Comments to NCQA on Proposed Behavioral Health Measures

On behalf of the Association for Community Affiliated Plans (ACAP) health plan members, we thank you for the opportunity to comment on the proposed measures that focus on screening and monitoring for physical health conditions for people with severe mental illness and alcohol or other drug use disorders. ACAP is a trade association that represents 58 non-profit, safety net health plans in 24 states that serve over 10 million lives.

ACAP members are strong advocates for ensuring the highest quality of care and supporting quality measurement. Our members also recognize and fully support the need to develop quality measurement that gets directly to the issue of improved integration of physical and behavioral health care. However, quality measurement as a means to foster quality improvement and improved care integration must be done in a workable and realistic manner.

While the overview states that the measures were developed for health plan use, it does not specify the lines of business impacted. One of the specifications seems to indicate that the measures are specific to Medicaid lines of business. Given the incidence of behavioral health and alcohol and drug disorders throughout the population in general, we see no reason why the measures would be limited to Medicaid and not include commercial health plans.

In most cases, the proposed measures are hybrid measures that will require chart review and abstraction. We have a number of concerns in this regard. While we continue to support quality measurement, there has and continues to be a general proliferation of measures that required chart review without regard to collection burden on health plans, both in terms of costs, resources and realistic work effort. Moreover, there are no existing HEDIS hybrid measures that have to collect information in as complicated a fashion as these proposed measures. They require not only collection of multiple pieces of information over a time span, but most have qualitative aspects that have been shown to be highly problematic in practice, requiring multiple specification re-writes and NCQA clarifications not to mention evidence of differential treatment by various plans and auditing firms. In addition, there are significant legal restrictions around the access of behavioral health and substance abuse records. Obtaining access to the actual medical record has been found to be quite difficult and time-consuming and health plan efforts are often unsuccessful.

Regarding the emergency room measure, it is not clear how a behavioral health organization/plan would necessarily know that the member had an ED visit. When both the physical and benefit health benefit are the responsibility of a single managed care entity, there is often a significant lag time receiving data and claims from hospitals making it extremely difficult to meet the 7-day follow-up rate. In addition, in emergency department situations, timely follow-up is often difficult because the initial patient information frequently do not indicate a behavioral health diagnosis; therefore plans are often not made aware that these individuals need follow-up because they have a SMI or AOD until well after the event. It is also not clear whether the specification applies to any SMI or AOD diagnosis or just the primary diagnosis for the service. Finally, the specification should read “diagnosis” not “condition,” since the information used to identify the sample will be based on the diagnosis on the claim record.

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