ACAP Comment Letter on Non-Acute Mental Health Utilization Quality Measure for Dual-Eligible Beneficiaries

April 27, 2017

To: Whom It May Concern

Re: Quality Measure Development and Maintenance for CMS Programs Serving Medicare-Medicaid Enrollees and Medicaid-Only Enrollees – HHSM-500-2013-13011I, Task Order # HHSM-500-T0004 – ACAP Support with Modifications

Submitted via

Measure Name: Non-Acute Mental Health Service Utilization

Level of Support: Support with modifications

The Association for Community Affiliated Plans (ACAP) represents 60 Safety Net Health Plans that cover more than 17 million people through Medicaid, CHIP, Medicare, the Marketplaces and other publicly-sponsored health programs. Our plans cover nearly half of all people in Medicaid managed care, and are on the forefront of innovative efforts to reform health care, especially health care for people with low incomes.  We thank you for this opportunity to comment on the proposed measures for dual-eligible individuals entitled “Non-Acute Mental Health Service Utilization.”

While we support the use of quality measures to ensure that dual-eligible beneficiaries are receiving high-quality care to meet their mental health needs, we do have some concerns with the specifics of the measure and will address each of the issues raised in the request for comment below.

General Questions

  • Are the candidate measures useful for measuring important domains of quality for the dual eligible population?

The measure seeks to identify and address unmet mental health needs for dual eligible.  ACAP believes that such a measure with appropriate specifications could be worthwhile.

  • Do the measures duplicate comparable measures that have already been validated and widely used, are now under development, or will be submitted for consensus-based entity (NQF) endorsement?

For many years, the only measures that looked at mental health issues were the HEDIS Initiation and Engagement measures and Follow-up after a Hospitalization related to Mental Illness.  Recently, there have been several mental health measures added to the Medicaid HEDIS suite.  Most of the measures, however, have focused on issues related to follow-up care, medication management and integration of behavioral health and physical health. This measure attempts to address unmet mental health needs, which is a unique and currently unmet niche.

Additional Measure Specification Questions

  • How should this measure handle individuals who have dementia or delirium and may be using antipsychotic medication to control behavioral problems – exclude these individuals from the denominator or expand the numerator and denominator to include these diagnoses as evidence of mental health service need?

ACAP believes that individuals who have dementia or delirium and may be using antipsychotic medication to control behavioral problems should be excluded from the denominator. While it is imperative that measures are developed to ensure that individuals with dementia or delirium are not facing unmet need, the specific and unique challenges facing that population are distinct from the broader pool of Medicare-Medicaid enrollees with mental health services need. They present different challenges that would be best addressed in a distinct measure.

  • Should this measure be stratified by use of LTSS (i.e., institutional dwelling, community dwelling with LTSS, and community dwelling without supports)?

ACAP opposes stratification of this measure based on the site that LTSS are being provided. Stratification is illuminating and useful when the characteristic being stratified has a substantial impact on a given measure. It is unclear whether the site that the LTSS are provided has an impact or plays a role as to whether someone’s mental health need is being met. Stratification would therefore add needless administrative complexity without demonstrating any benefit.


Other Concerns

The measure’s numerator includes all individuals receiving at least one mental health service meeting in the past 12 months, while the denominator includes dual-eligible beneficiaries 18 and older with a mental health service need in the prior 24 months. ACAP is concerned that this imbalance in time periods between the numerator and denominator will skew the measure to overemphasize mental health service need. As an example, one can imagine an individual who had a mild mental health service need at the beginning of the 24-month identification window. Over the ensuing eleven months, she received needed care, including follow-up to resolve the issue. For the next year, the mental health need did not recur and no further treatment was needed. Under the calculus of the proposed measure, this individual would be considered to have unmet need, as she had a mental health need in the prior 24 months but no mental health service in the prior 12 months. ACAP believes that this mismatch in time frames has the potential to  misrepresent the extent of unmet need in mental health services for dual eligible beneficiaries.

If you have any questions or comments on this response, please feel free to contact me at



Deborah Kilstein

VP Quality Management and Operational Support