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 key components of the guideline include the definition, diagnosis of asthma, managing asthma long term, managing exacerbations and patient education.

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. (NOTE: Medicare, report only members 18 to 85 years of age.)
   (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Asthma Medication Ratio)
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 an asthma controller medication for at least 75% of their treatment period. (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Medication Management for People with Asthma)

Links:

• National Asthma Education and Prevention Program Expert Panel Report

Reference: Gateway Health adopts American Psychiatric Association Clinical Practice Guideline titled “The Treatment of Patients with Bipolar Disorder” (Second Edition, Revision 2002). Key components of the guideline include: an executive summary of the recommendations, formulation and implementation of a treatment plan including psychiatric management, acute and maintenance treatments, special clinical features influencing the treatment plan, background information on the disease and review of available evidence including somatic treatments, rapid cycling and psychosocial interventions.

Since the publication in 2002 of the Practice Guideline for the Treatment of Patients with Bipolar Disorder, 2nd Edition, new options for the acute treatment of manic, mixed, or depressive episodes have emerged. Knowledge of pharmacological and psychosocial interventions for maintenance has also increased.

Since the publication in 2002 of the Practice Guideline for the Treatment of Patients with Bipolar Disorder, 2nd Edition, new options for the acute treatment of manic, mixed, or depressive episodes have emerged. Knowledge of pharmacological and psychosocial interventions for maintenance has also increased.

Clinical Indicators:

1. Members 18–64 years of age with schizophrenia or bipolar disorder, who were dispensed an antipsychotic medication and had a diabetes screening test during the measurement year. (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications )
2. Discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had a visit with a mental health practitioner. Two rates are reported:
   • The percentage of discharges for which the member received follow-up within 30 days of discharge.
   • The percentage of discharges for which the member received follow-up within 7 days of discharge.
   (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Follow-Up After Hospitalization for Mental Illness)

Links:

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

Reference: Gateway adopts the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (GOLD) clinical practice guideline as developed by the Global Initiative for Chronic Obstructive Lung Disease, which was formed through the collaborative efforts of the National Heart, Lung, and Blood Institute, National Institutes of Health, USA and the World’s Health Organization in 1998. The guideline outlines the definition, diagnosis and assessment, therapeutic options, management of stable COPD, management of exacerbations, COPD and co-morbidities and the asthma and COPD Overlap Syndrome (ACOS). COPD affects people 40 years of age and older with a history of smoking but can also affect people exposed to fumes, chemicals, and dust found in the environment.

COPD is one of Gateway’s Lifestyle Management Program for chronic respiratory management.

Clinical Indicators:

1. Percentage of members 40 years and older with a new diagnosis of COPD or newly active COPD, who have received spirometry testing to confirm the diagnosis. (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Use of Spirometry Testing in the Assessment and Diagnosis of COPD)
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 was evidence of an active prescription) within 14 days of the event. (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Pharmacotherapy Management of COPD Exacerbation Dispensed a systemic corticosteroid within 14 days of the event)
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 a bronchodilator (or there was evidence of an active prescription) within 30 days of the event. (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Pharmacotherapy Management of COPD Exacerbation Dispensed a bronchodilator within 30 days of the event)

Links:

• GOLD Reports 2018

Reference:Gateway adopts four clinical practice guidelines for the cardiac related diagnoses:

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

Key components of the guidelines include initial evaluation of patients with heart failure, CAD and other atherosclerotic vascular disease, therapies and treatment of the population. Treatment includes, but is not limited to: testing and medication regimes; and, the recommendations for cholesterol treatment and management.

Cardiac Disease in one of Gateways top 10 diseases by average cost per disease and per member per reporting period 2/1/2017 to 1/31/2018 and one of Gateway’s Lifestyle Management Programs.

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® 2018, Vol. 2, Technical Specifications, Persistence of Beta-Blocker Treatment after a Heart Attack )
2. The percentage of members 18-59years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled during the measurement year <140/90. (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Controlling High Blood Pressure )
3. 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 and met the following criteria:
   • Received statin therapy: Members who were dispensed at least one high or moderate-intensity statin medication during the measurement year.
   • Statin Adherence 80%: Members who remained on a high or moderate-intensity statin medication for at least 80% of the treatment period.
   (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Statin Therapy for Patients with Cardiovascular Disease )

Links:

• Treatment of Blood Cholesterol
• Guideline for the Management of Heart Failure
• Secondary Prevention and Risk Reduction for Coronary and other Atherosclerotic Vascular Disease

Reference: Gateway Health adopts the ADA’s Standards of Medical Care in Diabetes.

Diabetes is a complex, chronic illness requiring continuous medical care for glycemic control. The condition can go undiagnosed and increases the risk of heart attack, stroke, kidney failure, amputation and blindness. It requires patient self-management, education and support to prevent these complications.

Diabetes is one of Gateway’s top 10 diseases by member count and total disease cost per reporting period 2/1/2017 to 1/31/2018 and one of Gateway’s Lifestyle Management Programs.

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® 2018, Vol. 2, Technical Specifications, Comprehensive Diabetes Care-HbA1c testing)
2. The percentage of members 18–75 years of age with diabetes (type 1 and type 2) who had an HbA1c poor control >9%. (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Comprehensive Diabetes Care-Poor Control >9%)
3. The percentage of members 18–75 years of age with diabetes (type 1 and type 2) who had and eye exam. (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Comprehensive Diabetes Care-Eye exam)
4. The percentage of members 18–75 years of age with diabetes (type 1 and type 2) whose blood pressure was <140/90 (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Comprehensive Diabetes Care-BP control <140/90)

Links:

• 2018 ADA Standards of Care

Reference: Gateway adopts the Practice Guideline for the Treatment of Patients with Major Depressive Disorder, Third Edition. Depression is one of Gateway’s Behavioral Health Care Management Programs.

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. Two rates are reported:
   • 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® 2018, Vol. 2, Technical Specifications, Antidepressant Medication Management)

Links:

• PRACTICE GUIDELINE FOR THE Treatment of Patients With Major Depressive Disorder

Reference: Gateway Health adopts the HIV Clinical Practice Guideline titled, “Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents” is a national guideline, following the recommendations by the U.S. Department of Health and Human Services (DHHS) 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. The guideline outlines General Care, Antiretroviral Lab Testing and Therapy, Care of Adolescents and Women with HIV/AIDS, drug interactions, HIV-related preventative care and ancillary services. It also provides available HIV Resources. Medication management for HIV is important to Gateway Health since Antiretroviral therapy should be started as soon as possible for people with HIV which helps reduce the risk of HIV transmission.

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. (HRSA)
3. Percentage of individuals with pharmacy claims for HIV medications in the past 12 months with an 80% medication possession ratio.

Links

• Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents

Reference: Gateway adopts the 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults Report from the Panel Member Appointment to the Eighth Joint National Committee (JNC 8). Hypertension is the most common condition seen in primary care and can lead to heart attack, stroke, renal failure and death if not detected early.

Clinical Indicators:

1. Percentage of members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose BP was adequately controlled during the measurement year based on the following criteria:
   • Members 18-59 years of age whose BP was <140/90 mm Hg.
   • Members 60-85 years of age with a diagnosis of diabetes whose BP was <140/90 mm Hg.
   • Members 60-85 years of age without a diagnosis of diabetes whose BP was <150/90 mm Hg. Note: Use the Hybrid Method for this measure. A single rate is reported and is the sum of all three groups.
   • Results can be broken out by race and ethnicity.
   (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Controlling High Blood Pressure)

Links:

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

Reference: Gateway adopts the Centers for Disease Control and Prevention, Overweight and Obesity efforts on policy and environmental strategies to make health eating and active living accessible to everyone which include: strategies to prevent and manage obesity and adult overweight and obesity. The CDC adult obesity facts reports that prevalence of obesity was 39.8% and affected 93.3 million of U.S. adults in 2015-2016.¹

Clinical Indicators:

1. 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® 2018, Vol. 2, Technical Specifications, Adult BMI)

Links:

• Overweight & Obesity

¹Centers for Disease and Control and Prevention, Adult Obesity Facts; Obesity is common, serious and costly.

Reference: The “Clinical Practice Guidelines for Quality Palliative Care” 2013, 3^rd Edition, was formed through the collaborative efforts of palliative care leaders from across the United Stated in 2001 to form the National Consensus Project for Quality Palliative Care with representation from five major hospice and palliative care organizations at the time: The American Academy of Hospice and Palliative Medicine, The Center to Advanced Palliative Care, The Hospice and Palliative Nurses Association, Last Acts Partnership, and the National Hospice and Palliative Care Organization. Key components of the guideline describe core concepts and structures for quality palliative care, including eight domains of practice. The 2013 edition was produced through a consensus process among leadership professional hospice and palliative care organizations. In this revision, the emphasis is on continuity, consistency and quality of care.

Clinical Indicators:

1. 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.
   • Documentation of an advance care planning discussion with the provider and the date when it was discussed. The documentation of discussion must be noted during the measurement year.
   • Notation that the member previously executed an advance care plan.
   (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Care of the Older Adult-Advanced Care Planning)
2. At least one pain assessment during the measurement year, as documented through either administrative data or medical record review. (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Care of the Older Adult-Pain Assessment)

Links:

• “Clinical Practice Guidelines for Quality Palliative Care,” 2013, 3rd Edition, based on the National Consensus Project for Quality Palliative Care:

Reference: Gateway adopts the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC) as the guideline to promote patient care and safety that addresses the US opioid overdose epidemic. The guideline serves clinicians who prescribe opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care. The guideline addresses 1) improved communication between clinician and patients about the benefits and risks of using prescription opioids for chronic pain; 2) provide safer, more effective care for patients with chronic pain; and 3) help reduce opioid use disorder and overdose. CDC developed the guideline using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework, and recommendations are made on the basis of a systematic review of the scientific evidence while considering benefits and harms, values and preferences, and resource allocation. CDC obtained input from experts, stakeholders, the public, peer reviewers, and a federally chartered advisory committee. It is important that patients receive appropriate pain treatment with careful consideration of the benefits and risks of treatment options which is why it is of relevance to Gateway’s population.

The CDC Guideline for Prescribing Opioids for Chronic Pain was published in March 2016 and provides recommendations about appropriate prescribing of prescription opioids and other treatment options to improve pain and patient safety. The CDC also provides a checklist for prescribing opioids for chronic pain.

Clinical Indicators:

1. Use of Opioids at High Dosage ages 18+, the rate per 1,000 receiving prescription opioids for ≥15 days at a high dosage (average morphine equivalent dose >120mg
2. Use of Opioids From Multiple Providers ages 18+ the rate per 1,000 receiving prescription opioids for ≥ 15 days who received opioids from multiple providers. Three rates are reported:
   • multiple prescribers defined as the rate per 1,000 members receiving rx for opioids from 4 or more different prescribers
   • multiple pharmacies defined as the rate per 1,000 members receiving prescriptions for opioids from 4 or more different pharmacies
   • 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
   (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Use of Opioid at High Dosage )

Links:

• CDC GUIDELINE FOR PRESCRIBING OPIOIDS FOR CHRONIC PAIN
• Opioid Overdose
• Checklist for prescribing opioids for chronic pain

Reference: Gateway adopts the American Psychiatric Association Clinical Practice Guideline titled “Practice Guideline for the Treatment of Patients with Schizophrenia, Second Edition” (2004). Key components of the guideline include: formulation and implementation of a treatment plan, establishing a therapeutic alliance, acute, stabilization and stable phase treatments, treatment setting and housing options. Background information and review of available evidence including pharmacological treatments, somatic therapies and psychosocial interventions are also included.

Clinical Indicators:

1. The percentage of members 18-64 years of age with schizophrenia or bipolar disorder, who were dispensed an antipsychotic medication and had a diabetes screening test during the measurement year. (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Diabetes Screening for People with Schizophrenia who are using Antipsychotic Medications)
2. The percentage of members 18–64 years of age with schizophrenia and cardiovascular disease, who had an LDL-C test during the measurement year. (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia)
3. The percentage of members 18–64 years of age with schizophrenia and diabetes who had both an LDL-C test and an HbA1c test during the measurement year. (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Diabetes Monitoring for People with Diabetes and Schizophrenia)

Links:

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

Reference: Gateway adopts the American Psychiatric Association’s “Practice Guideline For The Treatment of Patients With Substance Abuse Disorders,” Second Edition (2006). The guideline mainly consists of three parts:

1. “Treatment Recommendations for Patients With Substance Use Disorders,”
2. “Background Information and Review of Available Evidence,” and,
3. “Future Research Needs.”

Key elements of Part A, “Treatment Recommendations for Patients with Substance Use Disorders,” includes (but is not limited to): an executive summary of recommendations, general treatment principles, and the treatment of nicotine dependence, alcohol-related disorders, marijuana-related disorders, cocaine-related disorders, and opioid-related disorders.

Clinical Indicators:

1. The percentage of members who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization, telehealth or medication assisted program (MAT) within 14 days of the diagnosis.
2. 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® 2018, Vol. 2, Technical Specifications, Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence (AOD) Treatment )

Links:

• Treatment of Patients With Substance Use Disorders

Reference:Gateway follows the Centers for Disease Control and Prevention, recommended Adult Immunization Schedule-United States, 2017. 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® 2017, Vol. 2, Technical Specifications, BCS)
2. 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® 2017, Vol. 2, Technical Specifications, ABA)

Links:

• Immunization
• Recommended Vaccinations Indicated for Adults Based on Medical and Other Indications
• Adult Preventive Guideline

Reference: Gateway adopts The American College of Obstetricians and Gynecologists, Committee on Obstetric Practice, Committee Opinions and Practice Bulletins and the Centers for Disease Control and Prevention (CDC); Advisory Committee on Immunization Practices (ACIP); American College of Obstetricians and Gynecologists (ACOG) and the American College of Nurse-Midwives (ACNM).

Maternity is one of the top diagnoses in the Gateway population with a mean maternal age of 25 years and is one of Gateway’s Lifestyle Management Programs. Historically, Gateway Health® two most frequent risk factors are smoking followed by depression. Smoking is associated with increased perinatal mortality, ectopic pregnancy and bleeding complications of pregnancy and a higher incidence of small, low birth weight babies and preterm deliveries. Untreated depression has been associated with unfavorable health behaviors in pregnancy and subsequent fetal growth restrictions, preterm deliveries, placental abruption, and newborn irritability. With early identification of maternal risk factors, Gateway can make an impact on reducing risk factors that can lead to poor pregnancy outcome, low birth weight and infant mortality.

Clinical Indicators:

1. The percentage of deliveries that received a prenatal care visit as a member of the organization in the first trimester, on the enrollment start date or within 42 days of enrollment in the organization. (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Timeliness of Prenatal Care)
2. A postpartum visit for a pelvic exam or postpartum care on or between 21 and 56 days after delivery, as documented through either administrative data or medical record review. (Source: HEDIS® 2018, Vol. 2, Technical Specifications, Postpartum Care)

Links:

• Search Clinical Guidance
• Adult Schedule

• 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.