Medicare Guidelines

Reference: “Guidelines for the Diagnosis and Management of Asthma” is a National Guideline developed by the National Heart, Lung and Blood Institute as part of the National Asthma Education and Prevention Program. The Expert Panel Report 3 was initially published in July 2007.

Found April 2014 Draft Needs Assessment Report for Potential Update of the Expert Panel Report 3 (2007)
https://www.nhlbi.nih.gov/files/docs/resources/lung/NHLBAC-Asthma-WG-Report.pdf

Clinical Indicators:

1. The percentage of members 5-85 years of age who were identified as having persistent asthma and had a ratio of controller medications of 0.50 or greater during the measurement year.
   Medicaid ages: 5-64
   (Source: HEDIS® 2019, Vol. 2, Technical Specifications AMR)
2. The percentage of members 5–64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period. Two rates are reported:
   • The percentage of members who remained on an asthma controller medication for at least 50% of their treatment period.
   • The percentage of members who remained on an asthma controller medication for at least 75% of their treatment period.

 

(Source: HEDIS® 2019, Vol. 2, Technical Specifications - MMA)

Links:

• National Asthma Education and Prevention Program Expert Panel Report

 

Reference: American Psychiatric Association Clinical Practice Guideline titled “The Treatment of Patients with Bipolar Disorder” (Second Edition, Revision 2002) The Practice Guideline for the Treatment of Patients with Bipolar Disorder, 2nd Edition

Clinical Indicators:

1. Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (Source: HEDIS® 2019, Vol. 2, Technical Specifications)
2. Follow-Up After Hospitalization for Mental Illness
   (Source: HEDIS® 2019, Vol. 2, Technical Specifications)
   *Applies to Medicare only

Links:

• http://psychiatryonline.org
• https://www.psychiatry.org
• https://www.network-health.org

 

Reference: The Global Initiative for Chronic Obstructive Lung Disease Guideline was formed through the collaborative efforts of the National Heart, Lung, and Blood Institute, National Institutes of Health, USA and the World Health Organization in 1998.

From the “Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease,” Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2019.

Clinical Indicators:

1. Percentage of members 40 years and older with a new diagnosis of COPD, who have received spirometry testing to confirm the diagnosis. (Source: HEDIS® 2019, Vol. 2, Technical Specifications, SPR)
2. Percentage of COPD exacerbations for members 40 years and older who had an acute inpatient discharge or ED visit between January 1-November 30 of the measurement year and who were dispensed a systemic corticosteroid (or there is evidence of an active prescription) within 14 days of the event. (Source: HEDIS® 2019, Vol. 3, Technical Specifications, PCE)
3. Percentage of COPD exacerbations for members 40 years and older who had an acute inpatient discharge or ED visit between January 1-November 30 of the measurement year and who were dispensed appropriate medications, and who were dispensed a bronchodilator (or there was evidence of an active prescription) within 30 days of the event. (Source: HEDIS® 2019, Vol. 2, Technical Specifications, PCE)

Links:

• GOLD Reports

 

Reference:

1. 2013 ACC/AHA Guideline on Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults
2. 2013 ACCF/AHA Guideline for the Management of Heart Failure
3. AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients with Coronary & Other Atherosclerotic Vascular Disease: 2011 Update
4. 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure

 

Clinical Indicators:

1. The percentage of members 18 years of age and older during the measurement year who were hospitalized and discharged from July 1 of the year prior to the measurement year to June 30 of the measurement year with a diagnosis of AMI and who received persistent beta-blocker treatment for six months after discharge. (Source: HEDIS® 2019, Vol. 2, Technical Specifications, PBH)
2. The percentage of males 21-75 and females 40-75 years of age during the measurement year who were identified as having clinical atherosclerotic cardiovascular disease (ASCVD) and who:
   • Received statin therapy: Members who were dispensed at least one high or moderate-intensity statin medication during the measurement year.
   • Met statin adherence 80%: Members who remained on a high or moderate-intensity statin medication for at least 80% of the treatment period. (Source: HEDIS® 2019, Vol. 2, Technical Specifications, SPC)
3. The percentage of members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure was adequately controlled during the measurement year <140/90.

Links:

• Treatment of Blood Cholesterol
• Guideline for the Management of Heart Failure
• Secondary Prevention and Risk Reduction for Coronary and other Atherosclerotic Vascular Disease
• 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults

 

Reference: American Diabetes Association’s (ADA) “Standards of Medical Care in Diabetes-2019” for its Diabetes Guideline, Supplement 1 (January 2019).

Clinical Indicators:

1. The percentage of members 18–75 years of age with diabetes (type 1 and type 2) who had HbA1c testing. (Source: HEDIS® 2019, Vol. 2, Technical Specifications, CDC)
2. The percentage of members 18–75 years of age with diabetes (type 1 and type 2) who had HbA1c Control <8.0%. (Source: HEDIS® 2019, Vol. 2, Technical Specifications, CDC)
3. The percentage of members 18–75 years of age with diabetes (type 1 and type 2) who had HbA1c poor control >9.0%. (Source: HEDIS® 2019, Vol. 2, Technical Specifications, CDC)
4. The percentage of members 18–75 years of age with diabetes (type 1 and type 2) who had a retinal eye exam. (Source: HEDIS® 2019, Vol. 2, Technical Specifications, CDC)
5. The percentage of members 18-75 years of age with diabetes (type 1 and type 2) who had a nephropathy screening test or evidence of nephropathy. (Source: HEDIS® 2019, Vol. 2, Technical Specifications, CDC)
6. The percentage of members 18–75 years of age with diabetes (type 1 and type 2) whose blood pressure was <140/90mm Hg. (Source: HEDIS® 2019, Vol. 2, Technical Specifications, CDC)
7. The percentage of members 40–75 years of age during the measurement year with diabetes who do not have clinical atherosclerotic cardiovascular disease (ASCVD) who were dispensed at least one statin medication of any intensity during the measurement year.
8. (Source: HEDIS® 2019, Vol. 2, Technical Specifications, SPD)
9. The percentage of members 40–75 years of age during the measurement year with diabetes who do not have clinical atherosclerotic cardiovascular disease (ASCVD) who remained on a statin medication of any intensity for at least 80% of the treatment period. (Source: HEDIS® 2019, Vol. 2, Technical Specifications, SPD)

Links:

• ADA Standards of Care

 

Reference: Treatment of Patients with Major Depressive Disorder, Third Edition

Institute for Clinical Systems Improvement Health Care Guideline titled, “Major Depression in Adults in Primary Care” (Seventeenth Edition, March 2016)

Clinical Indicators:

1. The percentage of members 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression and who remained on an antidepressant medication treatment.

• Effective Acute Phase Treatment: The percentage of members who remained on an antidepressant medication for at least 84 days (12 weeks).
• Effective Continuation Phase Treatment: The percentage of members who remained on an antidepressant medication for at least 180 days (6 months).

(Source: HEDIS® 2019, Vol. 2, Technical Specifications, AMM)

Links:

• Institute for Clinical Systems Improvement Health Care Guideline Adult Depression in Primary Care (Updated March 2016)
• US Department of Health and Human Services/Agency for Healthcare Research and Quality (AHRQ) – “Adult Depression in Primary Care”

 

Reference: “Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents” is a national guideline, following the recommendations by the HHS Panel on Antiretroviral Guidelines for Adults and Adolescents - A Working Group of the Office of AIDS Research Advisory Council (OARAC). This guideline describes the best clinical practices based on available knowledge and a consensus of experts as of July 14, 2016. Health Resources and Services Administration (HRSA), Measure HVL-AD: HIV Viral Load Suppression, as presented in the Core Set of Health Care Quality Measures for Adults Enrolled in Medicaid 2017 Technical Specifications and Resource Manual

Clinical Indicators:

1. Number of HIV+ individuals with at least one outpatient visit in the past 12 months.
2. Percentage of enrollees age 18 and older with a diagnosis of Human Immunodeficiency Virus (HIV) who had a HIV viral load test during the measurement year. (Health Resources and Services Administration)
3. Percentage of Enrollees with pharmacy claims for HIV medications in the past 12 months with an 80% medication possession ratio.

Links

• https://aidsinfo.nih.gov/contentfiles/lvguidelines/adultandadolescentgl.pdf
• http://aidsinfo.nih.gov/guidelines
• https://www.medicaid.gov/medicaid/quality-of-care/downloads/2017-adult-core-set.pdf
• https://aidsinfo.nih.gov/contentfiles/lvguidelines/adultandadolescentgl.pdf

Reference: “2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults:Report From the Panel Members Appointed to the Eighth Joint National Committee” (JNC 8).

Clinical Indicators:

Percentage of members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose BP was adequately controlled (BP was <140/90 mm Hg) during the measurement year.

• Results can be broken out by race and ethnicity.

 

(Source: HEDIS® 2019, Vol. 2, Technical Specifications, CBP)

Links:

• 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults

 

Reference: CDC – Overweight and Obesity

AACE/ACE – American Association of Clinical Endocrinologists and American College of Endocrinology Clinical Practice Guidelines for Comprehensive Medical Care of Patients with Obesity, 2016

Clinical Indicators:

1. Adult BMI
   The percentage of members 18–74 years of age who had an outpatient visit and whose body mass index (BMI) was documented during the measurement year or the year prior to the measurement year. (Source: HEDIS® 2019, Vol. 2, Technical Specifications - ABA))

Links:

• Overweight & Obesity
• https://journals.aace.com/doi/pdf/10.4158/EP161365.GL

Reference: “Clinical Practice Guidelines for Quality Palliative Care,” 2018, 4th Edition, based on the National Consensus Project for Quality Palliative Care.

Clinical Indicators:

1. Care of the Older Adult-Advanced Care Planning
2. Discussion about preferences for resuscitation, life-sustaining treatment and end of life care. Evidence of advanced care planning must include one of the following:

• The presence of an advance care plan in the medical record.
• Care of the Older Adult-Pain Assessment 

At least one pain assessment during the measurement year, as documented through either administrative data or medical record review.
3.   Care for Older Adults-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, as documented through either administrative data or medical record review.

4.   Care for Older Adults-Functional Status Assessment

• At least one functional status assessment during the measurement year, as documented through either administrative data or medical record review.

(Source: HEDIS® 2019, Vol. 2, Technical Specifications COA)

Links:

• Clinical Practice Guidelines for Quality Palliative Care

 

Reference: Centers for Disease Control and Prevention Guideline for Prescribing Opioids for Chronic Pain – United States, 2016 (CDC)

Clinical Indicators:

The rate per 1,000 members 18 years and older, receiving prescription opioids for ≥15 days during the measurement year at a high dosage (average milligram morphine dose [MME] >120mg).

The rate per 1,000 members 18 years and older, receiving prescription opioids for ≥15 days during the measurement year who received opioids from multiple providers. Three rates are reported.

1. Multiple prescribers defined as the proportion of members receiving prescriptions for opioids for four or more different prescribers during the measurement year
2. Multiple pharmacies defined as the rate per 1,000 members receiving prescriptions for opioids from four or more different pharmacies during the measurement year.
3. Multiple prescribers and multiple pharmacies defined as the rate per 1,000 members receiving prescriptions for opioids from 4 or more different prescribers and 4 or more different pharmacies during the measurement year.

Links:

• Opioid Overdose Information
• When is Taking an Opioid Okay?
• Medication-Assisted Treatment for Opioid Use Disorder FAQ’s
• Understanding the Opioid Epidemic
• Reducing Shame by Changing the Language of Addiction
• A Safe Way to Stop Taking Opioids

Reference: American Psychiatric Association’s Clinical Practice Guideline, “The Treatment of Patients with Schizophrenia,” Second Edition, (2004)

Clinical Indicators:

1. Diabetes Screening for People with Schizophrenia or Bipolar Disorder who are using Antipsychotic Medications (Source: HEDIS® 2019, Volume 2 Technical Specifications, SSD)
2. Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia
   (Source: HEDIS® 2019, Vol. 2, Technical Specifications, SMC)
3. Diabetes Monitoring for People with Diabetes and Schizophrenia
   (Source: HEDIS® 2019, Vol. 2, Technical Specifications, SMD)
4. Adherence to Antipsychotic Medications for Individuals with Schizophrenia  (Source: HEDIS® 2019, Vol. 2, Technical Specifications, SAA) 

*Adapted by NCQA with permission of the measure developer, CMS.

Links:

• https://www.psychiatry.org/psychiatrists/practice/clinical-practice-guidelines
• http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/schizophrenia.pdf
• https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/schizophrenia-watch.pdf

Reference: American Psychiatric Association’s “Practice Guideline For The Treatment of Patients With Substance Use Disorders,” Second Edition, (2006).
National Institute on Drug Abuse (NIDA) Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition).
Dartmouth-Hitchcock Knowledge Map, Unhealthy Alcohol and Drug Use – Adult Primary Care – February 2017

Clinical Indicators:

1. Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence (AOD) Treatment
   • 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.(Source: HEDIS® 2019, Vol. 2, Technical Specifications, IET)
   • Engagement of AOD Treatment. The percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit. (Source: HEDIS® 2019, Vol. 2, Technical Specifications, IET)
2. The percentage of emergency department (ED) visits for members 13 years of age and older with a principal diagnosis of alcohol or other drug (AOD) abuse or dependence, who had a follow up visit for AOD. 
   
   Two rates are reported:
   Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence
   • The percentage of ED visits for which the member received follow-up within 30 days of the ED visit (31 total days).
   • Engagement of AOD Treatment. The percentage of members who initiated treatment and who had two or more additional AOD services or MAT within 34 days of the initiation visit. (Source: HEDIS® 2019, Vol. 2, Technical Specifications, IET)

(Source: HEDIS® 2019, Vol. 2, Technical Specifications, FUA)

Links:

• http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/substanceuse.pdf
• https://www.drugabuse.gov/node/pdf/675/principles-of-drug-addiction-treatment-a-research-based-guide-third-edition
• https://med.dartmouth-hitchcock.org/documents/unhealthy-alcohol-drug-use-clinical-practice-guideline.pdf

Reference:Gateway follows the Centers for Disease Control and Prevention, recommended Adult Immunization Schedule-United States, 2019.
The Adult Immunization Schedule has been approved by ACIP, ACOG, ACP & AAFP.

Clinical Indicators:

1.   The percentage of women 50–74 years of age who had a mammogram to screen for breast cancer.

(Source: HEDIS® 2019, Vol. 2, Technical Specifications, BCS)
2.   The percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria:

• Women 21-64 years of age who had a cervical cytology performed every 3 years
• Women 30-64 years of age who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years

(Source: HEDIS® 2019, Vol. 2, Technical Specifications - CCS)

3.   The percentage of women 16-24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement year. Report two age stratifications:

• 16-20 years
• 21-24 years

The total rate is reported.
(Source: HEDIS® 2019, Vol. 2, Technical Specifications - CHL)

4.   The percentage of members 18–74 years of age who had an outpatient visit and whose body mass index (BMI) was documented during the measurement year or the year prior to the measurement year.

(Source: HEDIS® 2019, Vol. 2, Technical Specifications, ABA)

Links:

• Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2019

U.S. Preventive Services Task Force:

• Breast Cancer Screening
• Cervical Cancer Screening
• Chlamydia and Gonorrhea Screening

Reference:American College of Obstetricians and Gynecologists (ACOG) Clinical Guidance and Publications

National Heart, Lung, and Blood Institute, National Institute of Health; Management Asthma During Pregnancy, Recommendations for Pharmacologic Treatment (2004) – NHLBI/NIH

ACOG – High Blood Pressure (Hypertension) - ACOG

American College of Allergy, Asthma & Immunology: Pregnancy and Asthma (2014) - ACAAI

 

Clinical Indicators:

1. Timeliness of Prenatal Care. The percentage of deliveries that received a prenatal care visit as a member of the organization in the first trimester or within 42 days of enrollment in the organization.
2. Postpartum Care. The percentage of deliveries that had a postpartum visit on or between 21 and 56 days after delivery, as documented through either administrative data or medical record review.
   (Source: HEDIS® 2019, Vol. 2, Technical Specifications, PPC)

Links:

• https://www.acog.org/Clinical-Guidance-and-Publications/Search-Clinical-Guidance
• https://www.nhlbi.nih.gov/files/docs/astpreg_qr.pdf
• https://www.acog.org/womens-health/high-blood-pressure-hypertension
• https://acaai.org/asthma/who-has-asthma-and-why/pregnancy-and-asthma

• Guidelines may not apply to every patient or clinical situation; some variation from guidelines is expected. Provider judgment and knowledge of an individual patient supersedes clinical guidelines.
• Guidelines do not determine insurance coverage of health care services or products. Coverage decisions are based on member eligibility, contractual benefits, and determination of medical necessity.