ACAP Comments on Proposed NCQA 2017 HEDIS Changes
March 16, 2016
Follow-Up After Emergency Department Visit for Mental Illness
Support with Modifications
Concerning the specifications, ACAP supports the use of only the primary diagnosis for determining the denominator. We also support excluded individuals with an inpatient stay during the 30-day period.
In terms of the appropriate follow-up, we request that the measure specification clearly allow follow-up visits with a PCP, especially if they have been following ongoing treatment for a mental health diagnosis.
We do NOT support the use of the 7-day measure given that not all individuals who have an emergency visit need follow-up within a 7-day period and this measure makes not allowance for making that determination.
Concerning the question raised on telehealth, we do support the use of telehealth, although it must be recognized that it will not be an apples-to-apples comparison since some states do limit the use of telehealth. We also strongly support the use of telephone consultation, especially when utilized to conduct triage and determine the appropriate timeframe for a follow-up visit. Finally, it should be clearly stated if mental health services are carved out of the benefit package in whole or in part, the plan should be exempt from reporting this measure without penalty.
Follow-Up After Emergency Department Visit for Alcohol and Other Drug Dependence
Do Not Support
Because of the unique consent requirements for substance use treatment imposed by 42 CFR Part 2 for substance use treatment, ACAP is very concerned that health plans will not have ready access to whether follow-up treatment occurred. This consent issues are further exacerbated when the patient is an adolescent. Therefore, we cannot support this measure.
Concerning the specifications, ACAP supports the use of only the primary diagnosis for determining the denominator. We also support excluded individuals with an inpatient stay during the 30-day period. In terms of the appropriate follow-up, we request that the measure specification clearly allow follow-up visits with a PCP.
Concerning the question raised on telehealth, we do support the use of telehealth, although it must be recognized that it will not be an apples-to-apples comparison since some states do limit the use of telehealth. We also strongly support the use of telephone consultation, especially when utilized to conduct triage and determine the appropriate timeframe for a follow-up visit. Finally, it should be clearly stated if substance use treatment services are carved out of the benefit package in whole or in part, the plan should be exempt from reporting this measure without penalty.
Standardized Healthcare-Associated Infection Ratio
Do Not Support
ACAP recognizes that patient safety is an important issue. However, ACAP strongly opposes the adoption of this measure. Hospital-reporting standard infection ratios (SIR) are already reported through Hospital Compare, and the value of this measure reported at the health plan level is unclear. We believe that continuing to report this measure at the facility level to monitor patient safety is the most appropriate response.
In terms of hospital infections, health plans have limited ability to impact this measure. A health plan’s most significant tool for impacting this measure is to exclude low-performing hospitals from participating in a plan’s network. However, for a Medicaid health plan, this is an unrealistic expectation. Oftentimes, the provider is the only hospital in the geographic area, especially in very urban and very rural areas. Not only would exclusion impact a plan’s ability to meet network adequacy standards, it would put a significant burden on the patient and their family to reach another facility. In fact, in emergency situations, there may be no choice. Moreover, for Medicaid health plans, the measure fails to recognize the impact of socio-economic status on a patient’s susceptibility to hospital acquired infection and the impact of where they live on the facility they utilize for their care.
A much better approach would be to address this issue via the standards. A standard could be developed that would require health plans to demonstrate the efforts they have taken to collaborate with low-performing hospitals to lower infection rates. This would have a quality improvement focus without penalizing plans for including these hospitals in their network.
Depression Remission or Response for Adolescents and Adults
Do Not Support
ACAP recognizes and supports the need for tracking follow-up. However, due to a host of issues with this measure, ACAP does not support the inclusion of this measure and advocates that more work be done prior to adopting this measure.
First, while appropriate for screening, our member plans do not agree that PHQ is an appropriate tool for measuring treatment response. Second, the PHQ results are not captured via claims and will require chart review to support the measure where there is not EHR penetration or there are ongoing issues with inoperability. Third, we strongly suspect that there will be significant issues regarding sample size. Fourth, in Medicaid due to the impact of churning, we believe a significant number of adults will be excluded from the measure because of lack of continuous enrollment.
Use of High-Risk Medications in the Elderly
ACAP supports the effort to align measures. We also support the elimination of the exclusion for dementia.
We seek clarification from NCQA regarding the inclusion of denied claims in the numerator and denominator. The measure specifications state that the “although denied claims are not included when assessing the numerator, all claims (paid, suspended, pending and denied) must be included when identifying the eligible population”. We are concerned that excluding denied claims in the numerator while including denied claims in the denominator may inaccurately include members in the measurement. We recommend NCQA modify this specification.
Fall Risk Management
Do Not Support
While we support the intent of the measure, ACAP does not support modifying the effort at this time. We believe that the measure should not be changed until NQF completes a review of the fall measures as part of the Patient Safety Project. We also do not support the addition of the Vitamin D related change to the question. It would make much more sense to add a more relevant example to the survey question.
Immunizations for Adolescents & Human Papillomavirus Vaccine for Female Adolescents
Support with Modifications
ACAP supports modification of this measure to include males receiving HPV vaccine. However, we believe it is important to stratify the measure by gender. We believe that it will take much more work on the part of health plans to increase the HPV vaccination rates for adolescent males. Stratification will allow health plans to better focus their quality improvement activities and will provide gender specific benchmarks. While we ultimately support going to a single measure, we believe that the time is not quite right for this to occur.
Pneumococcal Vaccination Status for Older Adults
ACAP continues to have concerns with this measure being based on the HOS survey, given the issue associated with member recall. However, we do not oppose the change to the measure.
Use of Imaging Studies for Low Back Pain
ACAP does not hold this measure in high regard because of a lack of utility in improving clinical conditions or reducing costs. We think the measure should be considered for retirement. However, we do not oppose the change to the measure.