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HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).
Note: This publication is protected by U.S. and international copyright laws. You may reproduce this document for the sole purpose of facilitating public comment. 2012 by the National Committee for Quality Assurance 2012 by the National Committee for Quality Assurance 1100 13th Street NW, Suite 1000 Washington, DC 20005 All rights reserved. Printed in U.S.A. NCQA Customer Support: 888-275-7585 www.ncqa.org
Technical Specifications for ACO MeasuresPublic Comment OverviewObsolete After April 6, 2012
Synopsis
NCQA seeks feedback on proposed technical specifications for performance measures for Accountable Care Organizations (ACO). Public Comment documents are: Public Comment Overview. Provides background and rationale for NCQAs approach to measuring ACO performance and explains how NCQA arrived at some of the decisions reflected in the accompanying documents. Technical Specifications for ACO MeasuresOverview and General Guidelines. The first two sections of the Technical Specifications for ACO Measures publication provide guidance on defining the population for ACO measurement, reporting measure results to NCQA, data collection and sampling methods for a core set of performance measures. The publication also includes three appendices for reference. Selected measures Revised specifications for five selected measures that illustrate the application of the general guidelines for ACO measurement to the actual measure specification: Colorectal Cancer Screening. Comprehensive Adult Diabetes CareLDL Control. Use of Appropriate Medications for People With Asthma. Use of Imaging Studies for Low Back Pain. Follow-Up After Hospitalization for Mental Illness. Submit comments by April 6 at 5:00 p.m. EST.
NCQA 2012
Technical Specifications for ACO MeasuresPublic Comment OverviewObsolete After April 6, 2012 Although there is room for much innovation and experimentation, NCQAs definition of an ACO requires the organization to include a group of physicians with a strong primary care base and enough specialty physicians to support the care needs of a defined population of patients. A well-run ACO should align the clinical and financial incentives of its providers. Providers will need to be clinically integrated and work together to seamlessly coordinate care for assigned patients. Given the evidence that alignment of clinical and financial incentives is desirable, ACOs will also need the administrative infrastructure to manage budgets; collect data; report performance; make payments related to performance; and organize providers around shared goals. By coordinating and integrating care, ACOs have the potential to simplify the care process for patients, enhance quality and reduce costs. ACOs have the potential to get better quality at lower cost by aligning incentives to promote coordination and transform health care delivery. However, not every group of providers that wants to call itself an ACO has what it takes to accomplish this vital mission. That is why NCQA, working with a broad array of stakeholders, developed clear criteria and standards for guiding ACOs to success. NCQAs ACO Accreditation provides independent evaluation of organizations abilities to coordinate and be accountable for the high -quality, efficient, patientcentered care expected from ACOs. Like NCQAs Patient-Centered Medical Home (PCMH) program, ACO accreditation provides a roadmap to help providers make the challenging and much-needed transformation into ACOs. The program aligns with many of the expectations that the Centers for Medicare & Medicaid Services (CMS) has for the Medicare Shared Savings Program, as well as common expectations of private purchasers.
NCQA 2012
Technical Specifications for ACO MeasuresPublic Comment OverviewObsolete After April 6, 2012
Measure specification complexity varies because of the amount of data available to ACOs. ACOs with payer contracts that include the exchange of paid claims (pharmacy and medical), enrollment and laboratory data for the ACO population, as well as fully functioning EHRs across all settings of care, may have a rich array of data available. Other ACOs may need to use manual billing systems and paper records that differ in level of completeness. Recognizing that measurement programs applied across a diverse set of ACOs must accommodate the least advanced measurement capabilityat least for nowNCQA has attempted to provide specifications that apply to all levels of data sophistication. NCQA believes that satisfying performance reporting requirements for ACO standards will differentiate ACOs based on their ability to effectively improve the quality of care for the populations they serve. Our development process identified a number of key policy issues for applying HEDIS specifications to an ACO environment. NCQA convened an external ACO Advisory Panel to provide input on these issues and discussed them with a variety of standing committees, including the Committee on Performance Measurement. NCQA now seeks Public Comment on our proposals addressing these issues.
NCQA 2012
Technical Specifications for ACO MeasuresPublic Comment OverviewObsolete After April 6, 2012 Method 1 1A 1B If the ACO has at least one ACO contract in force as of January 1 of the measurement year, it has two options: Report on the aggregate ACO contract population, as defined through contractual attribution models or assignment methods, or Report on the aggregate ACO contract population, plus all or at least 80 percent of the patient population (consistent with how the population is defined for NCQA ACO Accreditation), as defined by NCQAs Recommended Patient Attribution Model. If the ACO has no ACO contract in force as of January 1 of the measurement year, it reports on all or at least 80 percent of its patient population (consistent with how the population is defined for NCQA ACO Accreditation), using NCQAs Recommended Patient Attribution Model.
Method 2
For the purposes of Methods 1B and 2, two steps apply when using NCQAs Recommended Patient Attribution Model. The first step is to define the universe of an ACOs patient population as all active patients as of January 1 of the measurement year (and for purposes of actual measurement, defined as of December 31 of the measurement year) with any provider participating in the ACO as contractually defined by the ACO (e.g., primary and specialty care, acute care, surgical care, post-acute care, long term care). The second step is applying NCQAs Recommended Patient Attribution Model to at least 80 percent of that universe of patients. The intent is for an ACOs entire patient population to be considered through this process. NCQA expects that ACOs will use a consistently defined population across all performance measures. NCQA requires that ACOs disclose the attribution models used to identify their population for measurement, regardless of the model used to define the population. Refer to Disclosure of Patient Attribution Model. A-2. NCQAs Recommended Patient Attribution Model (pages 1112) Background. Accountable care populations are generally defined by patients receiving medical care from providers participating in an ACO or by assigning people (sometimes voluntarily) to a defined ACO. Neither approach defines a broad community of individuals for whom an ACO can be held accountable for achieving the Triple Aim. With this in mind, NCQA intends to define patient attribution in terms of where the industry is today and will be in the near futureto account for ACOs in their current status. Patient attribution or assignments will be contractually defined and may therefore differ by ACO and by contract; therefore, NCQAs approach to recommending an attribution model must accommodate different attribution models currently in the field and encourage standardization. NCQA will require ACOs to report the attribution models they use to identify their population for measurement and expects that the population will remain consistent across all performance measures. NCQA considered several patient attribution models, including the CMS Physician Group Practice and Medicare Shared Savings Program (MSSP), the Brookings-Dartmouth ACO Collaborative and organization-specific methodologies (e.g., BCBS of Illinois). Several of these models required ACOs to have access to payeradjudicated claims (e.g., use of episode groupers or allowed charges), which raised concerns about broad applicability across ACOs. While none of these models identify all individuals (e.g., those not seeking health care) for which an ACO may be accountable, specifying an attribution methodology is a reasonable starting place. NCQA encourages long-term standardization of patient attribution models across the health care industry and seeks harmony with CMS accountable care evaluation methods. NCQA also recognizes the ongoing empirical contributions to this model by researchers at The Dartmouth Institute, and therefore proposes to specify an attribution method for organizations opting to report on ACO populations as follows.
NCQA 2012
Technical Specifications for ACO MeasuresPublic Comment OverviewObsolete After April 6, 2012 Recommended Attribution Method: Use the patient attribution model as defined by CMS MSSP, with the following modifications:
1. Apply a 24 month period, rather than the CMS 12-month period, given the broader demographic of all ages, rather than only CMS beneficiaries who use more services than younger cohorts use. 2. Apply the plurality of primary care visits, rather than the CMS plurality of primary care allowed charges, given the probable dependence on payer paid claims to determined allowed charges.
Primary Care Service Codes for Attribution. Publish and maintain specific primary care service HCPCS codes, G-codes and corresponding revenue codes (as required for inclusion of Federally Qualified Health Centers and rural health centers), in accordance with CMS MSSP.
Retrospective Attribution for Measurement. Although the populations targeted for measurement are determined as of January 1 of the measurement year (refer to A-1, above), patient attribution to those populations, for the purposes of ACO measurement, should be determined as of December 31 of the measurement year. This is consistent with CMS MSSP, whereby there is an initial prospective attribution at the start of the measurement year to determine the populations to be evaluated and a final attribution at the close of the year for measurement.
NCQA 2012
Technical Specifications for ACO MeasuresPublic Comment OverviewObsolete After April 6, 2012
Submission of ACO Attribution Models. NCQA proposes that ACOs submit all models of attribution they use to define the population. This will allow NCQA to collect information for exploring the potential for future standardization in models across ACOs. Where ACOs use multiple attribution models, NCQA will request information on the model and the proportion of the aggregate ACO population identified using that model. ACO specifications will not include continuous enrollment or patient inclusion criteria, because patient attribution methodologies will adequately assign the accountability of patients to ACOs.
NCQA 2012
Technical Specifications for ACO MeasuresPublic Comment OverviewObsolete After April 6, 2012 Data Elements for ACO Submission. Consistent with NCQAs requirement for health plan HEDIS reporting, ACOs will be asked to annually submit a set of data elements stipulated for each measure and information about their organization and populations. NCQA expects to phase in requirements for data submission (e.g., begin with data collection methodology, numerator, denominator, rate and attribution methods and expand to requirements similar to health plan HEDIS data submission). B-4. Audit Requirement for ACO Measurement (page 17) A key facet of the NCQA Accreditation programs is their ability to benchmark performance, which requires optimum consistency in measurement and scoring. Consistency is achieved when audits are instituted as a requirement for reporting. Because NCQA encourages emerging ACOs to develop the internal capacity for reporting quality measures across their aggregate ACO population, measure audits will be a future requirement. At this time, NCQA does not anticipate an audit requirement before the June 2014 submission on the 2013 measurement year.
NCQA 2012
Technical Specifications for ACO MeasuresPublic Comment OverviewObsolete After April 6, 2012 C-3. Exclusions for ACO Measurement (page 15)
For many HEDIS measure specifications, exclusions are cited as the result of careful consideration by expert measurement panels assigned to each measure. Optional exclusions also allow organizations to receive credit for services received, even when a member meets the exclusion criteria. HEDIS 2012 Technical Specifications for Physician Measurement takes a different approach and requires exclusions to ensure consistent measurement and comparisons between providers. NCQA believes that ACO performance measurement is more closely aligned with physician measurement. Both the CMS MSSP and National Quality Forum have shown preference for requiring exclusions. Require Exclusions for ACO Measurement. NCQA proposes to diverge from HEDIS Health Plan Measurement and align with HEDIS 2012 Technical Specifications for Physician Measurement by requiring exclusions to provide more consistent and accurate measurement. C-4. Pharmacy Data for ACO Measurement (pages 2021) Eleven core measures for NCQA ACO Accreditation rely on pharmacy or prescription data in the numerator, in the denominator, or both. An ACO that does not have access to the requisite pharmacy data can opt not to pursue the 11 measures. HEDIS Health Plan Measurement requires the use of dispensed medications (fills) , in order to have the most accurate estimate of care received by the health plan members. In NCQAs HEDIS 2012 Technical Specifications for Physician Measurement, records of prescriptions (scrips) count the same as records of dispensed medications, because of providers general inability to access payers paid pharmacy claims or dispensed data from e-prescription services for their patients. NCQA expects ACOs to have greater access to information about dispensed medications through paid pharmacy claims from their ACO payer and vendor partners. It is critical that payers exchange data with ACO partners, as CMS does through the MSSP. This would give ACOs full knowledge of patients medications; of medications received vs. prescribed by participant providers; and of medications prescribed by providers outside the ACO, in order to effectively manage medications. In this context, NCQA and its external advisory sources considered three options with respect to pharmacy data requirements for ACO measures. Option A Option B Specify the use of only dispensed medications for both denominators and numerators. Specify the use of either dispensed medications or scrips for both denominators and numerators (allowing the greatest flexibility for ACOs without paid pharmacy claims).
Pharmacy Data Requirements. For the first year of ACO Measure Specifications , NCQA would require Option B. For subsequent years and over time, NCQA will raise expectations toward Option A, with transparency in NCQAs measure guidelines.
NCQA 2012
Technical Specifications for ACO MeasuresPublic Comment OverviewObsolete After April 6, 2012
Submitting Comments
Submit all comments through NCQAs Public Comment Web site (http://publiccomments.ncqa.org). NCQA does not accept comments via mail, e-mail or fax. All comments are due by Friday, April 6, by 5 p.m. ET. To enter comments: 1. Go to the Public Comment database. 2. Enter your e-mail address and contact information. 3. Select Technical Specifications for Accountable Care Organizations (ACO). 4. Select the Topic and Issue on which you would like to comment. 5. Select your support option (e.g., Support, Do not support, Support with modifications, Other). If you choose Do not support, include your rationale in the text box. If you choose Support with modifications, enter the suggested modification in the text box. There is an 1,800 character limit for each comment. Comments are cut off at 1,800 characters. Please try to be brief and to the point in your feedback. We suggest that you develop your comments in Word, in order to check your character limit and save a copy for reference. Use the cut and paste function to copy your comment into the text box.
Thank you for your feedback on the Technical Specifications for ACO Measures!
NCQA 2012
This publication is protected by U.S. and international copyright laws. You may reproduce this document for the sole purpose of facilitating public comment. 2012 by the National Committee for Quality Assurance 1100 13th Street NW, Suite 1000 Washington, DC 20005 All rights reserved. Printed in U.S.A. NCQA Customer Support: 888-275-7585 www.ncqa.org
Table of Contents
Table of Contents
Overview Background.................................................................................................................................................... 1 Accountable Care Organization Accreditation ........................................................................................ 1 Provider Quality Measurement in Context .............................................................................................. 1 NCQA and Provider Performance Measurement ................................................................................... 2 1 HEDIS .................................................................................................................................................. 2 Standardizing Measurement ................................................................................................................... 3 Selecting Quality of Care Measures ....................................................................................................... 4 About ACO Measure Specifications .............................................................................................................. 5 Principles of ACO Measurement ............................................................................................................. 6 How Are ACO Measure Specifications Used? ........................................................................................ 6 Cautionary Statements............................................................................................................................ 7 How This Publication Is Organized ......................................................................................................... 8 If You Have Questions About the Specifications .................................................................................... 8 Additional Resources .............................................................................................................................. 8 General Guidelines for ACO Measure Specifications Defining the Population for ACO Measurement .......................................................................................... 11 About ACO Measure Specifications ............................................................................................................ 14 ACO Measure Reporting to NCQA .............................................................................................................. 16 Data Collection Methods ............................................................................................................................. 18 The Electronic Method ................................................................................................................................. 18 The Hybrid Method ...................................................................................................................................... 21 Sampling Methods ....................................................................................................................................... 26 Coding Conventions .................................................................................................................................... 31 References .................................................................................................................................................. 34
Appendices
Appendix 1: Modifications from HEDIS Health Plan Measurement Appendix 2: ACO Standards and GuidelinesPR 1 A: Performance Reporting Appendix 3: Core Measures Included in ACO Measure Specifications
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HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).
Draft Technical Specifications for ACO Measures for Public CommentObsolete After April 6, 2012
Draft Technical Specifications for ACO Measures for Public CommentObsolete After April 6, 2012
Overview
Draft Technical Specifications for ACO Measures for Public CommentObsolete After April 6, 2012
Overview
Draft 2013 Technical Specifications for ACO Measures for Public CommentObsolete After April 6, 2012
Overview
NCQA released updated physician and hospital quality (PHQ) standards for organizations in June 2008. The release of HEDIS 2012 Technical Specifications for Physician Measurement (HEDIS Physician Measurement) further encourages and supports standardized provider performance measurement and data reporting, the demand for which has never been higher. These products reflect the call for rigorous measurement criteria, the options for overcoming the methodological and logistical challenges associated with obtaining meaningful provider performance measurement and the need for data to support informed decision making and pay-for-performance efforts.
HEDIS
HEDIS, the most widely used set of performance measures for inpatient and ambulatory care, is developed and maintained by NCQA, a private, nonprofit organization dedicated to improving health care quality through measurement, transparency and accountability. NCQA accredits and certifies a wide range of health care organizations; recognizes physicians and physician practices in key clinical areas; and provides health care quality information in order to help consumers, employers and others make informed health care choices. Originally designed to address private employers needs as purchasers of health care, HEDIS measurement specifications have been adapted for use by public purchasers, regulators, consumers and clinicians. Quality improvement activities, health management systems and physician profiling efforts have often based their measurement efforts on HEDIS.
Draft Technical Specifications for ACO Measures for Public CommentObsolete After April 6, 2012
Overview
HEDIS has evolved into a critical component of an emerging measurement system to establish accountability in health care. HEDIS measures are equally useful as part of a quality improvement effort in a physician practice; as a purchaser request for quality information at the health plan or clinician level; as elements of NCQAs numerous Accreditation, Certification or Recognition Programs; and as the basis of consume r report cards. HEDIS is also the model for emerging systems of performance measurement in other areas of health care delivery.
Standardizing Measurement
NCQA addresses the following key concepts to create standardized, reliable performance measures some of these are directly addressed in this publication and others are explicit in our measure development process. Engage in a consensus process Involve multiple health care stakeholders. Model national organizations best practice processes. Review measures against explicit criteria. Include Public Comment mechanisms to enrich perspectives on measures proposed for consensus. Technical construction of rates Ensure that measures reflect evidence-based medicine. Define the eligible population as the denominator (age, gender, diagnoses, and exclusions). Define the desired event as the numerator (processes, outcomes, time windows). Define data elements (e.g., electronic codes, diagnoses, clinical procedures/tests, medications). Field-test to refine validity of measures. Define audit or data validation specifications. Define implementation rules and guidelines Specify accountable parties and to whom measures apply. Define units of observation (groups, sites, individuals, specialties). Define how patients are assigned to observation units. Specify required statistical and technical considerations. Analysis of information Use descriptive statistics (distribution, confidence intervals, benchmarking) in reporting. Promote understanding through analytical statistics (correlation, regression, and modeling). Annual maintenance and review of measures and guide-lines Perform regular refinement (updating codes, clinical logic, evidence re-review, evidence-based medicine). Perform ad hoc review (take action based on emerging, ground-breaking evidence). Maintain and update technical specifications and data collection tools.
Draft 2013 Technical Specifications for ACO Measures for Public CommentObsolete After April 6, 2012
Overview
Relevance
Meaningfulness
Health importance
Scientific Soundness
Clinical evidence Reproducible Valid
Perhaps in no other industry is scientific soundness as important as in health care. Scientific soundness must be a core value of our health care system. There should be evidence that documents the link between clinical process and outcome addressed by the measure. Measures should produce the same results when repeated in the same population and setting. Measures should make sense logically and clinically. They should correlate well with other measures of the same aspects of care.
Draft Technical Specifications for ACO Measures for Public CommentObsolete After April 6, 2012
Overview Accurate Risk adjustment Measures should precisely evaluate what is actually happening. Measure variables should not differ appreciably beyond the health care system s control, or variables should be known and measurable. Risk stratification, or a validated model for calculating an adjusted result, can be used for measures with confounding variables. Accuracy, reproducibility and validity should not be affected if different systems use different data sources for a measure. The goal is not only to include feasible measures, but also to catalyze a process wherein relevant measures can be made feasible. Measures should have clear specifications for data sources and methods for data collection and reporting. Measures should not impose an inappropriate burden on health care systems. Data collection should not violate accepted standards of patient confidentiality. Required data should be available. Measures should not be susceptible to manipulation or gaming that would be undetectable in an audit.
Feasibility
Precise specification Reasonable cost Confidentiality Logistical feasibility Auditability
Draft 2013 Technical Specifications for ACO Measures for Public CommentObsolete After April 6, 2012
Overview Respect the current limitations of most ACOs with respect to their ability to measure quality of care across populations. Allow ACO measurement to evolve as NCQA, ACOs and others gain experience.
The ACO Measure Specifications publication specifically supports PR 1 A: Performance Reporting, Element A. Core Performance Measures (Appendix 2). It enumerates specific requirements for reliable, valid, equitable ACO reporting, and is intended for use by ACOs or by third-party organizations conducting population health analytics on behalf of the ACO for all populations served by the ACO. Measure specification complexity varies because of the varying amount of data available to ACOs. ACOs with payer contracts that include the exchange of paid claims (pharmacy and medical), enrollment and laboratory data for the ACO population, as well as fully functioning EHRs across all settings of care, may have a rich array of data available. Other ACOs may need to use manual billing systems and paper records that differ in level of completeness. Recognizing that measurement programs applied across a diverse set of ACOs must accommodate the least advanced measurement capabilityat least for nowNCQA has attempted to provide specifications that apply to all levels of data sophistication. For comparative purposes, the ability to satisfy performance reporting requirements for NCQA ACO Accreditation will distinguish the capacity of ACOs to improve the quality of care for the populations they serve.
Draft Technical Specifications for ACO Measures for Public CommentObsolete After April 6, 2012
Overview Sharing data. By using the underlying denominator and numerator definitions for population measures, ACOs can also provide data to help physicians, hospitals, practice sites or medical groups identify and engage patients who have missed appropriate services or need follow-up. Establishing contract performance standards. Payers will include performance standards in ACO contracts with financial consequences, withholding a portion of payment for low performance or providing additional payment for high performance. Managing ACO physician networks. Some ACOs may use performance information to identify high- and low-performing physicians in selecting or tiering their networks. Benefit design. To address significant gaps in quality performance, ACOs may collaborate with payer partners to structure benefits to promote patients lifestyle choices, provider choices and compliance with treatment plans through differential copay or coinsurance for specific services, provider types or drugs. Pay for performance. These measures can be the basis for rewarding high levels of performance or improvement in performance. External reporting for consumer decision making. In accordance with NCQA ACO Accreditation, ACOs will be expected to offer publicly available performance reports.
Cautionary Statements
NCQA cannot guarantee results. The measures included in the ACO Measure Specifications are not clinical guidelines and do not establish a standard of medical care. Gaps in the breadth and completeness of health care quality measurement affect the ability to provide performance measures applicable to a variety of value-based outcomes. Some gaps exist because of a lack of scientific knowledge regarding treatments or interventions; others exist because of a lack of consensus regarding treatment approaches; still others exist because of a lack of consensus around measures of value to stakeholders, such as patients. As methodology and technology advance the capability to effectively address these issues, so too will the ACO Measure Specifications. Because of the complexity of methods and technical issues related to using measurement to evaluate performance, this publication cannot replace consultation with statisticians and quality measurement experts, which is necessary to ensure that measures and measurement methods described in this publication are both appropriate to and implemented in the most effective manner for a specific program. This is especially critical where measures are used outside of internal quality improvement. Give careful attention to the limitations of the data and methodology before comparing ACO performance with external benchmarks. Use caution when comparing results obtained through ACO Measure Specifications with other HEDIS measurement sets, such as NCQAs HEDIS Health Plan Measurement. The methodology used to compile the measures may vary (e.g., the type and source of data) While this release of ACO Measure Specifications does not currently provide explicit auditing guidelines for measurement, ensuring the validity and integrity of data and methodology is an important component of any measurement program.
Draft 2013 Technical Specifications for ACO Measures for Public CommentObsolete After April 6, 2012
Overview
Additional Resources
In addition to its publications, NCQA provides a variety of resources to help user organizations understand and use these measure guidelines and specifications. E-pubs. All HEDIS publications are available as easy-to-use electronic publications (e-pubs) that contain the complete text of NCQA printed publications and are sold by user licenses. E-pubs are protected Microsoft Word and Excel files sent to the purchaser via e-mail. E-pubs are simple to download onto a PC, network or intranet. HEDIS Electronic Coding Table. To save programming hours, eliminate the manual search for codes and reduce keying errors, NCQA offers the HEDIS Electronic Coding Table (ECT). Available in 2, Microsoft Excel, the ECT provides an easy way to incorporate CPT HCPCS, ICD-9-CM, UB Revenue, 3 UB Type of Bill, DRG and Logical Observation Identifiers Names and Codes (LOINC ) into a data collection program. Educational Seminars. NCQA educational seminars provide valuable information on NCQA quality measurement programs. Course offerings range from a basic introduction to HEDIS and NCQA standards to advanced techniques for quality improvement. For information about NCQA conferences, go to www.ncqa.org/ Education or call NCQA Customer Support at 888-275-7585. Publications on Quality Measurement. NCQA produces many publications that are relevant to quality measurement. To obtain a list or to order publications, call the NCQA Publications Center at Customer Support at 888-275-7585 or go to www.ncqa.org.
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CPT is a trademark of the American Medical Association. Current Procedural Terminology (CPT) is copyright 2012 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. LOINC is a registered trademark of the Regenstrief Institute.
Draft Technical Specifications for ACO Measures for Public CommentObsolete After April 6, 2012
Draft Technical Specifications for ACO Measures for Public CommentObsolete After April 6, 2012
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Defining the Population for ACO Measurement 1. Minimum Population for Measurement
An ACO must have a minimum of 5,000 patients in the population targeted for ACO measurement as of January 1 of the measurement year.
Method 2
For the purposes of Methods 1B and 2, two steps apply when using NCQAs Recommended Patient Attribution Model. Step 1 Define the universe of an ACOs patient population as all active patients as of January 1 of the measurement year (and for purposes of actual measurement, defined as of December 31 of the measurement year) with any provider participating in the ACO as contractually defined by the ACO (e.g., primary and specialty care, acute care, surgical care, post-acute care, long term care). Apply NCQAs Recommended Patient Attribution Model to at least 80 percent of that universe of patients. The intent is for an ACOs entire patient population to be considered through this process.
Step 2
NCQA expects that ACOs will consistently define the population across all performance measures. NCQA requires ACOs to disclose the attribution models used to identify their population for measurement, regardless of the model used to define the population. Refer to Disclosure of Patient Attribution Models.
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To satisfy the requisite specifications in this publication, NCQA recommends the attribution model as defined by the CMS MSSP, with two adaptations as follows. 1. Apply a 24-month period, rather than the CMS 12-month period, given the broader demographic of all ages, rather than only CMS beneficiaries, who use more services than younger cohorts. 2. Apply the plurality of primary care visits, rather than the CMS plurality of primary care allowed charges, given the probable dependence on payer paid claims to determine allowed charges. This applies to ACOs that opt to use Method 1B or Method 2 to define their ACO population, in accordance with ACO Contracts and Measurement, above.
Primary care physician includes general or family practice physicians, geriatricians, general internal medicine physicians, general pediatricians and obstetricians/gynecologists (OB/GYN). Primary care professional includes physician or nonphysician (e.g., physician assistant, nurse practitioner) who offers primary care services. Licensed practical nurses and registered nurses are not included in this definition.
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Source: Final CMS MSSP rules published in the Federal Register, Vol. 76, No. 212, Wednesday, November 2, 2011, Rules and Regulations, 425.20 page 67975, available at: http://www.gpo.gov/fdsys/pkg/FR-2011-11-02/pdf/2011-27461.pdf
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9. Measurement Period
The previous calendar year is the standard measurement year for HEDIS data and is to be used for ACO measurement. . Although measurement periods can be adjusted for internal use as long as all date-related specifications are also adjusted and data completeness (e.g., run out to allow claim processing time) is carefully considered, non-calendar year reporting periods do not satisfy ACO Measure Specifications.
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12. Exclusions
For many HEDIS measure specifications, exclusions are the result of careful consideration by expert measurement panels assigned to each measure. For HEDIS Health Plan Measurement and California Integrated Healthcare Associations measure specifications, exclusions are optional unless otherwise specified. Optional exclusions allow ACOs to receive credit for services received even when a member meets the exclusion criteria. HEDIS Physician Measurement takes a different approach and requires exclusions to ensure consistent measurement and comparisons between providers. NCQA believes that ACO performance measurement more closely aligns with physician measurement. Therefore, for ACO Measure Specifications, NCQA requires exclusions to provide for more consistent measurement and future benchmarking of ACO performance. Exclusion criteria are specified for both the Electronic Method and the Hybrid Method.
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ACO Measure Reporting to NCQA 14. Stratifying the Population for ACO Measurement
ACOs are designed to focus on the care of populations, rather than on specific managed care product lines or age groups. NCQA recognizes that providers generally deliver care regardless of payer or product, and believes is it important not to artificially compartmentalize measures through stratification. NCQA also recognizes that Medicaid programs are entering into ACO contracts and that Medicaid populations historically perform differently on quality measures than other populations. ACOs are required to report on their aggregate population as a whole, but have the option to report on Medicaid separatelybut only for measures with Medicaid specifications defined for the corresponding measure in HEDIS Health Plan Measurement. Refer to Appendix 3: Core Measures Included in ACO Measure Specifications. This publication can be used outside the NCQA ACO Accreditation process for discrete populations attributed to the ACO. For example, an ACO may desire to have separate measurement reports for each ACO population it manages, by payer contract, but this section specifies the allowed population stratification for measurement for NCQA ACO Accreditation.
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22. Benchmarking
In this context, benchmarking is defined as comparing one ACO quality performance with that of another ACO, or against national averages for ACOs. Benchmarking ACO measurement is valuable for providing context to measurement for ACOs and their stakeholders, but it is not yet viable. Until standardization evolves, benchmarking results across all ACOs at a national level will be difficult because of the numerous variations of such efforts. However, establishing national ACO measurement consistency is one of the key goals of NCQA ACO Accreditation standards, in order to support benchmarking in the future. NCQA advises caution when comparing results with other quality measurement programs whose specifications differ, even if the differences seem minimal; this includes comparing HEDIS health plan results to ACO results.
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Draft Technical Specifications for ACO Measures for Public CommentObsolete After April 6, 2012
General Guidelines for ACO Measure Specifications Laboratory results, including electronic data from a lab vendor. Retrievable coded data from EMR or EHR databases and patient registries. Some EMRs and EHRs do not meet this definition and are considered medical records from which data must be manually abstracted.
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To be considered a source of electronic data for purposes of this publication, EMR/EHR information must be aggregated into a database that stores multiple records and can be programmed for electronic evaluation according to ACO Measure Specifications. Historical patient data that have been entered into the EMR or EHR manually or electronically are considered viable for use in ACO measurement. NCQA urges ACOs electronically accessing data from EMR or EHR databases to adhere to the following guidelines. EMR and EHR information must distinguish between ordered and completed appointments, procedures, and lab and radiology orders. Only completed events count toward measures. Some EMRs and EHRs capture and record CPT codes when a practitioner completes a service order on the Order screen. A CPT code found as a stand-alone on the ordered list does not comply with numerator criteria for quality of care measurement. All data elements specified in a measure (e.g., date of service, procedure codes, diagnosis codes, prescriptions) must be identified as rendered by the time specified in the measure (e.g., a mammogram during the measurement year or the year prior to the measurement year for the Breast Cancer Screening measure). The ACO may count a service for a measure if the EMR or EHR contains the following information: Claim data captured through a patient management system linked to the EMR, or A note indicating the date on which the service was rendered, and the result (when applicable). Be cautious when using an EMR or EHR database to identify the denominator for a measure for which a population-based sample is desired, unless the ACO is confident that the EMR database contains all patients of the aggregate ACO population, rather than a subset of the eligible population. EMR and EHR databases may generally be more reliable for identifying numerator-compliant events, such as the delivery of a specific service.
Note
An EMR or EHR that entails manual abstraction of data elements from the electronic record for reporting purposes is not considered electronic data. ACO Measure Specifications provides the option of manually abstracting data from electronic or paper medical records for the numerator of all measures included in this publication.
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Current Procedural Terminology 2012 American Medical Association. All rights reserved.
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General Guidelines for ACO Measure Specifications Given the current state of the health care industry, for ACO Measure Specifications, either prescriptions or dispensed medications can be used for both denominators and numerators of measures that require pharmacy data. This may evolve over time as ACOs gain greater access to data on dispensed medications from payer partners or pharmacy vendors.
21
For measures that rely on medications, measure specifications include medication tables that must be referenced. When using dispensed medications, tables must be used in conjunction with the National Drug Code (NDC) lists posted to NCQAs Web site. The tables include a Description column that indicates the therapeutic category, and a Medication column that includes all appropriate medications in their generic form. ACOs must use the NDC lists for each pharmacy-dependent measure. Final NDC lists for pharmacy-related measures are posted to the NCQA Web site annually in mid-November.
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Note
The Hybrid Method can be used for all measures in this publication. If the eligible population is smaller than the required sample size for a measure, the ACO may apply the Hybrid Method without drawing a systematic sample from the population.
23
For documented history of an event (e.g., documented history of a disease), undated documentation may be used if it is specific enough to determine that the event occurred during the time frame specified in the measure. For example, for the Breast Cancer Screening measure, undated documentation on a problem list stating bilateral mastectomy in 1999 is specific enough to determine that this exclusion occurred prior to December 31 of the measurement year.
____________ Current Procedural Terminology 2012 American Medical Association. All rights reserved.
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General Guidelines for ACO Measure Specifications Measure-specific results collected by practitioners and provided in an abstraction tool are acceptable. ACOs must provide guidelines for practitioner abstraction. Verbal or written guidance should include clear instructions for applying the technical specifications to medical record review. Abstraction tools must have all necessary data elements and must be subject to quality control processes, such as interrater reliability or rater-to-standard reliability validation. Note: Do not use practitioner attestation forms; they do not require practitioners to verify services using the medical record.
Step 2
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General Guidelines for ACO Measure Specifications Step 11 Calculate the rate.
25
The rate may be calculated using the denominator (MRSS with substitutions) or the denominator plus the entire oversample (FSS), but the method should be consistent across measures. Refer to Substituting Medical Records.
Approach 2
Step 1 Step 2 Identify the eligible population through electronic data, according to the measure specification. Search the electronic data for numerator events for the entire eligible population. Follow the electronic specifications to search electronic data for numerator events for the eligible patient population identified in step 1. Step 3 Search for electronically identified exclusions. For patients for whom electronic data does not show a positive numerator event, search electronic data for an exclusion to the service/procedure being measured, if applicable. Step 4 Exclude patients with electronically identified exclusions. Remove from the eligible population patients from step 3 for whom electronic data identified an exclusion to the service/procedure being measured. Step 5 Step 6 Determine the FSS and draw a systematic sample from the eligible population. Search the electronic data for numerator events for the sampled patients. From the patients identified as compliant for numerator events from step 2, pull the patients in the FSS. Step 7 Search the medical records for numerator events for the sampled population. Review the medical records of patients in the sample for whom a numerator event or exclusion to the service/procedure being measured was not identified using electronic data. Refer to Using The Hybrid Method to Collect Measures With Multiple Numerator Events. Step 8 Search for medical record exclusions. For patients for whom electronic data or the medical record does not show a positive numerator event, search the medical record for an exclusion to the service/procedure being measured, if applicable. Step 9 Exclude patients with medical record identified exclusions. Remove from the denominator patients for whom the medical record identified an exclusion. Step 10 Step 11 Step 12 From the oversampled population, substitute for the excluded records. Refer to Substituting Medical Records, below. Use either electronic or medical record data to identify the numerator event for additional patients used as replacements. Determine the numerator. Include only patients in the sample who were identified through either electronic data or medical record review as having received or experienced the numerator event.
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General Guidelines for ACO Measure Specifications Calculate the rate. The rate may be calculated using the denominator (MRSS with substitutions) or the denominator plus the entire oversample (FSS), but the method should be consistent across measures. Refer to Substituting Medical Records.
36. Using the Hybrid Method to Collect Measures With Multiple Numerator Events
The Childhood Immunization Status measure may be collected using the Hybrid Method, and requires more than one event to satisfy the numerator. Three separate vaccinations are collected to report the IPV rate for Childhood Immunization Status. For this measure, ACOs may use a combination of electronic data and medical record data to satisfy the numerator for patients in the denominator, if the events across medical record data and electronic data are at least 14 days apart. ACOs may count two IPV vaccines identified through electronic data and the third IPV identified through medical record review for a patient in the denominator, if the medical record date of service is not within 14 days of either electronic date of service. ACOs may also count three IPVs identified through electronic data and four DTaPs identified through medical record data for the same patient. The ACO must use only the medical record event if it has one event from the medical record and one from electronic data and cannot determine if the dates are at least 14 days apart.
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General Guidelines for ACO Measure Specifications Population definition In some cases, the size of the eligible population for a measure may be smaller than the recommended sample size. For example, there may be very few attributable patients for a measure such as Follow-Up After Hospitalization for Mental Illness. In this case, use the entire eligible population and report the data with a 95 percent confidence interval.
27
Consistent with HEDIS Health Plan Measurement, a sample size of 411 is required when the Hybrid Method is used for direct comparison between health plans or, in this case, between ACOs on a single measure. The sample size was calculated assuming a two-tailed test of significance between two proportions ( = .05, 80 percent power, two-tailed test of significance). A normal approximation to the binomial with a continuity correction was employed in the sample size calculation. The worst-case 50 percent expected value was assumed. The detectable difference for most measures applied to health plans is 10 percentage points. This was chosen by NCQA because the difference is large enough to be actionable using a single measure and directly comparing one health plan or ACO to another, it is not unduly burdensome for data collection and it is not so small that it will be swamped by nonsampling error.
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General Guidelines for ACO Measure Specifications Step 7 Before choosing patients, determine the starting patient (START). It is important that the sample be selected from a single pass through the patient list. START can have many values and still allow only one pass. Determine a Random Number (RAND) value between 0 and 1 for each measure where the Hybrid Method is applied. The random number for each respective measure should be used to calculate the starting point from which to draw the final sample. Many analytical and data management software packages can generate a random number between 0 and 1. For example, in Microsoft Excel, the formula = RAND( ) typed into a cell and entered (press the Enter key) will replace the formula with a random number between 0 and 1. Calculate the number from which to start drawing the final sample as follows. START = (RAND N) (round per the .5 rule to the nearest whole number greater than 0), where RAND equals the random number for each respective measure identified. Step 8 Select the sample, choosing every i patient using the formula: i patient = START + [(i-1) x (EM/FSS)] (rounding [(i-1) x (EM/FSS)] per the .5 rule to the nearest whole number greater than 0). For i = 2,3,4, , FSS where EM equals the eligible patient population (step 1). FSS equals the final sample size (step 3). Starting with the patient corresponding to the number START, choose every i patient until the MRSS is met. This becomes the primary list of sampled patients. Continue choosing every i patient until the FSS is met. This set of patients becomes the auxiliary list of sampled patients (i.e., the oversample). The ACO can stop once the FSS is achieved, or use all patients in the primary and auxiliary list.
th th th th
Note: From step 4, if MRSS <EP FSS, sort the eligible patients in alphabetical order by the last name, first name and date of birth. Choose the first MRSS eligible patients as the primary sample and the remaining eligible patients as the auxiliary sample.
Example 1
The eligible population for Cervical Cancer Screening is 500. Based on experience, estimate a 5 percent oversample rate. Following the systematic sampling scheme: Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 EP = 500. MRSS = 55. FSS = 55 + (55 .05) = 57.75 (the next whole number above 57.75 is 58, so FSS = 58). Since 500 >58, go to step 5. Sort the list alphabetically: last name, first name, date of birth. N = 500/58 = 8.62 (the next whole number below 8.62 is 8, so N = 8).
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General Guidelines for ACO Measure Specifications Step 7 For this example, assume that RAND = 0.66, so START = 0.66 x 8 = 5.28. Rounding using the .5 rule, START = 5. The 5th sorted patient is chosen first. The 2nd patient chosen is the 5 + [(2-1) x 8] = 5 + 8 = 13th sorted patient. The 3rd patient chosen is the 5 + [(3-1) x 8] = 5 + 16 = 21st sorted patient. The 55th patient (the last one in the primary list) is the 5 + [(55-1) x 8] = 5 + 432 = 437th sorted patient. The last patient in the auxiliary sample is the 18 + [(58-1) x 8] = 5 + 456 = 461st sorted patient.
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Example 2
The eligible population for Cholesterol Management for Patients With Cardiovascular Conditions is 100. Following the systematic sampling scheme: Step 1 Step 2 Step 3 Step 4 EP = 100. MRSS = 150. Since 100 <150, skip to step 4. Skip this step. Include all 150 patients on your primary list.
Example 3
The eligible population for Childhood Immunization Status is 175. Following the systematic sampling scheme: Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 EP = 175. MRSS = 155. FSS = 155 + (155 .10) = 170.5 (the next whole number above is 170.5, so FSS = 171). Since 155 <171, skip to step 8. Skip this step. Sort the list and choose the first 155 as the primary list. The remaining 20 patients become the auxiliary list.
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2n
Where p = the ACOs rate and n = the sample size. For example, suppose the ACO has a sample size of 96 eligible women for the Cervical Cancer Screening rate. Of these, 50 received a Pap test during the year. The calculation would proceed as follows.
p = 50 96 = 52%
.52 (1 .52)
96
1 192
= 41.5%
Thus, the user can be 95 percent certain that the physicians true Pap test rate is between 41.5 percent and 62.5 percent.
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General Guidelines for ACO Measure Specifications The medical record must have evidence that a patient does not meet the criteria for the measure; a medical record without any notation either substantiating or refuting the diagnosis is not evidence that the patient does not have the condition being measured. 2. Exclusion to treatment being measured 3. Selecting an employee/ dependent for the sample A patient has a valid exclusion to the treatment being measured; for example, a patient with a diagnosis of colorectal cancer or total colectomy is a valid exclusion in the denominator for the Colorectal Cancer Screening measure.
31
An employee of the ACO or the vendor, or the employees dependent, was selected for the sample, and the employee or dependents medical record must be reviewed to determine compliance with the measure. The ACO or vendor may exclude employees and their dependents in this situation only.
Coding Conventions
Note: This section does not pertain to the codes used in Code Set for the Attribution Model.
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Current Procedural Terminology 2012 American Medical Association. All rights reserved.
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Reporting tables
____________ Current Procedural Terminology 2012 American Medical Association. All rights reserved.
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References
Bynum, J.P, E. Bernal-Delgado, D. Gottlieb, E. Fisher. 2007. Assigning ambulatory patients and their physicians to hospitals: a method for obtaining population-based provider performance measurements. Health Services Research. 42:1, Part I: 4562. Deming, W.E. On the interpretation of censuses as samples. 1941. Journal of the American Statistical Association. 36:459. Fleiss, L. Statistical Methods for Rates and Proportions. 1981. 2nd Ed. (New York: John Wiley & Sons, Inc.): 3842. Fleiss, J.L., B. Levin, M.C. Paik. 2003. Statistical Methods for Rates & Proportions. Wiley-Interscience: Indianapolis, IN. Greenfield, S., S.H. Kaplan, R. Kahn, J. Ninomiya, J.L. Griffith. January 15, 2002. Profiling care provided by different groups of physicians: effects of patient case-mix (bias) and physician-level clustering on quality assessment results. Ann Intern Med. 136(2):11121. Kaplan, S.H., J.L. Griffith, L.L. Price, L.G. Pawlson, S. Greenfield. Assessing Physician Performance: addressing the science and recognizing the future. Unpublished. Krein, S.L., T.P. Hofer, E.A. Kerr, R.A. Hayward. 2002. Whom Should We Profile? Examining Diabetes Care Practice Variation among Primary Care Providers, Provider Groups, and Health Care Facilities. Health Services Research. 37(5):115980. Safran D.G., M. Karp, K. Coltin, H. Li A. Chang, J. Ogren, W.H. Rogers. 2006. Measuring patients' experiences with individual primary care physicians. Results of a statewide demonstration project. Journal of General Internal Medicine. 21(1):1321. Scholle, S.H., et al. NCQA PB report. Unpublished. Tucker, J.L., 3rd. 2000. The theory and methodology of provider profiling. Int J Health Care Qual Assur Inc Leadersh Health Serv. 13(6-7):31621.
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APPENDIX 1
MODIFICATIONS FROM HEDIS HEALTH PLAN MEASUREMENT
Key Specification HEDIS Health Plan Measurement Defining the Population for ACO Measurement The Organization Evaluated Managed care organizations (Commercial HMO, POS, PPO, Medicare Advantage, Medicaid) that administer health insurance benefits on behalf of their private and public customers. Individuals in the Population Members of the health plan. ACO Contracts and Measurement Commercial, Medicare and Medicaid populations defined by insurance licenses held by the managed care organizations. ACO Measure Specifications ACOs that provide health care services to defined populations through a specified legal entity that can contract with payers. Patients of the ACO. Methods: 1. If an ACO has at least one contract in force, it has two options: 1A. Report on the aggregate ACO contract population as defined through contractual attribution models or assignment methods, or 1B. Report on the aggregate ACO contract population plus all or at least 80 percent of its patient population, as defined by NCQAs recommended attribution model. 2. If the ACO has no ACO contract in force, it reports on all or at least 80 percent of its patient population, using NCQAs recommended attribution model. For method 1B and 2, NCQA recommends the CMS MSSP method of attributing patients to ACO provider participants based on a two-step process of primary care first and then other providers of care, with two modifications: Use a 24-month period (vs. CMS 12-month period). Use a plurality of primary care visits (vs. CMS plurality of allowed charges for primary care visits). Minimum population of 5,000 as of January 1 of the measurement year, regardless of whether the population is stratified for measurement (see below). Continuous Enrollment is not provided in ACO measure specifications.
Suggested minimum is 15,000 per product reported. Defined for each measure to ensure adequate opportunity for health plans to intervene. Separate commercial (HMO, POS, PPO), Medicaid and Medicare reports.
The ACO aggregate population is reported as a whole; with an option to report Medicaid separately for measures for which HEDIS Health Plan Measurement offers Medicaid specifications. Refer to Appendix 2.
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Appendix 1Modifications From HEDIS Health Plan Measurement ACO Measure Specifications The ACO retains responsibility for reporting ACO measures according to ACO measure specifications. Same. Similar to HEDIS Health Plan Measurement (June) with an ACO defined set of data elements. Phased in audit requirement. No audit required before the June 2014 submission on the 2013 measurement year. Electronic and Hybrid. Allows manually abstracted medical record data for all numerators. Same. To start, ACO measures will require a base minimum sample of 411. Once ACOs establish historical results using standard measure specifications, NCQA will explore sample size adjustments based on the reported rate. Same. Require measure exclusions similar to NCQAs HEDIS Physician Measurement. Use of pharmacy claims or scripts for both denominators and numerators to allow for the greatest flexibility for ACOs without paid pharmacy claims. Defined in alignment with HEDIS Physician Measurement: Data routinely captured for payment or care delivery including payer claims (medical and pharmacy), provider claims (billing systems); patient registration, lab results, and EMR databases used by practices or health systems. Same with respect to what is defined for select measures, as well as the option to stratify for Medicaid populations with applicable measures. However, no further population stratification by type of insurance will be allowed. Same.
Key Specification HEDIS Health Plan Measurement Measure Reporting to NCQA Reporting to NCQA Reporting can be done by the Health Plan, the Certified HEDIS Vendor or contracted medical record abstractors, in accordance with HEDIS Specifications. Measurement Year Generally the calendar year unless otherwise specified. Report Submission HEDIS submission required annually (June 15 of the reporting year, on the prior calendar measurement year) by a defined set of requirements. Measurement Audit HEDIS Compliance Audit is required with each annual measure submission to NCQA. Methods and Definitions for Compiling Measures Methods Offered Administrative and Hybrid. Hybrid Method Allows manually abstracted medical record data for select numerators. Systematic sampling. Sampling for Hybrid Method Sample Sizes for Hybrid There is a base minimum sample size of 411, but specific sample size Method parameters are based on previous years result. Medical Records for Denominator Exclusions Pharmacy Data Electronic Data Allows manually abstracted medical record data to confirm the denominator for Controlling High Blood Pressure. Specified for each measure; many measures have optional exclusions and some are required. Use of pharmacy claims only, where dispensed medications (or fills) are used for denominator and numerators. Not a defined term in HEDIS, similar to administrative data (payer enrollment and claims); with specific supplemental data allowed per the guidelines.
Methods and Definitions for Compiling Measures Risk Adjustment Product stratification and what is defined within select measures. Coding Tables As specified for each measure and maintained annually.
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APPENDIX 2
ACO STANDARDS AND GUIDELINES EXCERPT PR 1 A: Performance Reporting
The organization measures and reports clinical quality of care, patient experience and resource stewardship. Intent The organization strives to improve the quality of services by evaluating its performance using valid measures and making results available to the public and participating providers. Element A: Core Performance Measures At least annually, the organization monitors core performance measures. 100% The organization submits 40 core performance measures Reports NCQA scores this element once for the organization. 75% The organization submits 30 core performance measures 50% The organization submits 20 core performance measures 25% No scoring option 0% The organization submits 0-19 core performance measures 2.40 points
Scoring
NCQA reviews reports detailing performance on measures within the 12 months prior to survey. This is a must-pass element. Organizations must earn a score of 50% or higher. All four must-pass elements are required to reach Level 2 accreditation. Core performance measures Performance monitoring is a necessary component of an organizations quality improvement strategy. At least annually, the organization assesses the population it serves by collecting and monitoring core performance measures. Core performance measures are the minimum set of measures that organizations must monitor, and include indicators of clinical quality and cost. Refer to Appendix 2: Core Performance Measures for a description of measure domains. For each measure, the organization must use valid data and methodology to produce a quantitative result. To calculate core performance measures, organizations may evaluate: Patients for whom the organization has accepted accountability for the total quality, costs and overall care (i.e., the assigned or attributed ACO population), or All patients seen by participating ACO providers.
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APPENDIX 3
CORE MEASURES INCLUDED IN ACO MEASURE SPECIFICATIONS
ACO Core Measure Prevention and Screening Adult BMI Assessment (AABA) Weight Assessment and Counseling for Nutrition and Physical Activity for Children/ Adolescents (AWCC) Childhood Immunization Status (ACIS) Immunizations for Adolescents (AIMA) Breast Cancer Screening (ABCS) Cervical Cancer Screening (ACCS) Colorectal Cancer Screening (ACOL) Chlamydia Screening in Women (ACHL) Care for Older Adults (ACOA) Respiratory Conditions Appropriate Testing for Children With Pharyngitis (ACWP) Appropriate Treatment for Children With Upper Respiratory Infection (AURI) Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis (AAAB) Use of Spirometry Testing in the Assessment and Diagnosis of COPD (ASPR) Use of Appropriate Medications for People With Asthma (AASM) Cardiovascular Conditions Cholesterol Management for Patients With Cardiovascular Conditions (ACMC) Controlling High Blood Pressure (ACBP) Diabetes Comprehensive Adult Diabetes Care (ACDC) Note: This measure includes seven core ACO measures as indicators. Musculoskeletal Conditions Disease Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis (AART) Osteoporosis Management in Women (AOMW) Use of Imaging Studies for Low Back Pain (ALBP) Behavioral Health Antidepressant Medication Management (AAMM) Follow-Up Care for Children Prescribed ADHD Medication (AADD) Follow-Up After Hospitalization for Mental Illness (AFUH) Medication Management Annual Monitoring for Patients on Persistent Medications (AMPM) Medication Reconciliation Post-Discharge (AMRP) Potentially Harmful Drug-Disease Interactions in the Elderly (ADDE) Use of High-Risk Medications in the Elderly (ADAE) Access/Availability of Care Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (AIET) Utilization and Relative Resource Use Medicaid Option Measure Status In Development In Development In Development In Development In Development In Development Available In Development In Development In Development In Development In Development In Development Available In Development In Development Available In Development In Development Available In Development In Development Available In Development In Development In Development In Development In Development
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ACO Core Measure All-Cause Readmissions (AACR) Relative Resource Use for People With Diabetes (ADRI) Relative Resource Use for People With Asthma (ARAS) Relative Resource Use for People With Cardiovascular Conditions (ARCA) Relative Resource Use for People With Hypertension (ARHY) Relative Resource Use for People With COPD (ARCO)
Draft Technical Specifications for ACO Measures for Public CommentObsolete After April 6, 2012
Note: This publication is protected by U.S. and international copyright laws. You may reproduce this document for the sole purpose of facilitating public comment. 2012 by the National Committee for Quality Assurance 2012 by the National Committee for Quality Assurance 1100 13th Street NW, Suite 1000 Washington, DC 20005 All rights reserved. Printed in U.S.A. NCQA Customer Support: 888-275-7585 www.ncqa.org
Draft Technical Specifications for ACO Measures for Public CommentObsolete After April 6, 2012
ACO Measure Specifications Removed: Product Lines. Continuous Enrollment. Allowable Gap. Anchor Date. Benefit. Added Defining the Population, which includes Attribution and Medicaid Stratification criteria. Renamed Administrative to Electronic. Exclusion criteria are required and moved to Eligible Population, when appropriate. Provided electronic and hybrid specifications to identify exclusions. Added hybrid specification to measures that only allow the Administrative Method in HEDIS Health Plan Measurement. Removed option to reduce the sample size from the hybrid specification. For measures that in HEDIS Health Plan Measurement only allow the Administrative Method, added a Hybrid column with the following data element: Numerator events by medical records. For measures in HEDIS Health Plan Measurement that have a hybrid specification, removed the following from the Data Elements table: Number of required exclusions (if applicable). Number of numerator events by electronic data in eligible population (before exclusions). Current years electronic rate (before exclusions). Minimum required sample size (MRSS) or other sample size. Oversampling rate. Final sample size (FSS). Number of numerator events by electronic data in FSS. Electronic rate on FSS. Number of original sample records excluded because of valid data errors. Number of electronic data records excluded. Number of medical records excluded. Number of employee/dependent medical records excluded. Records added from the oversample list. For measures that require pharmacy data, prescribed medications can also be used for denominators and numerators.
Specification Method Exclusions Hybrid Method Sample Sizes for Hybrid Method Data Elements
Pharmacy Data
NCQA 2012
Draft Technical Specifications for ACO Measures for Public CommentObsolete After April 6, 2012
Description
The percentage of adults 5075 years of age who had appropriate screening for colorectal cancer.
Eligible Population
Ages Defining the population Event/ diagnosis Exclusion 5175 years as of December 31 of the measurement year. Attribution. Report on the aggregate ACO population; refer to the General Guidelines. Medicaid stratification. No option to report Medicaid separately. None. Electronic Method Specification A diagnosis of colorectal cancer or total colectomy (Table ACOL-B). Look for evidence of colorectal cancer or total colectomy as far back as possible in the patients history, using electronic data or medical record review. Note: If using the Electronic Method, medical record documentation may not be used to identify exclusions. Hybrid Method Specification Apply the exclusion specifications for the Electronic Method to the electronic steps of the Hybrid Method. Exclusionary evidence in the medical record must include a note indicating a diagnosis of colorectal cancer or total colectomy, which must have occurred by December 31 of the measurement year. Note: If using the Hybrid Method, both medical records and electronic data may be used to identify exclusions.
Electronic Specification
Denominator Numerator The eligible population. One or more screenings for colorectal cancer. Appropriate screenings are defined by one of the following criteria. Fecal occult blood test (FOBT) during the measurement year. Regardless of FOBT type, guaiac (gFOBT) or immunochemical (iFOBT), assume that the required number of samples was returned. Flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year.
NCQA 2012
Draft Technical Specifications for ACO Measures for Public Comment Obsolete After April 6, 2012 Colonoscopy during the measurement year or the nine years prior to the measurement year. A patient had an appropriate screening if a submitted claim/encounter contains any code in Table ACOL-A.
CPT
ICD-9-CM Procedure
45.8
Hybrid Specification
Denominator Numerator A systematic sample drawn from the eligible population; refer to the General Guidelines. One or more screenings for colorectal cancer. Appropriate screenings are defined by any one of the four criteria below. FOBT during the measurement year. Flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year. Colonoscopy during the measurement year or the nine years prior to the measurement year. Electronic Refer to Electronic Specification to identify positive numerator hits from the electronic data.
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Current Procedural Terminology 2012 American Medical Association. All rights reserved.
NCQA 2012
Draft Technical Specifications for ACO Measures for Public CommentObsolete After April 6, 2012 Medical Record Documentation in the medical record must include a note indicating the date when the colorectal cancer screening was performed. A result is not required if the documentation is clearly part of the medical history section of the record. If it is unclear whether the documentation is part of the medical history, then the result or finding must be present (this ensures that the screening was performed and not merely ordered). There are two types of FOBT tests: guaiac (gFOBT) and immunochemical (iFOBT). Depending on the type of FOBT test, a certain number of samples are required for numerator compliance. Follow the instructions below to determine patient compliance. If the medical record does not indicate the type of test and there is no indication how many samples were returned, assume the required number was returned. The patient meets the screening criteria for inclusion in the numerator. If the medical record does not indicate the type of test and the number of returned samples is specified, the patient would only meet the screening criteria if the number of samples specified is greater than or equal to three samples. If the number of samples is less than three, the patient does not meet the screening criteria for inclusion in the numerator. iFOBT tests may require fewer than three samples. If the medical record indicates that an iFOBT was done, the patient meets the screening criteria for inclusion in the numerator regardless of the number of returned samples. If the medical record indicates that a gFOBT was done, follow the scenarios below. If the medical record does not indicate the number of returned samples, assume the required number was returned. The patient meets the screening criteria for inclusion in the numerator. If the medical record indicates that three or more samples were returned, the patient meets the screening criteria for inclusion in the numerator. If the medical record indicates that fewer than three samples were returned, the patient does not meet the screening criteria. Do not count digital rectal exam as evidence of a colorectal screening because it is not specific or comprehensive enough to screen for colorectal cancer .
NCQA 2012
Draft Technical Specifications for ACO Measures for Public Comment Obsolete After April 6, 2012
Description
The percentage of patients 564 years of age during the measurement year who were identified as having persistent asthma and were appropriately prescribed or dispensed medication during the measurement year.
Definitions
Note: While not explicitly stated here, the intent is that specifications about the use of pharmacy data refer to both prescribed and dispensed medications Oral medication dispensing event One prescription of an amount lasting 30 days or less. To calculate dispensing events for prescriptions longer than 30 days, divide the days supply by 30 and round down to convert. For example, a 100-day prescription is equal to three dispensing events (100/30 = 3.33, rounded down to 3). The organization should allocate the dispensing events to the appropriate year based on the date when the prescription is filled. Multiple prescriptions for different medications dispensed on the same day should be assessed separately. If multiple prescriptions for the same medication are dispensed on the same day, the organization should sum the days supply and divide by 30. Use the Drug ID to determine if the prescriptions are the same or different. Two prescriptions for different medications dispensed on the same day, each with a 60-day supply, equals four dispensing events (two prescriptions with two dispensing events each). Two prescriptions for different medications dispensed on the same day, each with a 15-day supply, equals two dispensing events (two prescriptions with one dispensing event each). Two prescriptions for the same medication dispensed on the same day, each with a 15-day supply, equals one dispensing event (sum the days supply for a total of 30 days). Two prescriptions for the same medication dispensed on the same day, each with a 60-day supply, equals four dispensing events (sum the days supply for a total of 120 days). Inhaler/ Injection dispensing event Inhalers and injections count as one dispensing event. For example, an inhaler with a 90-days supply is considered one dispensing event. In addition, multiple inhalers or injections of the same medication (as identified by Drug ID in the NDC list) filled on the same date of service should be counted as one dispensing event. For example, a patient may obtain two inhalers on the same day (one for home and one for work), but intend to use both during the same 30-day period. The organization should allocate the dispensing events to the appropriate year based on the date when the prescription is filled.
NCQA 2012
Draft Technical Specifications for ACO Measures for Public Comment Obsolete After April 6, 2012
Eligible Population
Ages 564 years by December 31 of the measurement year. Report the total rate. 511 years 1218 years 19-50 years The total is the sum of the four age stratifications. Defining the population Event/ diagnosis Step 1 Attribution. Report on the aggregate ACO population; refer to the General Guidelines. Medicaid stratification. Option to report Medicaid separately. Follow the steps below to identify the eligible population for the measure. Identify patients as having persistent asthma who met at least one of the following criteria during both the measurement year and the year prior to the measurement year. Criteria need not be the same across both years. At least one ED visit (Table AASM-B), with asthma as the principal diagnosis (Table AASM-A). At least one acute inpatient discharge (Table AASM-B), with asthma as the principal diagnosis (Table AASM-A). At least four outpatient visits (Table AASM-B), with asthma as one of the listed diagnoses (Table AASM-A) and at least two asthma medication prescribing or dispensing events (Table AASM-C). At least four asthma medication prescribing or dispensing events (i.e., an asthma medication was prescribed or dispensed on four occasions) (Table AASM-C). 51-64 years Total
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Current Procedural Terminology 2012 American Medical Association. All rights reserved.
NCQA 2012
Draft Technical Specifications for ACO Measures for Public Comment Obsolete After April 6, 2012
Fluticasone-salmeterol Flunisolide Fluticasone CFC free Mometasone Zafirlukast Indacateroll Salmeterol Nedocromil Oxtriphylline Theophylline Metaproterenol Pirbuterol
Mometasone-formoterol Triamcinolone
Leukotriene modifiers Long-acting, inhaled beta2 agonists Mast cell stabilizers Methylxanthines Short-acting, inhaled beta2 agonists
Zileuton
Note: NCQA will post a comprehensive list of medications and NDC codes to www.ncqa.org by November 15, 2012. Step 2 A patient identified as having persistent asthma because of at least four asthma medication prescribing or dispensing events, where leukotriene modifiers were the sole asthma medication dispensed in that year, must also have at least one diagnosis of asthma, in any setting, in the same year as the leukotriene modifier (i.e., measurement year or year prior to the measurement year). Electronic Method Specification Exclude from the eligible population all patients diagnosed with emphysema, COPD, cystic fibrosis or acute respiratory failure (Table AASM-E) any time on or prior to December 31 of the measurement year. Look as far back as possible in the patients history through December 31 of the measurement year. Note: If using the Electronic Method, medical record documentation may not be used to identify exclusions. Hybrid Method Specification Apply the exclusion specifications for the Electronic Method to the electronic steps of the Hybrid Method. Exclusionary evidence in the medical record must include a note indicating a diagnosis of emphysema, COPD, cystic fibrosis or acute respiratory failure any time on or prior to December 31 of the measurement year. Note: If using the Hybrid Method, both medical records and electronic data may be used to identify exclusions.
Step 3: Exclusion
NCQA 2012
Draft Technical Specifications for ACO Measures for Public Comment Obsolete After April 6, 2012
Electronic Specification
Denominator Numerator The eligible population. Prescribed or dispensed at least one prescription for a preferred therapy during the measurement year (Table AASM-D).
Zileuton
Note: NCQA will post a comprehensive list of medications and NDC codes to www.ncqa.org by November 15, 2012.
Hybrid Specification
Denominator Numerator Electronic Medical Record A systematic sample drawn from the eligible population; refer to the General Guidelines. Prescribed or dispensed at least one prescription for a preferred therapy during the measurement year (Table AASM-D). Refer to Electronic Specification to identify positive numerator hits from the electronic data. The medical record must include a note indicating the name of the preferred therapy and the date when the prescription was written or filled during the measurement year.
Note
The HEDIS age strata for asthma measures are designed to align with both clinical practice guidelines and reporting requirements for child health quality improvement programs. Clinical guidelines specify appropriate age cohorts for measuring use of asthma medications as 5 11 years of age and 1250 years of age to account for the differences in medication regimens for children vs. for adolescents and adults. Implementation requires further stratification of the age ranges to enable creation of comparable cohorts that align with child health populations.
NCQA 2012
Draft Technical Specifications for ACO Measures for Public Comment Obsolete After April 6, 2012
Table AASM-1/2a and 2b: Data Elements for Use of Appropriate Medications for People With Asthma
Electronic Measurement year Data collection methodology (Electronic or Hybrid) Eligible population Denominator Numerator events by electronic data Numerator events by medical records Reported rate Lower 95% confidence interval Upper 95% confidence interval
For total only For total only For total only For total only
Hybrid
For total only For total only For total only For total only For total only For total only
NCQA 2012
10
Draft Technical Specifications for ACO Measures for Public Comment Obsolete After April 6, 2012
Description
The percentage of patients 1875 years of age with type 1 or type 2 diabetes who had the following: LDL-C control (<100 mg/dL).
Eligible Population
Ages Defining the population Event/ diagnosis 1875 years as of December 31 of the measurement year. Attribution. Report on the aggregate ACO population; refer to the General Guidelines. Medicaid stratification. Option to report Medicaid separately. Diabetes. There are two ways to identify patients with diabetes: by pharmacy data and electronic data. The organization must use both methods to identify the eligible population, but a patient only needs to be identified by one method to be included in the measure. Patients may be identified as having diabetes during the measurement year or the year prior to the measurement year. Pharmacy data. Patients who were dispensed or prescribed insulin or oral hypoglycemics/antihyperglycemics on an ambulatory basis during the measurement year or the year prior to the measurement year (Table ACDC-A).
Metformin-pioglitazone Metformin-rosiglitazone Metformin-sitagliptin Insulin lispro Insulin lispro-insulin lispro protamine Insulin regular beef-pork Insulin regular human Insulin regular pork Insulin zinc beef-pork Insulin zinc extended human Insulin zinc human Insulin zinc pork
Insulin
Meglitinides
NCQA 2012
Draft Technical Specifications for ACO Measures for Public Comment Obsolete After April 6, 2012 Description Miscellaneous antidiabetic agents Sulfonylureas Thiazolidinediones Medication Sitagliptin Glyburide Tolazamide Tolbutamide
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Liraglutide
Note: Glucophage/metformin is not included because it is used to treat conditions other than diabetes; patients with diabetes on these medications are identified through diagnosis coding only. NCQA will post a complete list of medications and NDC codes to www.ncqa.org by November 15, 2012. Electronic data. Patients who had two face-to-face encounters in an outpatient setting or nonacute inpatient setting on different dates of service, with a diagnosis of diabetes (Table ACDC-B), or one face-to-face encounter in an acute inpatient or ED setting, with a diagnosis of diabetes, during the measurement year or the year prior to the measurement year. Services that occur over both years may be counted. Refer to Table ACDC-C for codes to identify the visit type.
______________ Current Procedural Terminology 2012 American Medical Association. All rights reserved.
NCQA 2012
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Draft Technical Specifications for ACO Measures for Public Comment Obsolete After April 6, 2012 Hybrid Method Specification Apply the exclusion specifications for the Electronic Method to the electronic steps of the Hybrid Method. Exclusionary evidence in the medical record must include a note indicating polycystic ovaries at any time in the patients history, but must have occurred by December 31 of the measurement year. The patient must not have a face-to-face encounter in any setting, with any diagnosis of diabetes, during the measurement year or the year prior to the measurement year. Exclusionary evidence in the medical record must include a note indicating a diagnosis of gestational or steroid-induced diabetes during the measurement year or the year prior to the measurement year. The patient must not have a face-to-face encounter in any setting, with a diagnosis of diabetes, during the measurement year or the year prior to the measurement year.
Note: If using the Hybrid Method, both medical records and electronic data may be used to identify exclusions. Table ACDC-D: Codes to Identify Exclusions
Description Polycystic ovaries Steroid induced Gestational diabetes ICD-9-CM Diagnosis 256.4 249, 251.8, 962.0 648.8
Electronic Specification
Denominator Numerator LDL-C Control <100 mg/dL Identify the most recent LDL-C test (Table ACDC-E) during the measurement year using claim/encounter or automated laboratory data. The organization may use a calculated or direct LDL for this indicator. The patient is numerator compliant if the most recent LDL-C level is <100 mg/dL. The patient is not numerator compliant if the automated result for the most recent LDL-C test during the measurement year is 100 mg/dL or is missing, or if an LDL-C test was not done during the measurement year. An organization that uses CPT Category II codes to identify numerator compliance for this indicator must search for all codes in Table ACDC-F and use the most recent code during the measurement year to evaluate whether the patient is numerator compliant. The eligible population.
______________ Current Procedural Terminology 2012 American Medical Association. All rights reserved.
NCQA 2012
Draft Technical Specifications for ACO Measures for Public Comment Obsolete After April 6, 2012
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Hybrid Specification
Denominator Numerators LDL-C Control <100 mg/dL Electronic Medical Record The most recent LDL-C level performed during the measurement year is <100 mg/dL, as documented through automated laboratory data or medical record review. Refer to Electronic Specification to identify positive numerator hits from the electronic data. Documentation in medical record must include, at a minimum, a note indicating the date when the LDL-C test was performed and the result. The organization may use a calculated LDL for these indicators. LDL-C levels may be calculated from total cholesterol, HDL-C and triglycerides using the Friedewald equation if the triglycerides are 400 mg/dL. (LDL-C) = (total cholesterol) (HDL) (triglycerides/5) If lipoprotein (a) is measured, this calculation is: (LDL-C) = (total cholesterol) (HDL) (triglycerides/5) 0.3[lipoprotein (a)] These formulae are used when all levels are expressed in mg/dL and may not be used if triglycerides >400 mg/dL. A systematic sample drawn from the eligible population; refer to the General Guidelines.
Table ACDC-1/2a and 2b: Data Elements for Comprehensive Adult Diabetes Care LDL-C control
Electronic Measurement year Data collection methodology (Electronic or Hybrid) Eligible population Denominator Numerator events by electronic data Numerator events by medical records Reported rate Lower 95% confidence interval Upper 95% confidence interval Hybrid
______________ Current Procedural Terminology 2012 American Medical Association. All rights reserved.
NCQA 2012
14
Draft Technical Specifications for ACO Measures for Public Comment Obsolete After April 6, 2012
Description
The percentage of patients with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis.
Calculations
The measure is reported as an inverted rate [1 (numerator/denominator)]. A higher score indicates appropriate treatment of low back pain (i.e., proportion for whom imaging studies did not occur).
Definitions
Intake Period IESD Negative Diagnosis History January 1December 3 of the measurement year. The Intake Period is used to identify the first outpatient or ED encounter with a primary diagnosis of low back pain. Index Episode Start Date. The earliest date of service for any outpatient or ED encounter (Table ALBP-B) during the Intake Period with a primary diagnosis of low back pain. A period of 180 days (6 months) prior to the IESD when the patient had no claims/ encounters with any diagnosis of low back pain.
Eligible Population
Ages Defining the population Event/ diagnosis Step 1 18 years as of January 1 of the measurement year to 50 years as of December 31 of the measurement year. Attribution. Report on the aggregate ACO population; refer to the General Guidelines. Medicaid stratification. Option to report Medicaid separately. Outpatient or ED visit with a primary diagnosis of low back pain . Follow the steps below to identify the eligible population: Identify all patients in the specified age range who had an outpatient or ED encounter (Table ALBP-B) with a primary diagnosis of low back pain (Table ALBP-A) during the Intake Period.
NCQA 2012
Draft Technical Specifications for ACO Measures for Public Comment Obsolete After April 6, 2012
15
ED*
*Do not include ED visits that result in an inpatient admission. Step 2 Step 3 Step 4 Determine the IESD. For each patient identified in step 1, determine the earliest episode of low back pain. If the patient had more than one encounter, include only the first encounter. Test for Negative Diagnosis History. Exclude patients with any low back pain diagnosis during the 180 days (6 months) prior to the IESD. Test for clinically appropriate imaging studies. Identify patients who have a diagnosis for which an imaging study (Table ALBP-C) in the presence of low back pain is clinically indicated. Electronic Method Specification Exclude patients with a diagnosis of cancer. Look as far back as possible in the patients history through 28 days after the Episode Start Date. Exclude patients diagnosed with recent trauma, intravenous drug abuse, or neurological impairment in the 12 months (1 year) prior to the IESD through 28 days after the Episode Start Date. Note: If using the Electronic Method, medical record documentation may not be used to identify exclusions. Hybrid Method Specification
Exclusions
Apply the Exclusion specifications for the Electronic Specification, above, to the electronic steps of the Hybrid Specification.
Exclusionary evidence in the medical record must include a note indicating a diagnosis of cancer. Look as far back as possible in the patients history through 28 days after the Episode Start Date. Exclusionary evidence in the medical record must include a note indicating diagnosis of recent trauma, intravenous drug abuse or neurological impairment in the 12 months (1 year) prior to the IESD through 28 days after the Episode Start Date. Note: If using the Hybrid Method, both medical records and electronic data may be used to identify exclusions.
_____________ Current Procedural Terminology 2012 American Medical Association. All rights reserved.
NCQA 2012
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Draft Technical Specifications for ACO Measures for Public Comment Obsolete After April 6, 2012
Table ALBP-C:
Codes to Identify Exclusions (Clinically Appropriate Indications for Low Back Imaging)
ICD-9-CM Diagnosis 140-209, 230-239, V10 800-839, 850-854, 860-869, 905-909, 926.11, 926.12, 929, 952, 958-959 304.0-304.2, 304.4, 305.4-305.7 344.60, 729.2
Electronic Specification
Denominator Numerator The eligible population. An imaging study conducted on the IESD or in the 28 days following the IESD. Refer to Table ALBP-D for codes to identify imaging studies that count toward the numerator. A diagnosis code from Table ALBP-A must be used in conjunction with an imaging study code in Table ALBP-D.
Hybrid Specification
Denominator Numerator Electronic Medical Record A systematic sample drawn from the eligible population; refer to the General Guidelines. Patients with documentation in the medical record of an imaging study (plain x-ray, MRI, CT scan) of the lower back conducted on the IESD or in the 28 days following the IESD. Refer to Electronic Specification to identify positive numerator hits from the electronic data. Documentation of an imaging study (plain x-ray, MRI, CT scan) of the lower back must include the date and result of the study.
_____________ Current Procedural Terminology 2012 American Medical Association. All rights reserved.
NCQA 2012
Draft Technical Specifications for ACO Measures for Public Comment Obsolete After April 6, 2012
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Table ALPB-ACO 1/2a and 2b: Data Elements for Use of Imaging Studies for Low Back Pain
Electronic Measurement year Data collection methodology (Electronic or Hybrid) Eligible population Denominator Numerator events by electronic data Numerator events by medical records Reported rate Lower 95% confidence interval Upper 95% confidence interval Hybrid
NCQA 2012
18
Draft Technical Specifications for ACO Measures for Public Comment Obsolete After April 6, 2012
Description
The percentage of discharges for patients 6 years of age and older who were hospitalized for treatment of selected mental health disorders and had an outpatient visit, intensive outpatient encounter or partial hospitalization with a mental health provider. Two rates are reported. 1. The percentage of discharges for which the patient received follow-up within 30 days of discharge. 2. The percentage of discharges for which the patient received follow-up within 7 days of discharge.
Eligible Population
Ages Defining the population Event/diagnosis 6 years and older as of the date of discharge. Attribution. Report on the aggregate ACO population; refer to the General Guidelines. Medicaid stratification. Option to report Medicaid separately. Discharged alive from an acute inpatient setting (including acute care psychiatric facilities) with a principal mental health diagnosis (Table AFUH-A) on or between January 1 and December 1 of the measurement year. The denominator for this measure is based on discharges, not on patients. If patients have more than one discharge, include all discharges on or between January 1 and December 1 of the measurement year.
If the discharge is followed by readmission or direct transfer to an acute facility for any mental health principal diagnosis (Table AFUH-B, AFUH-C) within the 30-day follow-up period, count only the readmission discharge or the discharge from the facility to which the patient was transferred. Although rehospitalization might not be for a selected mental health disorder, it is probably for a related condition. Exclude both the initial discharge and the readmission/direct transfer discharge if the readmission/direct transfer discharge occurs after December 1 of the measurement year. Exclude discharges followed by readmission or direct transfer to a nonacute facility for a mental health principal diagnosis (Tables AFUH-B, AFUH-C) within the 30-day follow-up period. These discharges are excluded from the measure because readmission or transfer may prevent an outpatient follow-up visit from taking place. Refer to Table AFUH-D for codes to identify nonacute care.
NCQA 2012
Draft Technical Specifications for ACO Measures for Public Comment Obsolete After April 6, 2012 Non-mental health readmission or direct transfer Exclude discharges in which the patient was transferred directly or readmitted within 30 days after discharge to an acute or nonacute facility for a non-mental health principal diagnosis. This includes any ICD-9-CM Diagnosis code or DRG code other than those listed in AFUH-B and AFUH-C. These discharges are excluded from the measure because rehospitalization or transfer may prevent an outpatient follow-up visit from taking place.
19
Respite Intermediate care facility 1002 Residential substance abuse treatment facility Psychiatric residential treatment center T2048, H0017-H0019 1001 Comprehensive inpatient rehabilitation facility Other nonacute care facilities that do not use the UB Revenue or Type of Bill codes for billing (e.g., ICF, SNF)
54 55 56 61
NCQA 2012
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Draft Technical Specifications for ACO Measures for Public Comment Obsolete After April 6, 2012
Electronic Specification
Denominator Numerator 30-Day Follow-Up 7-Day Follow-Up An outpatient visit, intensive outpatient encounter or partial hospitalization (Table AFUH-E) with a mental health practitioner within 30 days after discharge. Include outpatient visits, intensive outpatient encounters or partial hospitalizations that occur on the date of discharge. An outpatient visit, intensive outpatient encounter or partial hospitalization (Table AFUH-E) with a mental health practitioner within 7 days after discharge. Include outpatient visits, intensive outpatient encounters or partial hospitalizations that occur on the date of discharge. The eligible population.
Note
Organizations may have different methods for billing intensive outpatient encounters and partial hospitalizations. Some methods may be comparable to outpatient billing, with separate claims for each date of service; others may be comparable to inpatient billing, with an admit date, a discharge date and units of service. Organizations whose billing methods are comparable to inpatient billing may count each unit of service as an individual visit. The unit of service must have occurred during the period required for the rate (e.g., within 30 days after discharge or within 7 days after discharge). Visits for substance abuse are not compliant events for the numerator. Refer to the last page of this specification for the definition of mental health practitioner.
___________ Current Procedural Terminology 2012 American Medical Association. All rights reserved.
NCQA 2012
Draft Technical Specifications for ACO Measures for Public Comment Obsolete After April 6, 2012
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Hybrid Specification
Denominator Numerator 30-Day Follow-Up 7-Day Follow-Up Electronic Medical Record Documentation of an outpatient visit, intensive outpatient encounter or partial hospitalization with a mental health practitioner within 30 days after discharge. Documentation of an outpatient visit, intensive outpatient encounter or partial hospitalization with a mental health practitioner within 7 days after discharge. Refer to Electronic Specification to identify positive numerator hits from the electronic data. Documentation in the medical record of an outpatient visit, intensive encounter or partial hospitalization with a mental health practitioner within the specified timeframe. Include outpatient visits, intensive outpatient encounters or partial hospitalizations that occur on the date of discharge. Documentation must include the date of the visit. A systematic sample drawn from the eligible population; refer to the General Guidelines.
Table AFUH-1/2a and 2b: Data Elements for Follow-Up After Hospitalization for Mental Illness
Electronic Measurement year Data collection methodology (Electronic or Hybrid) Eligible population Denominator Numerator events by electronic data Numerator events by medical records Reported rate Lower 95% confidence interval Upper 95% confidence interval Each of the 2 rates Each of the 2 rates Each of the 2 rates Each of the 2 rates Hybrid
Each of the 2 rates Each of the 2 rates Each of the 2 rates Each of the 2 rates Each of the 2 rates Each of the 2 rates
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Draft Technical Specifications for ACO Measures for Public Comment Obsolete After April 6, 2012
Definitions
Mental health practitioner A practitioner who provides mental health services and meets any of the following criteria. An MD or doctor of osteopathy (DO) who is certified as a psychiatrist or child psychiatrist by the American Medical Specialties Board of Psychiatry and Neurology or by the American Osteopathic Board of Neurology and Psychiatry; or, if not certified, who successfully completed an accredited program of graduate medical or osteopathic education in psychiatry or child psychiatry and is licensed to practice patient care psychiatry or child psychiatry, if required by the state of practice. An individual who is licensed as a psychologist in his/her state of practice. An individual who is certified in clinical social work by the American Board of Examiners; who is listed on the National Association of Social Workers Clinical Register; or who has a masters degree in social work and is licensed or certified to practice as a social worker, if required by the state of practice. A registered nurse (RN) who is certified by the American Nurses Credentialing Center (a subsidiary of the American Nurses Association) as a psychiatric nurse or mental health clinical nurse specialist, or who has a masters degree in nursing with a specialization in psychiatric/mental health and two years of supervised clinical experience and is licensed to practice as a psychiatric or mental health nurse, if required by the state of practice. An individual (normally with a masters or a doctoral degree in marital and family therapy and at least two years of supervised clinical experience) who is practicing as a marital and family therapist and is licensed or a certified counselor by the state of practice, or if licensure or certification is not required by the state of practice, who is eligible for clinical membership in the American Association for Marriage and Family Therapy. An individual (normally with a masters or doctoral degree in counseling and at least two years of supervised clinical experience) who is practicing as a professional counselor and who is licensed or certified to do so by the state of practice, or if licensure or certification is not required by the state of practice, is a National Certified Counselor with a Specialty Certification in Clinical Mental Health Counseling from the National Board for Certified Counselors (NBCC).
NCQA 2012