individual therapy (Individual Therapy Value Set), family therapy (Family Therapy Value Set), group therapy (Group Therapy Value Set) or other therapy (Other Therapy Value Set) that was not used (i.e., no services documented) between the IESD and the Depression Response Score. This includes starting any type of therapy, adding a new type of therapy to an existing therapy (e.g., adding family therapy to individual therapy) or switching between types of therapies (e.g., from family therapy to individual therapy). Note: Switching between different lengths of therapy does not count as treatment adjustment. Total performance rate To calculate the performance rate, sum the numerators for remission, response and treatment adjustment and divide by the Depression Rate denominator. Table AMM-C: Antidepressant Medications Description Prescription Miscellaneous Bupropion Vilazodone antidepressants Monoamine oxidase inhibitors Phenylpiperazine antidepressants Psychotherapeutic combinations SSNRI antidepressants SSRI antidepressants Tetracyclic antidepressants Tricyclic antidepressants Isocarboxazid Phenelzine Nefazodone Selegiline Tranylcypromine Trazodone Amitriptyline-chlordiazepoxide Amitriptyline-perphenazine Desvenlafaxine Venlafaxine Duloxetine Citalopram Escitalopram Maprotiline Amitriptyline Amoxapine Clomipramine Fluoxetine Fluvoxamine Mirtazapine Desipramine Doxepin (>6 mg) Imipramine Fluoxetineolanzapine Paroxetine Sertraline Nortriptyline Protriptyline Trimipramine
Draft Document for HEDIS 2016 Public Comment Obsolete After March 18, 2015 16 Table XXX-X: Non-Antidepressant Psychotropic Medications Antipsychotics Description Antidepressant and antipsychotic combination Anticonvulsants Anti-anxiety Benzodiazepines Other hypnotics Stimulants Prescription Note: NCQA will post a comprehensive list of medications and NDC codes to www.ncqa.org by November 1, 2016. Exclusions (Required) Exclude members with any of the following at any time during the measurement period: Bipolar disorder (Bipolar Value Set; Bipolar Disorder ECDS Value Set). Personality disorder (Personality Disorder Value Set; Personality Disorder ECDS Value Set). Psychotic disorder (Psychotic Disorders Value Set). Autism spectrum disorder (Pervasive Developmental Disorder Value Set). Members admitted to hospice during the measurement year or with permanent residence in a nursing home. Note: Value Sets will contain all applicable SNOMED codes. Data Elements for Reporting Organizations that submit HEDIS data to NCQA must provide the following data elements. Table DRRT-1/2/3: Data Elements for Remission, Response and Treatment Adjustment Measurement year Data collection methodology (electronic clinical data) Eligible population ECDS Denominator ECDS Numerator Required exclusions Remission Numerator Response Numerator Treatment Adjustment Numerator Reported rate Lower 95% confidence interval Upper 95% confidence interval Electronic Clinical Data For each age stratification and total For each age stratification and total Each rate, for each age stratification and total Each rate, for each age stratification and total Each rate, for each age stratification and total Each rate, for each age stratification and total Each rate, for each age stratification and total Each rate, for each age stratification and total Each rate, for each age stratification and total Each rate, for each age stratification and total
Draft Document for HEDIS 2016 Public Comment Obsolete After March 18, 2015 17 Measure Flow Diagrams Figure 1: Electronic Data Capture Rate for Depression Care Eligible Population Was the member aged 12 or older at the beginning of the intake period? YES Did the member NO Not included in eligible population Have at least one encounter during the intake period where there was an active diagnosis of depression? YES Have a PHQ-9 score >9 within 30 days of a depression encounter? YES Have continuous enrollment in the health plan for the specified time frame? NO Not included in eligible population YES Exclusions Did the member have a diagnosis of bipolar disorder, personality disorder, psychotic disorder or pervasive developmental disorder during the measurement year? OR Was the member in hospice or have permanent residence in a nursing facility during the measurement year? YES Not included in denominator NO Does the health plan have direct access to the electronic clinical data as required by the measure specification? This includes any submission of clinical data directly to the health plan via electronic file transfer (e.g. QRDA 1, C-CDA, or CCD) for purposes of quality reporting. NO Not numerator compliant Numerator YES Are these data also directly accessible at the point of care by the provider? NO Not numerator compliant YES Numerator compliant
Draft Document for HEDIS 2016 Public Comment Obsolete After March 18, 2015 18 Figure 2: Measure Performance Eligible Population Was the member aged 12 or older at the beginning of the intake period? YES Did the member NO Not included in eligible population Have at least one encounter during the intake period where there was an active diagnosis of depression? YES Have a PHQ-9 score > 9 within 30 days of a depression encounter? YES Have continuous enrollment in the health plan for the specified time frame? NO Not included in eligible population YES Exclusions Did the member have a diagnosis of bipolar disorder, personality disorder, psychotic disorder or pervasive developmental disorder during the measurement year? OR Was the member in hospice or have permanent residence in a nursing facility during the measurement year? YES Not included in denominator NO Did the member have a Depression Response Score of <5 during the Depression Reevaluation Period? YES Numerator compliant NO Numerator Did the member have a Depression Response Score reduced by at least 50% during the Depression Reevaluation Period? NO YES Numerator compliant Did the member have Treatment Adjustment within 30 days of the Depression Response Score that showed no response during the Depression Reevaluation Period? YES Numerator compliant
Draft Document for HEDIS 2016 Public Comment Obsolete After March 18, 2015 19 Depression Screening and Follow-Up for Adolescents and Adults SUMMARY OF CHANGES TO HEDIS This is a new measure for HEDIS, using a new reporting methodology for electronic clinical data. Description The percentage of members 12 years of age and older who were screened for clinical depression using a standardized tool and, if screened positive, who received appropriate follow-up care. Two rates are reported. 1. ECDS Data Coverage Rate. The percentage of members 12 years of age who are covered by an electronic clinical data system (ECDS). 2. Depression Screening Rate. The percentage of members who were screened for clinical depression using a standardized tool and, if screened positive, received appropriate follow-up care. Definitions ECDS Electronic clinical data system. An electronic version of a patient s comprehensive medical experiences, maintained over time. May include some or all of the key administrative clinical data relevant to the patient s care (e.g., demographics, progress notes, problems, medications, vital signs, past medical history, social history, immunizations, laboratory data, radiology reports). The ECDS provides automated access to the patient s comprehensive information and has the ability to create data files to be used for quality reporting (e.g., QRDA 1, C-CDA, CCD) and may also support other care-related activities through various interfaces, including evidence-based decision support, quality management and outcomes reporting. To qualify for this measure, ECDS data must be automated and accessible to the care team at the point of care (e.g., EHRs, registries and case management or disease management systems that the provider has access to during a patient interaction). Adolescent screening tool (12 17 years) Adult screening tool (18 years and older) Intake period An assessment tool that has been normalized and validated for the adolescent patient population (e.g., Patient Health Questionnaire for Adolescents [PHQ-A], Beck Depression Inventory-Primary Care Version [BDI-PC], Mood Feeling Questionnaire [MFQ], Center for Epidemiologic Studies Depression Scale [CES-D], PRIME MD- PHQ2). An assessment tool that has been normalized and validated for the adult patient population (e.g., Patient Health Questionnaire [PHQ-9], Beck Depression Inventory [BDI or BDI-II], Center for Epidemiologic Studies Depression Scale [CES-D], Depression Scale [DEPS], Duke Anxiety-Depression Scale [DADS], Geriatric Depression Scale [GDS], Cornell Scale Screening and PRIME MD-PHQ-2, Edinburgh Postnatal Depression Scale [EPDS]). January 1 through December 1 of the measurement year.
Draft Document for HEDIS 2016 Public Comment Obsolete After March 18, 2015 20 Eligible Population Product lines Ages Commercial, Medicaid, Medicare (report each product line separately). 12 years of age and older as of January 1 of the measurement year. Report four age stratifications and a total rate. 12 17 years. 18 44 years. 45 64 years. 65+ years. Total. The total is the sum of the age stratifications. Continuous enrollment Allowable gap Anchor date Benefit Event/diagnosis The measurement year and the year prior to the measurement year. No more than one gap in continuous enrollment of up to 45 days during each year of continuous enrollment. To determine continuous enrollment for a Medicaid beneficiary for whom enrollment is verified monthly, the member may not have more than a 1-month gap in coverage (i.e., a member whose coverage lapses for 2 months [60 days] is not considered continuously enrolled). December 31 of the measurement year. Medical Members who had an outpatient visit (Depression Encounter Value Set) during the measurement year. Electronic Specification ECDS data coverage denominator ECDS data coverage numerator Denominator: Depression screening Numerator: Depression screening The eligible population. Identify all members for whom the plan has access to the electronic clinical data. This includes any provider or provider groups that can submit clinical data to the health plan via electronic file transfer (e.g., QRDA 1, C-CDA, CCD) or through thirdparty aggregator applications for purposes of quality reporting. Include members only if the electronic clinical interface is accessible by health care providers at the point of care. The eligible population: all members who meet the eligibility criteria for the ECDS data coverage numerator. Members who were screened for clinical depression using an age-appropriate standardized tool and, if the screen is positive, were provided follow-up care within 30 days of the positive result. Follow the steps below to determine numerator compliance:
Draft Document for HEDIS 2016 Public Comment Obsolete After March 18, 2015 21 Step 1 Step 2 Identify all members with a result for an age-appropriate screening tool (Depression Screen Value Set) documented during the intake period. For all members with a documented screening result, identify members whose result is negative (Negative Depression Screen Value Set) using the criteria specified by the screening tool. For example, a member whose PHQ-9 score is <5 is considered to have screened negative for depression. Step 3 For all members with a documented screening result, identify members whose result is positive (Positive Depression Screen Value Set) using the criteria specified by the screening tool. For example, a member whose PHQ-9 score is 5 is considered to have screened positive for depression. Step 4 For all members from step 3, count members for whom follow-up care was provided within 30 days (inclusive) of the date of the positive screen. Follow-up must include one or more of the following in the 30-day window following the initial positive screen: Dispensed an antidepressant medication (Table AMM-C) A follow-up encounter in behavioral health (Behavioral Health Encounter Value Set), including assessment, therapy, medication management, acute care. Note: Behavioral health encounters on the same day as the positive screen count as followup care. A follow-up outpatient visit (ECDS Follow-Up Visit Value Set) with a diagnosis of depression (Depression Value Set). Note: Outpatient encounters outside behavioral health on the same day as the positive screen do not count as follow-up care. For example, a visit with a primary care provider with a diagnosis of depression or dysthymia on the same day as the positive screen does not meet the criteria for follow-up care. Follow-up with a case manager (Case Management Encounter Value Set), with documented assessment of depression symptoms (any encounter that documents the provider addressing depression symptoms). Note: Case management encounters on the same day as the positive screen do not count as follow-up care. Assessment on the same day as the positive screen, which includes documentation of additional depression assessment indicating no depression. For example, if the initial positive screen resulted from a PHQ2 score, documentation of a negative PHQ-9 counts as evidence of follow-up. Step 5 Sum the total number of members identified in step 2 with a negative screening result and members who received appropriate follow-up from step 4 to report the total numerator events.
Draft Document for HEDIS 2016 Public Comment Obsolete After March 18, 2015 22 Table AMM-C: Antidepressant Medications Description Miscellaneous antidepressants Monoamine oxidase inhibitors Phenylpiperazine antidepressants Psychotherapeutic combinations SSNRI antidepressants SSRI antidepressants Tetracyclic antidepressants Tricyclic antidepressants Bupropion Isocarboxazid Phenelzine Nefazodone Prescription Vilazodone Selegiline Tranylcypromine Trazodone Amitriptyline-chlordiazepoxide Amitriptyline-perphenazine Desvenlafaxine Duloxetine Citalopram Escitalopram Maprotiline Amitriptyline Amoxapine Clomipramine Venlafaxine Fluoxetine Fluvoxamine Mirtazapine Desipramine Doxepin (>6 mg) Imipramine Fluoxetineolanzapine Paroxetine Sertraline Nortriptyline Protriptyline Trimipramine Note: NCQA will post a comprehensive list of medications and NDC codes to www.ncqa.org by November 1, 2016. Exclusions (Required) Members with either of the following: An active diagnosis of bipolar disorder (Bipolar Disorder Value Set; Bipolar Disorder ECDS Value Set) during the measurement year or the year prior to the measurement year. An active diagnosis of depression (Depression Value Set) in the year prior to the measurement year. Note: Value Sets will contain all applicable SNOMED codes. Data Elements for Reporting Organizations that submit HEDIS data to NCQA must provide the following data elements. Table ABA-1/2/3: Data Elements for Depression Screening and Follow-up Measurement year Data collection methodology (Electronic Clinical Data) Eligible population ECDS denominator ECDS numerator Required exclusions Depression Screening Numerator Reported rate Lower 95% confidence interval Upper 95% confidence interval Electronic Clinical Data For each age stratification and total For each age stratification and total Each rate, for each age stratification and total Each rate, for each age stratification and total Each rate, for each age stratification and total Each rate, for each age stratification and total Each rate, for each age stratification and total Each rate, for each age stratification and total
Draft Document for HEDIS 2016 Public Comment Obsolete After March 18, 2015 23 Measure Flow Diagrams Figure 1: Electronic Data Capture Rate for Depression Care Eligible Population Is the member aged 12 or older as of January 1 st of the measurement year? YES Did the member NO Not included in eligible population Have at least one outpatient encounter during the intake period? YES Have continuous enrollment in the health plan for the measurement year and the year prior? NO Not included in eligible population YES Exclusions Did the member have a diagnosis of bipolar disorder during the measurement year or the year prior? OR Did the member have a diagnosis of depression during the year prior to the measurement year? YES Not included in denominator NO Does the health plan have direct access to the electronic clinical data as required by the measure specification? This includes any submission of clinical data directly to the health plan via electronic file transfer (e.g. QRDA 1, C-CDA, or CCD) for purposes of quality reporting. NO Not numerator compliant Numerator YES Are these data also directly accessible at the point of care by the reporting provider? NO Not numerator compliant YES Numerator compliant
Draft Document for HEDIS 2016 Public Comment Obsolete After March 18, 2015 24 Figure 2: Measure Performance Eligible Population Is the member aged 12 or older as of January 1 st of the measurement year? YES Did the member NO Not included in eligible population Have continuous enrollment in the health plan for the measurement year and the year prior? YES Have at least one outpatient encounter during the intake period? NO Not included in eligible population YES Exclusions Did the member have a diagnosis of bipolar disorder during the measurement year or the year prior? OR A diagnosis of major depression or dysthymia during the year prior to the measurement year? YES Not included in denominator NO Was the member screened for clinical depression using an ageappropriate standardized tool? NO Not numerator compliant YES Numerator Did the member screen positive for clinical depression using an age-appropriate standardized tool? YES Did the member receive appropriate follow-up within 30 days of a positive result? NO NO YES Not numerator compliant Numerator compliant