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Medicaid PA Guidelines

Condition — Asthma

Reference: “Guidelines for the Diagnosis and Management of Asthma” is a National Guideline developed by the National Heart, Lung and Blood Institute as part of the National Asthma Education and Prevention Program. The Expert Panel Report 3 was initially published in July 2007.

Clinical Indicators:

  1. The percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period. Two rates are reported:
    • The percentage of members who remained on an asthma controller medication for at least 50% of their treatment period.
    • The percentage of members who remained on an asthma controller medication for at least 75% of their treatment period.
    (Source: HEDIS® 2016, Vol. 2, Technical Specifications, MMA)
  2. The percentage of members 5-85 years of age who were identified as having persistent asthma and had a ratio of controller medications of 0.50 or greater during the measurement year. (NOTE: Medicaid, report only members 5-64 years of age.)
    (Source: HEDIS® 2016, Vol. 2, Technical Specifications, AMR)

http://www.nhlbi.nih.gov/files/docs/guidelines/asthsumm.pdf

Condition — ADHD

Reference: October 2011 American Academy of Pediatrics (AAP) “Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents”.

Clinical Indicators:

  1. The percentage of children newly prescribed attention-deficit/hyperactivity disorder (ADHD) medication who had at least three follow-up care visits within a 10-month period, one of which was within 30 days of when the first ADHD medication was dispensed. Two rates are reported:
    • Initiation Phase. The percentage of members 6–12 years of age as of the IPSD with an ambulatory prescription dispensed for ADHD medication, who had one follow-up visit with practitioner with prescribing authority during the 30-day Initiation Phase.
    • Continuation and Maintenance (C&M) Phase. The percentage of members 6–12 years of age as of the IPSD with an ambulatory prescription dispensed for ADHD medication, who remained on the medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended.(Source: HEDIS® 2016, Vol. 2, Technical Specifications, ADD)

http://pediatrics.aappublications.org/content/pediatrics/early/2011/10/14/peds.2011-2654.full.pdf

Condition — COPD

Reference: “The Global Initiative for Chronic Obstructive Lung Disease Guideline was formed through the collaborative efforts of the National Heart, Lung, and Blood Institute, National Institutes of Health, USA and the World Health Organization in 1998.

From the “Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease,” Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2016.

Clinical Indicators:

  1. Percentage of members 40 years and older with a new diagnosis of COPD or newly active COPD, who have received spirometry testing to confirm the diagnosis. (Source: HEDIS® 2016, Vol. 2, Technical Specifications, SPR)
  2. Percentage of COPD exacerbations for members 40 years and older who had an acute inpatient discharge or ED visit between January 1-November 20 of the measurement year and who were dispensed a systemic corticosteroid within 14 days of the event.
  3. Percentage of COPD exacerbations for members 40 years and older who had an acute inpatient discharge or ED visit between January 1-November 20 of the measurement year and who were dispensed a bronchodilator within 30 days of the event. (Source: HEDIS® 2016, Vol. 2, Technical Specifications, PCE)

http://goldcopd.org/global-strategy-diagnosis-management-prevention-copd-2016/

Condition — Cardiac

Reference:

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

Clinical Indicators:

  1. The percentage of members 18 years of age and older during the measurement year who were hospitalized and discharged from July 1 of the year prior to the measurement year to June 30 of the measurement year with a diagnosis of AMI and who received persistent beta-blocker treatment for six months after discharge. (Source: HEDIS® 2016, Vol. 2, Technical Specifications, PBH)
  2. The percentage of males 21-75 and females 40-75 years of age during the measurement year who were identified as having clinical atherosclerotic cardiovascular disease (ASCVD) and who:
    • Received statin therapy: Members who were dispensed at least one high or moderate-intensity statin medication during the measurement year.
    • Met statin adherence 80%: Members who remained on a high or moderate-intensity statin medication for at least 80% of the treatment period.

(Source: HEDIS® 2016, Vol. 2, Technical Specifications, SPC)

Links:

Condition — Diabetes

Reference: American Diabetes Association’s (ADA) “Standards of Medical Care in Diabetes-2016” for its Diabetes Guideline (January 2016).

Clinical Indicators:

  1. The percentage of members 18–75 years of age with diabetes (type 1 and type 2) who had each of the following:
    •Hemoglobin A1c (HbA1c) testing
    •HbA1c poor control (>9.0%)
    •HbA1c control (<8.0%)
    •HbA1c control (<7.0%) for a selected population
    •Eye exam (retinal) performed
    •Medical attention for nephropathy
    • BP control (<140/90 mm Hg)
    (Source: HEDIS® 2016, Vol. 2, Technical Specifications, CDC)
  2. The percentage of members 40–75 years of age during the measurement year with diabetes who do not have clinical atherosclerotic cardiovascular disease (ASCVD) who were dispensed at least one statin medication of any intensity during the measurement year.
    (Source: HEDIS® 2016, Vol. 2, Technical Specifications, SPD)
  3.  The percentage of members 40–75 years of age during the measurement year with diabetes who do not have clinical atherosclerotic cardiovascular disease (ASCVD) who remained on a statin medication of any intensity for at least 80% of the treatment period.
    (Source: HEDIS® 2016, Vol. 2, Technical Specifications, SPD)

http://care.diabetesjournals.org/content/diacare/suppl/2015/12/21/39.Supplement_1.DC2/2016-Standards-of-Care.pdf

Condition — Depression

Reference: Institute for Clinical Systems Improvement Health Care Guideline titled, “Major Depression in Adults in Primary Care” (Sixteenth Edition, September 2013).

Clinical Indicators:

1. The percentage of members 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression and who remained on an antidepressant medication treatment.
Effective Acute Phase Treatment: The percentage of members who remained on an antidepressant medication for at least 84 days (12 weeks).
Effective Continuation Phase Treatment: The percentage of members who remained on an antidepressant medication for at least 180 days (6 months).(Source: HEDIS® 2016, Vol. 2, Technical Specifications, AMM)

https://www.icsi.org/_asset/fnhdm3/Depr-Interactive0512b.pdf

Condition — HIV

Reference: “Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents” is a national guideline, following the recommendations by the HHS Panel on Antiretroviral Guidelines for Adults and Adolescents - A Working Group of the Office of AIDS Research Advisory Council (OARAC).

Clinical Indicators:

  1. Number of HIV+ individuals with at least one outpatient visit in the past 12 months.
  2. Percentage of enrollees age 18 and older with a diagnosis of Human Immunodeficiency Virus (HIV) who had a HIV viral load test during the measurement year. (Health Resources and Services Administration)
  3. Percentage of Enrollees with pharmacy claims for HIV medications in the past 12 months with an 80% medication possession ratio.

Links:

https://aidsinfo.nih.gov/contentfiles/lvguidelines/adultandadolescentgl.pdf

Condition — Hypertension

Reference: “2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee” (JNC 8).

Clinical Indicators:

  1. Percentage of members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose BP was adequately controlled during the measurement year based on the following criteria:
    • Members 18-59 years of age whose BP was <140/90 mm Hg.
    • Members 60-85 years of age with a diagnosis of diabetes whose BP was <140/90 mm Hg.
    • Members 60-85 years of age without a diagnosis of diabetes whose BP was <150/90 mm Hg.
    (Source: HEDIS® 2016, Vol. 2, Technical Specifications, CBP) 

http://jama.jamanetwork.com/article.aspx?articleid=1791497

Substance Abuse

Reference: American Psychiatric Association’s “Practice Guideline For The Treatment of Patients With Substance Use Disorders,” Second Edition, (2006).

Clinical Indicators:

  1. Initiation of AOD Treatment. Percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) dependence who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of the diagnosis. (Source: HEDIS® 2016, Vol. 2, Technical Specifications, IET)
  2. Engagement of AOD Treatment. Percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) dependence who had two or more additional services with a diagnosis of AOD within 30 days of the initiation visit. (Source: HEDIS® 2016, Vol. 2, Technical Specifications, IET)

Links:

http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/substanceuse.pdf

Palliative Care

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

Clinical Indicators:

  1. Documentation of Evidence of Advanced Directives
  2. Number of Patients Screened for Palliative Care Needs
  3. Percent of Documentation of Pain Assessment

Links:

http://www.nationalconsensusproject.org/NCP_Clinical_Practice_Guidelines_3rd_Edition.pdf

Condition — Adult

Reference: "Gateway follows the Centers for Disease Control and Prevention, recommended Adult Immunization Schedule-United States, 2016. The Adult Immunization Schedule has been approved by ACIP, ACOG, ACP & AAFP. 

Clinical Indicators:

  1. The percentage of women 50–74 years of age who had a mammogram to screen for breast cancer. (Source: HEDIS® 2016, Vol. 2, Technical Specifications, BCS)
  2. The percentage of members 18–74 years of age who had an outpatient visit and whose body mass index (BMI) was documented during the measurement year or the year prior to the measurement year. (Source: HEDIS® 2016, Vol. 2, Technical Specifications, ABA)

Links:

Immuunization

Condition Child

Reference:PA Department of Human Services Periodicity Schedule, and 2016 CDC Immunization Schedule Birth-18 Years and Catch-up

Clinical Indicators:

  1. The percentage of members who turned 15 months old during the measurement year and who had the following number of well-child visits with a PCP during their first 15 months of life:
    • No well-child visits.
    • One well-child visit.
    • Two well-child visits.
    • Three well-child visits.
    • Four well-child visits.
    • Five well-child visits.
    • Six or more well-child visits.
    Source: HEDIS® 2016, Vol. 2, Technical Specifications, W15)
  2. The percentage of enrolled members 12–21 years of age who had at least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during the measurement year.
    Source: HEDIS® 2016, Vol. 2, Technical Specifications, AWC)

Links:
Child Preventive Summary of Changes

 

Condition — Routine and High Risk Prenatal Care

Clinical Indicators:

  1. The percentage of Medicaid deliveries between November 6 of the year prior to the measurement year and November 5 of the measurement year that had the following number of expected prenatal visits:
    • < 21% of expected visits
    • 21%-40% of expected visits
    • 41%-60% of expected visits
    • 61%-80% of expected visits
    • ≥ 81% of expected visits
    (Source: HEDIS® 2016, Vol. 2,Technical Specifications, FPC)
  2. The percentage of deliveries of live births between November 6 of the year prior to the measurement year and November 5 of the measurement year. • Timeliness of Prenatal Care. The percentage of deliveries that received a prenatal care visit as a member of the organization in the first trimester or within 42 days of enrollment in the organization. • Postpartum Care. The percentage of deliveries that had a postpartum visit on or between 21 and 56 days after delivery.
    (Source: HEDIS® 2016, Vol. 2, Technical Specifications, PPC)

General Guideline Limitations: 

  • Guidelines may not apply to every patient or clinical situation; some variation from guidelines is expected. Provider judgment and knowledge of an individual patient supersedes clinical guidelines. 
  • Guidelines do not determine insurance coverage of health care services or products. Coverage decisions are based on member eligibility, contractual benefits, and determination of medical necessity.