Developing Quality Measures for Medicaid Beneficiaries with Schizophrenia: Final Report. Appendix D. Summary of Public Comment

01/30/2012

TABLE D.1. Public Comment Summary
Organization
Name
Feedback
Type
Comments Comments
Modified
Disposition
Schizophrenia Measure Set -- Overall
Accountable Behavioral Health Alliance Support with modification. In Central Oregon our Oregon Health Plan/SPMI population dies at the average age of 45. Preliminary reasoning includes poor overall physical health, lack of medical care follow-up and side effects from the long-term use of antipsychotic medications. Standards must be set with this high risk population to ensure that both physical and mental health are actively tracked to receive adequate services to improve overall health and life expectancy. I also fear how indigent individuals are fairing. More attention should be focused on the holistic view of this at risk population subgroup with better follow-up and improved access. Consider approaching these measures in a more holistic way due to the fact that the SMI population in general a high risk group. NCQA will share this thought with Mathematica.
University of California, Irvine Support. Long-Acting Depot preparations are going to revolutionize outcomes and decrease recidivism. The reason they are not being used today in great numbers is the very poor reimbursement. One small study showed that if every schizophrenic in this country was on a long-acting injectable (LAI), within 6 months half of our psychiatry hospitals would no longer be needed. The cost savings would be close to $11 Billion dollars per year. So the way to get greater use is to increase the reimbursement for the practitioner who administers the injection. I see this as the biggest cost saving and patient improvement program in the history of our treatment of schizophrenia. Please contact me for this concept. Consider focusing on a long-term solution, which would be focusing on LAIs. The measure is intended to include injectables as part of the definition of antipsychotic medication. Will verify that list includes them.
Seven Counties Services Support with modification. Good set of measures. I am sure that it will get shorter, but I want to include 2 additional measures: one for smoking assessment and one for exercise assessment. The smoking assessment is critical. Along with bad antipsychotic management it is one of the 2 major killers for people with schizophrenia. Let's start assessing and offering evidence-based interventions. Consider adding measures for smoking assessment and exercise assessment. Smoking assessment and exercise assessment are not readily available in claims and therefore cannot be included.
National Association of County Behavioral Health and Developmental Disability Directors (NACBHDD) Support with modification. Why are you beginning at age 25 when adult Medicaid begins at age 22 and early onset schizophrenia can begin as early as 17? Issue is that you need be create a clear line between adolescence and adulthood. Concerned that the age specifications in the measures are not representative of Medicaid or early onset schizophrenia. TAG recommended 25 to ensure stability of diagnosis.
New Hampshire Department of Health and Human Services (DHHS) Support with modification. The list of antipsychotics needs to be updated. Concerned that the list of antipsychotics are not updated. NCQA and Mathematica will review the list of antipsychotics.
Kaiser Health Plan Support with modification. Kaiser Permanente is supportive of a creation of a measure set for people with schizophrenia focusing on the pharmacological and physical health needs of this population. The group recognizes that people with schizophrenia often receive sub-optimal care in the areas which these candidate measures seek to address. We are glad to have been a part of this discussion and look forward to working to improve the quality of care that our members with schizophrenia receive. There is a concern however, that given that most of the Kaiser Permanente members who are Medicaid recipients, have split coverage. In most regions, the behavioral health coverage is carved out and provided at the community mental health clinic level while their physical health coverage is provided with the Kaiser Permanente system. This might make coordinating this care difficult and data collection nearly impossible. Comments on Inclusion Criteria: There is consensus that the diagnoses proposed are adequate for identification of people with schizophrenia and that the number of visits in differing venues was reasonable. There was a concern raised however, about how diagnoses made in an ED would count. Diagnoses made in the ED are often erroneous and depending on how these are included, may increase the denominator. If ED diagnoses would require 2 visits on separate dates with the diagnoses, this could address the issue.
  1. Concerned that plans will be burdened by split coverage, where behavioral health coverage is carved out and physical health coverage is provided by the plan.
  2. Concerned that diagnoses made in the ED setting are erroneous and we should consider requiring 2 visits on separate dates with the same diagnosis.
  1. These are intended for state Medicaid use, so states may have capacity to integrate across settings.
  2. ED visits are treated like other outpatient settings and so require a second OP visit with schizophrenia diagnosis to qualify.
Gulf Coast Health Center Support with modification. Over 30 years of respected research supports the use of a biopsychosocial model for effective and efficient treatment of schizophrenia, as well as schizoaffective and bipolar disorders including psychosis. You limit measures of treatment quality/effectiveness to medical encounters, specifically readmission to an inpatient facility. The designation "health care" should replace the term medical, to more accurately measure treatment which really works. Additionally, by your standard, "treatment" is successful if the person is not readmitted for inpatient services. So all the psychotic persons wandering our streets, sleeping on our park benches and clogging up our county jails received successful treatment, by your limited measure(s). Diseases like diabetes, primary hypertension, alcohol and other drug dependence, schizophrenia, bipolar disorder--and several other disorders--need to be treated as chronic conditions by a varied mix of care providers, not limited to medical practitioners. And quality measures of successful treatment must include quality of life components, the bare basics being clothing, housing, and employment. Your current measure of "success" has caused a mushroom-like proliferation of intensive outpatient and partial hospitalization programs, with 20% of the price tag for this "treatment" (for persons without both Medicare AND Medicaid coverage) falling directly on the shoulders of the patients you are purportedly treating in a successful manner. Your quality measure for schizophrenia treatment is woefully inadequate. Concern that the proposed measures do not go nearly far enough. The concerns raised do not account for the difficulty of collecting data for performance measures. NCQA will share these thoughts with Mathematica.
University of Pittsburgh Support with modification. It is quite clear that these measures fit a model of care that predates the emerging recovery approach. I have no particular issues with them except there inadequacy to care quality care--all these things could be done without a recovery framework. I understand that you considered other measures but found the data sources too weak to support their use. Obviously we need to develop and Implement other measures--and soon. Candidate measures I would suggest is if there is any evidence that the person receiving services was supported in the opportunity to outline their own goals for care or had any role in shared decision making about the care and its goals. I hope your report suggests this. In the mean time--I would suggest that you consider as a measure how often individuals are admitted involuntarily, put into seclusion/ restraints or given forced medications. This data is collected, so should be available. Clearly all efforts to decrease coercion in the context of care are elements of improved care. The campaign to radically reduce seclusion and restraint proves the merit of collecting this data as a quality indicator. Consider including a measure about individuals being admitted involuntarily, put into seclusion/restraints or given forced medications. NCQA will share this thought with Mathematica.
University of Pittsburgh Support with modification. One final measurable recovery oriented quality measure would be if they were ever encountered by a peer support specialist during their care, and if so, to what extent. This should show in billing data and in electronic health records (EHRs). Also data that could be available is to track how many persons with schizophrenia get on disability if they have no source of income, how long it takes and how many ever come off. Harder to get but an incredibly important element of care. Thanks. I would be very happy to discuss Any of these ideas if that would be useful.
  1. Consider adding a measure that looks at people with schizophrenia that encountered a peer support specialist during treatment. This would show in billing data and EHRs.
  2. Consider adding a measure that looks at how long it takes people on disability to get off it.
  1. Peer support is unlikely to be captured in claims data and will be inconsistent across state if collected.
  2. Will consider for future projects.
National Council for Community Behavioral Healthcare Support. We applaud NCQAs work on these measures. The measures are practical, timely and necessary. Support. Support.
American Psychological Association Support with modification. I am writing on behalf of the American Psychological Association the largest organization of psychologists worldwide with over 154,000 members. The Association supports NCQA's efforts to measure important aspects of both physical and mental health care for Medicaid beneficiaries with schizophrenia. The proposed measures can be used to further the important goals of improving access to care and quality of care for this vulnerable population. However, we disagree with the decision not to include measures of psychosocial care and recommend that you develop a measure(s) for this important aspect of schizophrenia treatment. There is substantial evidence of the benefits of psychosocial care. For example, a 2011 study by Grant et al. found that low-functioning patients with schizophrenia who were treated with cognitive therapy showed statistically significant and clinically meaningful improvements in functioning and reductions in symptom severity (http://archpsyc.ama-assn.org/cgi/content/full/archgenpsychiatry.2011.129). An excellent source of relevant data in this area is the Schizophrenia PORT project. PORT recently released a comprehensive summary of current evidence-based psychosocial interventions for patients with schizophrenia along with specific treatment recommendations (http://schizophreniabulletin.oxfordjournals.org/content/36/1/48.full.pdf+html). In addition, the "Resolution on APA Endorsement of the Concept of Recovery for People with Serious Mental Illness" provides citations to several important studies that demonstrate the value of psychological interventions (http://www.apa.org/practice/leadership/smi/recovery-resolution.pdf). The Association resolution highlights the need to make potentially beneficial services accessible. In addition, the "Resolution on APA Endorsement of the Concept of Recovery for People with Serious Mental Illness" provides citations to several important studies that demonstrate the value of psychological interventions (http://www.apa.org/practice/leadership/smi/recovery-resolution.pdf). The Association resolution highlights the need to make potentially beneficial services accessible, particularly for minorities and people of lower socioeconomic status such as Medicaid beneficiaries. Concerned that psychosocial measures are not included. These measures were in the original list of potential measures, but plans do not currently have the ability to gather all the data using claims.

NCQA will share these thoughts with Mathematica.

OptumHealth Behavioral Solutions Support with modification. Thank you for focusing on this very important diagnostic category for our Medicaid population. As we mention in our comments, our most significant concern is that the reliability of the results may be compromised based on potentially low denominators. We hope that the development of these datasets will encourage states to review common datasets and have standard, consistent expectations. Overall, these metrics are a very good start. We encourage NCQA to find ways to look at treatment outcome measures in future metrics. There may be ways to look at "treat to remission" and relapse prevention measures using normed instruments. OptumHealth Behavioral Solutions would value the opportunity to work with you to develop future measures. Consider looking at outcomes in future measure development. Will consider for future projects.
American Psychiatric Association (APA) Support with modification The CPT code 90862 (Pharmacological Management) is often used for clinical encounters with psychiatrists, and should be added to the specifications of these measures (e.g., in establishing the diagnosis) as appropriate. The specifications of these measures should clearly indicate that these are system-level measures. Should these measures be expanded for institution or clinician level analysis in the future, additional specification would be required. Some measures, such as the measure on follow-up after hospitalization (FUH), involves many factors and may not be appropriate for measurement and accountability at the clinician level of analysis. We understand the rationale for excluding psychosocial interventions from this measure set, and encourage that additional interventions be considered for inclusion as the tools for performance measurement advance. Consider adding the CPT code 90862 (Pharmacological Management) in the measure specifications. NCQA and Mathematica will evaluate this code and its applicability to the measure set.
National Alliance on Mental Illness (NAMI) Support. NAMI would like to express strong support for the Quality Measures for Medicaid Beneficiaries with Schizophrenia developed by the NCQA. As the nation's largest organization representing people living with SMI and their families, NAMI applauds NCQA for this important effort to move forward with this groundbreaking effort to more effectively assess treatment and outcomes in the Medicaid program. NAMI is especially supportive of the breadth of these proposed measures and the inclusion of key indicators for psychiatric treatment such as treatment adherence, ED utilization and post-acute care follow-up services. However, even more important are the diverse measures for medical comorbidities experienced by Medicaid beneficiaries living with schizophrenia including cardiovascular, diabetes and cervical cancer screening and monitoring. Implementation of the measures will be critical for the field of publicly funded mental health services. For decades, data, outcome measures and accountability in publicly funded mental health services has lagged far behind other major health care disciplines. In many states, existing data have been non-existent for available services, service needs and positive outcomes. Further, what data has existed is rarely standardized across states or public sector health plans, making comparisons and the identification of useful avenues for improvement extremely difficult. This is especially the case with the Medicaid program where accountability is spread across CMS (a federal agency whose role is limited to retroactively matching state spending), state Medicaid programs and state mental health agencies that oversee local providers. For years, federal officials, state mental health agencies and community providers have haggled over leadership definitions, and strategies for addressing the data collection and outcome measure Support. Support.
Cardiovascular Health and Diabetes Monitoring
BJC HealthCare Support with modification. Specify that Hemoglobin A1c (HbA1c) be used, not glucose. The American Diabetes Association now recommends HbA1c for screening and for monitoring. It is more reliable and readily testable as it can be done any time of the day with any amount of food or drink consumed. HbA1c is the standard for monitoring diabetes. It is much easier to have a system to test for it for both screening and monitoring rather than fasting glucose for screening and HbA1c for monitoring. Consider only using HbA1c testing for screening and monitoring to stay consistent with the American Diabetes Association's recommendation. Review guidelines and evidence for cardiovascular and diabetes screening and monitoring.
Kaiser Health Plan Support. Support. Support. Support.
OptumHealth Behavioral Solutions Support with modification.
  1. Denominators for this measure will be extremely small, due to small plan size and the low prevalence of the diagnosis along with, making the results difficult to interpret. There will be even fewer enrollees in this metric as they will need to be both diagnosed with schizophrenia and with either cardiovascular disease or diabetes. In order to maximize the denominator, we recommend decreasing the eligible age to 21 years old. Also, this population switches plans often, so a continuous enrollment requirement of one year with only a 45 day gap will eliminate many members. We suggest allowing up to 2 non-consecutive one-month gaps.
  2. Table B. Is this table necessary--we recommend that you remove it? If it remains, it needs to be modified. It includes codes for ophthalmological services, but does not include Healthcare Common Procedure Coding System (HCPCS) codes which are often used for this population and mandated by states (e.g., T1015 for medication management). We also recommend inclusion of telehealth codes (e.g., Q3014).
  1. Concern about small numbers for the denominator and recommend decreasing the eligible age to 21 years old.
  2. Concern that continuous enrollment of year with only 1 gap will eliminate many members, and recommend 2 non-consecutive 1-month gaps.
  3. Consider removing or revisiting Table B (Codes to Identify Visit Type).
  1. Review the MAX data to look at potential small numbers problems.
  2. Review the MAX data to look at continuous enrollment.
  3. Discuss the table's usefulness in the measure.
APA Support. We suggest including physical findings such as weight and BMI as monitoring requirements when this type of data can be more easily captured for performance measurement purposes (e.g., broader use of EHRs). Consider adding weight and BMI monitoring to the physical health measures for schizophrenia when there is broader use of EHRs. Will consider for future projects.
NAMI Support.
  1. Measure Relevance: As noted above, NAMI strongly support this proposed measure for cardiovascular health and diabetes monitoring. Measure usefulness for improving quality of care for Medicaid recipients with schizophrenia. Feasibility of data collection.
Support. Support.
Cardiovascular Health and Diabetes Screening
BJC HealthCare Support with modification. Specify that HbA1c be used, not glucose. Glucose is a much less reliable screen due to the need for it to be fasting. The American Diabetes Association now recommends HbA1c for screening. It is more reliable and readily testable as it can be done any time of the day with any amount of food or drink consumed. HbA1c is the standard for monitoring diabetes. It is much easier to have a system to test for it for both screening and monitoring rather than fasting glucose for screening and HbA1c for monitoring. Consider only using HbA1c testing for screening and monitoring to stay consistent with the American Diabetes Association's recommendation. Review guidelines and evidence for cardiovascular and diabetes screening and monitoring.
Kaiser Health Plan Support with modification. Relevance: We are concerned that both screening recommendations are too frequent. Would like to suggest that the frequency of screenings be reconciled against recommendations from the American Diabetes Association.

American Usefulness: We agree that the measure would be useful in improving quality of care.

Collection: This data could be collected.

Concern that screenings are too frequent and will not allow actionability. Measures are specified for people with schizophrenia, therefore a high frequency of screenings should not be an issue.
Bristol-Myers Squibb Company Support with modification. It is important that a lab test is done before or at the time of a new prescription to ensure appropriate decision making. We would suggest an additional measure such as the percentage of members with schizophrenia and who were prescribed any antipsychotic medication during the measurement year who received a diabetes/cardiovascular health screening prior to or at the time of their initial prescription. Consider adding a rate that looks at the percentage of people that received a diabetes and cardiovascular screening prior to or at the time of their initial antipsychotic prescription. Will consider for future projects.
OptumHealth Behavioral Solutions Support with modification.
  1. Denominators for this measure will be small, due to small plan size and the low prevalence of the diagnosis, making the results difficult to interpret. In order to maximize the denominator, we recommend decreasing the eligible age to 21 years old. Also, this population switches plans often, so a continuous enrollment requirement of 1 year with only a 45 day gap will eliminate many members. We suggest allowing up to two non-consecutive 1-month gaps.
  2. Many of these members receive injectables, but the specs are silent on how to handle this.
  1. Concern about small numbers for the denominator and recommend decreasing the eligible age to 21 years old.
  2. Concern that continuous enrollment of year with only 1 gap will eliminate many members, and recommend 2 non-consecutive 1-month gaps.
  3. Concern that the measure does not specify how to handle people that receive injectables.
  1. Review the MAX data to look at potential small numbers problems.
  2. Review the MAX data to look at continuous enrollment.
  3. Discuss the inclusion of specifications for injectables.
APA Support. We suggest including physical findings such as weight and BMI as screening requirements when this type of data can be more easily captured for performance measurement purposes (e.g., broader use of EHRs). Consider adding weight and BMI monitoring to the physical health measures for schizophrenia when there is broader use of EHRs. Will consider for future projects.
NAMI Support.
  1. Measure Relevance: NAMI is strongly supportive of both cardiovascular and diabetes screening and monitoring measures. There is a large and growing body of research demonstrating the tragedy of medical comorbidities and early mortality experienced by people living with schizophrenia. In 2006, the National Association of State Mental Health Program Directors released a series of reports documenting lower life expectancy and premature mortality for individuals with SMI served in the public sector mental health system. These reports examined medical histories and post-mortem records and found alarming rates of medical comorbidities that were directly related to premature death among these individuals: heart disease, pulmonary disorders, diabetes, etc. that were significantly higher than the general population not diagnosed with SMI. In the aggregate, these reports found life expectancy is 25 years lower than the general population. To put this in graphic terms, an American living with schizophrenia has a life expectancy that barely approaches that of an adult in Bangladesh. To be clear, this amounts to a crisis and national disgrace that BOTH the public health AND public mental health systems must come to grips with. The causes of these higher rates of medical comorbidities among non-elderly adults with SMI are varied and complicated. Significantly higher rates of tobacco consumption are documented in this population. Likewise, incidence of co-occurring substance abuse are not uncommon among adults with SMI. There is emerging evidence that poor diet and sedentary lifestyle are also major contributors among those individuals living on disability benefits (Supplemental Security Income and Social Security Disability Insurance) that for many amount to a sub-poverty monthly income. For many individuals living with mental illness the side effects associated with the psychotropic.
Support. Support.
Cervical Cancer Screening for Women with Schizophrenia
Wake Forest University School of Medicine Support with modification. This metric should not be a review criterion for the performance of a treating psychiatrist for a person with schizophrenia. it does not fit with the boundaries of the psychiatrists competence. Concern that the measure asks psychiatrists to perform a cervical cancer screening, because the screening does not fall within the boundaries of a psychiatrist's expertise. Clarify that the measure does not ask a psychiatrist to perform cervical cancer screening. The measure asks the entity being measured to identify patients with a schizophrenia diagnosis that had a cervical cancer screening.
Wake Forest Baptist Health (WFBH) Do NOT Support. I believe this is the responsibility of the PCP. Concern that the measure asks psychiatrists to perform a cervical cancer screening, because the screening does not fall within the boundaries of a psychiatrist's expertise. Clarify that the measure does not ask a psychiatrist to perform cervical cancer screening, but asks the entity being measured to identify patients with a schizophrenia diagnosis that had a cervical cancer screening.
WFBH Do NOT Support. Do NOT Support. Do NOT Support. Do NOT Support.
Wake Health Support with modification. How can a psychiatrist manage cervical cancer screening? Concern that the measure asks psychiatrists to perform a cervical cancer screening, because the screening does not fall within the boundaries of a psychiatrist's expertise. Clarify that the measure does not ask a psychiatrist to perform cervical cancer screening. The measure asks the entity being measured to identify patients with a schizophrenia diagnosis that had a cervical cancer screening.
University of Nevada School of Medicine Do NOT Support. A treating psychiatrist cannot control whether a female patient goes to a gynecologist to have Cervical Cancer Screening and cannot do exam himself. He can only refer, so this should not be a quality measure. Concern that the measure asks psychiatrists to perform a cervical cancer screening, because the screening does not fall within the boundaries of a psychiatrist's expertise. Clarify that the measure does not ask a psychiatrist to perform cervical cancer screening. The measure asks the entity being measured to identify patients with a schizophrenia diagnosis that had a cervical cancer screening.
Kaiser Health Plan Do NOT Support. Relevance: We feel this may be redundant to existing measures. Although an appreciation that this issue is often overlooked in women with schizophrenia, We have some concerns about the alignment of this with evidence.

Usefulness: We have concerns about how this measure would interface with the existing HEDIS measures for cervical cancer screening. Would these patients be in both denominators?

Collection: This data could be collected via claims.

  1. Concern about how the measure aligns with the existing HEDIS cervical cancer screening measure. The proposed measure just focuses on the members with schizophrenia, who are likely already in the HEDIS measure.
  2. Concern that the proposed measure does not align with current evidence.
  1. This measure is not designed for HEDIS. It is a separate measure for which states will collect data.
  2. NCQA and Mathematica will review and discuss the evidence base for the proposed measure.
OptumHealth Behavioral Solutions Support with modification.
  1. Denominators for this measure will be extremely small, due to small plan size and the low prevalence of the diagnosis, along with the focus on females, making the results difficult to interpret. In order to maximize the denominator, we recommend decreasing the eligible age to 21 years old. Also, this population switches plans often, so a continuous enrollment requirement of 1 year with only a 45 day gap will eliminate many members. We suggest allowing up to 2 non-consecutive 1-month gaps.
  2. Table B. Is this table necessary--we recommend that you remove it? If it remains, it needs to be modified. It includes codes for ophthalmological services, but does not include HCPCS codes which are often used for this population and mandated by states (e.g., T1015 for medication management). We also recommend inclusion of telehealth codes (e.g., Q3014).
  3. Please clarify the age range. It says 22-65 in the description but 25-65 in the eligible population section.
  4. Remove the inclusion of women who had a Pap test during the 2 years prior to the measurement year. It will be unusual in some markets to have 2 years of claims prior to the measurement period and the goal is to encourage annual Pap tests.
  1. Concern about small numbers for the denominator and recommend decreasing the eligible age to 21 years old.
  2. Concern that continuous enrollment of year with only 1 gap will eliminate many members, and recommend 2 non-consecutive 1-month gaps.
  3. Consider removing or revisiting Table B (Codes to Identify Visit Type).
  4. Clarify age range.
  5. Consider changing the numerator to women who had a Pap test in the measurement year only, because some markets will not have 2 years of claims, and the goal is to encourage annual Pap tests.
  1. Review the MAX data to look at potential small numbers problems.
  2. Review the MAX data to look at continuous enrollment.
  3. Discuss the table's usefulness in the measure.
  4. Does the age range specificationsmake sense? They are consistent with the current HEDIS measure logic.
  5. The 2 years look-back period is optional. Review evidence to see if guidelines recommend annual Pap tests.
APA Support. We support this measure, but suggest that the measure include justification and a description of the gap in care within the specifications. There are many general medical screenings that could have been included in this measure set (e.g., colonoscopy), so the rationale as to why this screening was singled out would be useful. Consider including the measure justification and a description of how this measure addressed the gap in care within the specifications. The specifications are not designed to include the measure rationale. NCQA and Mathematica will consider publishing the measure workups with the specifications.
NAMI Support.
  1. Measure Relevance: NAMI applauds inclusion of this measure. As with the measures for cardiovascular disease and diabetes mentioned above, the current state of basic health and wellness screening such as that for cervical cancer for women living with schizophrenia is abysmal. Measure usefulness for improving quality of care for Medicaid recipients with schizophrenia. In NAMI's view, NCQA should move forward on this measure. It will be important given its relevance to any reasonable assessment, and could serve as an accurate and reliable proxy, for assessing how a Medicaid health plan is doing in meeting the basic health care needs of female enrollees with schizophrenia. Feasibility of data collection NAMI would offer caution to NCQA in moving forward on this measure with respect to women living with schizophrenia that have a history of sexual trauma, or for those that experience symptoms of paranoia as part of schizophrenia. It will be incumbent on Medicaid health plans complying with these measures to sensitive to the unique needs of these patients with respect to a procedure such as cervical cancer screening. NAMI recommends that these plans undertake careful beneficiary education about the procedure, its risks and its effectiveness as an evidence prevention and early intervention service.
Concern that cervical cancer screening is a mental health risk for women with a history of sexual trauma or who have paranoia symptoms. If the measure did not exclude members with this history, then it will be incumbent on Medicaid plans to provide better education about the screening prior to the procedure. Discuss with Mathematica how to account for members with a history of sexual trauma and members with paranoia symptoms.
Emergency Department Utilization
Kaiser Health Plan Do NOT Support. Relevance: We have a concern regarding the inclusion criteria; would this include any ED visit or only those for an acute exacerbation of their schizophrenia symptoms?

Usefulness: We do not feel that this measure would not be as useful as the other candidate measures.

Collection: The data could be collected.

  1. Concern that the measure will not be actionable.
  2. Will any ED visit count, or only an ED visit for a schizophrenia symptom?
  1. Will discuss issue with Mathematica.
  2. Any ED visit counts for a person diagnosed with schizophrenia.
OptumHealth Behavioral Solutions Do NOT Support. The ED visits used to identify inclusion in the numerator are not tied to a specific problem or diagnostic code. This measure, therefore, does not reflect the effectiveness of care. Medicaid enrollees with a diagnosis of schizophrenia are at increased risk of living in poverty, having comorbid medical illnesses and not having adequate support or supervision. Assigning a rate to ED utilization may encourage health plans to address an issue that is not an established medical or treatment issue. The unintended consequences of this focus may be squandered resources and even potential restrictions on access to emergency services. Concern that this measure does not have enough focus and will encourage health plans to provide unnecessary treatment that will only increase resource use. For this measure, a lower rate represents better performance. NCQA will clarify that in the specification. NCQA and Mathematica will discuss the level of focus needed in the measure.
APA Do NOT Support. We do not feel we can support this measure without justification and a description of the gap in care included within its specifications. ED admissions unrelated to the diagnosis of schizophrenia should not be counted in the numerator. Concern that this measure does not have enough focus. Will review ED measure definition.
NAMI Support.
  1. Measure Relevance: This measure is extremely important for assessing treatment of schizophrenia. In most communities, hospital EDs have become the frontline for interfacing with untreated mental illness and the principal intervention for acute psychosis. Inclusion of this measure is integral to any assessment of acute care. EDs are the main portal to an inpatient psychiatric bed. Measure usefulness for improving quality of care for Medicaid recipients with schizophrenia. This measure will be extremely important in assisting health plans in assessing the performance of community-based providers in serving plan enrollees with schizophrenia. It is also important that measure not be diluted by removal diagnostic codes unrelated to acute psychosis. In many cases, individuals with schizophrenia present in hospital EDs with a broad range of medical conditions that are directly related to an acute psychiatric episode (i.e., injury sustained as part of a suicide attempt or injury related to co-occurring substance abuse). Feasibility of data collection In NAMI's view, utilization of EDs should be relatively easy for Medicaid health plans to collect and aggregate.
Support. Support.
Follow-Up After Hospitalization for Schizophrenia
BJC HealthCare Support with modification. Specify 7 "calendar" days and 30 "calendar days". Organizations easily move these standards to their business days. The data collected and standard sought should be "a week after discharge" and "a month after discharge" (i.e., calendar days). Clarify that the days are calendar days and not business days. HEDIS measure specifications do not specify calendar days versus business days. All HEDIS measures use calendar days.
NACBHDD Support with modification. Separate acute inpatient care for a mental health reason from other acute inpatient episodes. Otherwise, findings will be ambiguous. Consider separating the measure by the type of acute inpatient event. The measure only looks at acute inpatient episodes for members that had a schizophrenia diagnosis upon discharge.
Kaiser Health Plan Support with modification. Kaiser Permanente has several comments.

Relevance of measure: We agree that this measure is quite relevant. Much of our care is provided via telephone visits, which currently do not count toward meeting this measure. Could telephone visits be included in this measure?

Usefulness: We agree that the measure would be useful in improving quality of care. However, we have concerns on how this proposed measure would interface with the existing HEDIS measures for follow-up after psychiatric hospitalization. Would these patients be in both denominators?

Collection: This data would be difficult to collect for members who have carved out behavioral health coverage.

  1. Consider adding telephone visits to the measure numerator.Concern about how the measure aligns with the existing HEDIS follow-up measure. The proposed measure just focuses on the members with schizophrenia, who are likely already in the HEDIS measure.
  1. NCQA will discuss with Mathematica.
  2. This measure is not designed for HEDIS. It is a separate measure for which states will collect data.
American Psychological Association Support. We support the inclusion of a measure of follow-up care by a mental health practitioner after hospitalizations for schizophrenia, as it will help to avoid unnecessary hospital readmissions and promote continuity of care. Support. Support.
OptumHealth Behavioral Solutions Support with modification.
  1. Outpatient follow-up visits should allow for services that are clinically recommended for this population. These include telehealth appointments (Q3014), and clinic based appointments, which are mandated by some states (e.g., T1015 (medication management); T1017, T1017 HK, T1017 HA (case management); and H0032 and H0032 TS (treatment plan and treatment plan review)). In addition, consideration should be given to follow-up visits with PCPs and peer support groups/services, both of which are non-standard services that can be useful in engaging patients in treatment.
  2. This measure is not consistent with the standard FUH measure around how readmissions are handled. This measure requires a readmission with a schizophrenia diagnosis. It is possible, especially early in the patient's treatment, that a member could be readmitted for another mental illness diagnosis.
  3. Denominators for this measure will be small, due to small plan size and the low prevalence of the diagnosis, making the results difficult to interpret. In order to maximize the denominator, we recommend decreasing the eligible age to 21 years old. Also, this population switches plans often, so a continuous enrollment requirement of one year with only a 45 day gap will eliminate many members. We suggest allowing up to 2 non-consecutive 1-month gaps.
  1. 1.Consider adding telephone visits to the measure numerator.
  2. Consider allowing follow-up with PCPs and peer support groups.
  3. Concern that measure looks at follow-up for only people diagnosed with schizophrenia. For people in the early stages of treatment, it is possible that the follow-up will be listed under another mental health diagnosis.
  4. Concern about small numbers for the denominator and recommend decreasing the eligible age to 21 years old.
  5. Concern that continuous enrollment of year with only 1 gap will eliminate many members, and recommend 2 non-consecutive 1-month gaps.
  1. NCQA will discuss with Mathematica.
  2. NCQA will discuss with Mathematica.
  3. The measure does not specify a schizophrenia diagnosis for the follow-up. It only specified a schizophrenia diagnosis for the denominator (discharge from an acute inpatient setting).
  4. Review the MAX data to look at potential small numbers problems.
  5. Review the MAX data to look at continuous enrollment.
APA Support with modification. The definition of "mental health practitioner" was referenced but not made available for review in the public comment materials. Clarify the definition for mental health practitioner. Include definitions in final specifications.
NAMI Support.
  1. Measure Relevance: NAMI strongly supports inclusion of this measure. Meaningful and timely follow-up care after inpatient care has long been difficult in the treatment of schizophrenia. Despite requirements placed on inpatient settings through accreditation bodies such asJoint Commission on Accreditation of Healthcare OrganizationsandCommission on Accreditation of Rehabilitation Facilitieswith respect to discharge planning, follow-up care often lacks coordination and accountability. Too often, there is little an inpatient provider can do to hold a community-based provider or individual clinician accountable for rendering care or treatment included in a discharge plan. This measure is a tremendous step forward in allowing a Medicaid health plan to hold a range of providers accountable for follow-up care. Measure usefulness for improving quality of care for Medicaid recipients with schizophrenia. This measure will be extremely useful is assessing post-inpatient follow-up care for the BOTH psychiatric and medical treatment. Feasibility of data collection. This measure is extremely useful for assessing post-acute care. NAMI would note that the 7-day and 30-day intervals for follow-up care after an inpatient stay are standard measures that hospitals and data systems routinely use now. Thus, it should relatively easy and efficient for Medicaid health plans to acquire such data from providers. Collection of this data will also allow for comparisons and greater accountability in assessing how follow-up care schizophrenia looks when weighed against follow-up care for other medical conditions. NAMI would also note that this draft measure contains no allowance for a gap in Medicaid health plan enrollment, as there are for the other measures. NAMI recommends that NCQA retain this provision. Finally, NAMI would also urge NCQA to retain to the breadth of this measure as encompassing both inpatient psychiatric care, as well as inpatient medical care for plan enrollees with schizophrenia.
Support. Support.
Use and Continuity of Antipsychotic Medications
New Hampshire DHHS Support with modification. Please modify age--I do not understand why people under 25 years were omitted. Young people with schizophrenia are an extremely high need population and antipsychotic treatment is extremely important for their care. Consider modifying the age limits to include younger people. TAG recommended 25 to ensure stability of diagnosis.
Kaiser Health Plan Support with modification. Kaiser Permanente agrees this measure is relevant and useful in improving the quality of care for this population. We have a concern that information about prescriptions filled in owned and contracted pharmacies could not be collected. Concern that some prescription data will not be captured. NCQA will share this thought with Mathematica.
National Council for Community Behavioral Healthcare Support with modification. Would suggest that you include all antipsychotic medications to the list regardless of delivery mechanism, inclusive of long-acting injection medications. Consider being more comprehensive with the antipsychotic medication list by including long action and injectable medications. The measure is intended to include injectables as part of the definition of antipsychotic medication. Will verify that list includes them.
Johnson & Johnson Health Care Systems Support with modification. The candidate measure "Use & Continuity of Antipsychotic medications" utilizes the "proportion of days covered" (PDC) calculation to derive the measure, which we understand would exclude LAI medications. The resulting measurement would not incorporate an important treatment choice that physicians often choose for patients that have difficulty staying on their medication. We believe this would compromise the actual measure objective, namely improved adherence. It is important to note that the utilization of LAIs, which can provide medication "on board" for patients up to one month, has increased over the last few years. That trend is expected to continue as newer LAIs enter the marketplace. Johnson & Johnson Health Care Systems, Inc. Consider including LAI medications in the measures. This would require changes to the specifications for Use and Continuity of Antipsychotic medications. The measure is intended to include injectables as part of the definition of antipsychotic medication. Will verify that list includes them.
Mercer University College of Pharmacy and Health Sciences Support with modification. Please consider the inclusion of long-acting injections such as Haldol Decanoate, Invega Sustenna, Prolixin Decanoate and Risperidal Consta. These agents play a vital role on patient adherence. Our society has an unusual position regarding these agents, however, we must realize that patient adherence is a major issue in this population and this type of formulation provides an added option for patient treatment. Consider including LAI medications in the measures. This would require changes to the specifications for Use and Continuity of Antipsychotic medications. The measure is intended to include injectables as part of the definition of antipsychotic medication. Will verify that list includes them.
Valley Mental Heath Support with modification. LAIs are integral in treating this illness and a big part of future medication development. You are missing the boat by not incorporating LAI medicines in your measures Consider including LAI medications in the measures. This would require changes to the specifications for Use and Continuity of Antipsychotic medications. The measure is intended to include injectables as part of the definition of antipsychotic medication. Will verify that list includes them.
OptumHealth Behavioral Solutions Support with modification.
  1. Denominators for this measure will be small, due to small plan size and the low prevalence of the diagnosis, making the results difficult to interpret. In order to maximize the denominator, we recommend decreasing the eligible age to 21 years old. Also, this population switches plans often, so a continuous enrollment requirement of 1 year with only a 45 day gap will eliminate many members. We suggest allowing up to 2 non-consecutive 1-month gaps.
  2. Table B. Is this table necessary--we recommend that you remove it? If it remains, it needs to be modified. It includes codes for ophthalmological services, but does not include HCPCS codes which are often used for this population and mandated by states (e.g., T1015 for medication management). We also recommend inclusion of telehealth codes (e.g., Q3014).
  3. Many of these members receive injectables, but the specifications are silent on how to handle this.
  4. PDC calculation is missing in step 6. 5. September only has 30 days, so index prescribing period needs to be revised.
  1. Concern about small numbers for the denominator and recommend decreasing the eligible age to 21 years old.
  2. Concern that continuous enrollment of year with only 1 gap will eliminate many members, and recommend 2 non-consecutive 1-month gaps.
  3. Consider removing or revisiting Table B (Codes to Identify Visit Type).
  4. Consider including LAI medications in the measures. This would require changes to the specifications for Use and Continuity of Antipsychotic medications.
  5. Consider revised prescribing days for September for PDC calculation
  1. Review the MAX data to look at potential small numbers problems.
  2. Review the MAX data to look at continuous enrollment.
  3. Discuss the table's usefulness in the measure.
  4. NCQA will share this thought with Mathematica.
  5. NCQA will look at this issue.
Mercy Behavioral Health Support with modification. I was concerned that Injectable. Therapy was not considered as a cornerstone to the Continuity piece. This is the most effective way to ensure continuity both in the community and during the transition from hospital to community. I definitely believe that to make recommendations without including all options is misinforming. I am a large user and proponent of long-acting therapies for keeping people healthy and safe in the community. Consider including LAI medications in the measures. This would require changes to the specifications for Use and Continuity of Antipsychotic medications. The measure is intended to include injectables as part of the definition of antipsychotic medication. Will verify that list includes them.
Cerebral Palsy of New Jersey Support with modification. As a behavioral health executive with 35 years of experience managing inner city, comprehensive community mental health centers, I think it is excellent to see "use and continuity of antipsychotic medication" identified as a quality measure. Medication non-adherence puts patients at extreme risk for adverse outcomes and adds millions of dollars to the cost of health care in regards to rapid readmissions. I believe, however, it is crucial that long-acting injections be added to the measure. LAIs offer a superior way of monitoring adherence, offer a superior method of delivering the medication and offer a much less stressful adherence plan for consumers who are easily overwhelmed by trying to adhere to multiple doses of daily oral antipsychotics. I strongly urge the NCQA to include long-acting in this measure. Consider including LAI medications in the measures. This would require changes to the specifications for Use and Continuity of Antipsychotic medications. The measure is intended to include injectables as part of the definition of antipsychotic medication. Will verify that list includes them.
APA Support with modification. The following medications appear to be absent from the table: iloperidone; lurasidone; and asenapine. The following medications are included in the table but are no longer available in the United States: trifluoperazine; mesoridazine; and molindone. When electronic prescribing is more prevalent in the future, we suggest consider differentiating between prescriptions that were not written versus prescriptions which were written but not filled by the patient. Quality improvement approaches will differ depending on which is the cause of lack of medication use or continuity. Consider adding iloperidone; lurasidone; and asenapine to the medication measure. The following medications are included in the table but are no longer available in the United States: trifluoperazine; mesoridazine; and molindone. NCQA and Mathematica will review the list of antipsychotics.
NAMI Support.
  1. Measure Relevance: NAMI strong supports the relevance of this measure. Treatment adherence has always been a major challenge in schizophrenia. The currently available medications to treat schizophrenia each vary significantly in terms of how they address the complex symptoms of the disorder--from the positive symptoms such as delusional thinking, paranoia and auditory hallucinations, to the negative symptoms such as social withdrawal, flat mood and isolation. In addition, each of the currently available compounds has unique side effect profiles that can vary significantly among individual patients. In some instances, the more effective a medication is controlling symptoms and improving functioning, the more likely individual patients are to stop taking their medication. Finally, one of the very symptoms of schizophrenia is a condition known as "anosognosia" or lack of insight into delusional thinking or paranoia. This condition inevitably results in lack of treatment adherence in many consumers. It is critical that this assessment of treatment adherence be included in these proposed measures. Measure usefulness for improving quality of care for Medicaid recipients with schizophrenia. In NAMI's view, both the proposed "use" measure and the "continuity" measure are integral to helping meet the goal of improving quality. Feasibility of data collection NAMI strongly supports the proposed 6-step process set forth in the measure for identifying the numerator compliance. NAMI would urge NCQA not to retreat from the 80% minimum standard for the intake period included in the measure. At the same time, NAMI would urge NCQA to expand the list of compounds included in Table C of the draft measures. It is critical that this list be as inclusive as possible. First, the list should be expanded to include alternative delivery technologies available for existing compounds such as long-acting
Support. Support.
Inclusion of Bipolar Disorder in the Denominator
BJC HealthCare Do NOT Support. No. People with Bipolar Disorder are treated with a number of medications in addition to the antipsychotics. Those other medications can contribute to weight gain, and thus affect risk factors for heart disease, weight and diabetes. Therefore including bipolar in the denominator confounds the data unless all those medications which have weight gain as a side effect are included (i.e., several of the anti-depressants and mood stabilizers; e.g., trazadone, lithium, etc.) Concern that including bipolar disorder will confound the data due to medication differences. NCQA will pass share this thought with Mathematica.
NACBHDD Support with modification. Run 2 separate analyses for schizophrenia and bipolar. Otherwise results will be ambiguous. Concern that the results of the data will be ambiguous. NCQA will share this thought with Mathematica.
University of Nevada School of Medicine Do NOT Support. Bipolar disorder does not always require treatment with an antipsychotic (e.g., when patient is on Depakote or Lithium and the bipolar disorder is in remission). Sometimes it is contraindicated. Thus bipolar disorder should not be included in the numerator or denominator. Concern that including bipolar disorder will confound the data due to medication differences. NCQA will share this thought with Mathematica.
Kaiser Health Plan Support with modification. Please consider making this based upon the use of medications known to increase risk of diabetes and dyslipidemia, rather than limit this to those with a specific diagnosis and medication. Consider changing the measure focus away from a specific diagnosis to a focus on medications known to increase the risk of diabetes and dyslipidemia. The measures are intended to focus on people with schizophrenia.
National Council for Community Behavioral Healthcare Support. Support. Support. Support.
American Psychological Association Support. We support the proposed expansion of measure denominators to include Medicaid beneficiaries with bipolar disorder in order to increase screening and monitoring of cardiovascular health and diabetes. Support. Support.
Bristol-Myers Squibb Company Support. I would like to indicate support for the expansion of the denominator beyond schizophrenia to include patients with bipolar disorder for the following reasons: Patients with bipolar disorder typically suffer from a high burden of comorbid medical problems, including metabolic issues. Bipolar patients are often overweight and likely to meet criteria for "metabolic syndrome", placing them at increased risk of developing cardiovascular disease, stroke and Type 2 diabetes. Moreover, several medications used to treat bipolar disorder pose hazards for increasing body weight and worsening metabolic parameters. Given that obesity and illness of the endocrine/metabolic system have been correlated with poorer outcomes, the appropriate monitoring of metabolic health remains critical for this patient group. Consider adding bipolar disorder to the measure denominators, because patients with this diagnosis suffer from comorbid medical problems. NCQA will share this thought with Mathematica.
OptumHealth Behavioral Solutions Support. Support. Support. Support.
APA Support. We support the expansion of the cardiovascular screening and monitoring measures to the diagnosis of bipolar disorder, and suggest that these measures be considered for expansion to all patients treated with atypical antipsychotic medications, regardless of diagnosis, given the increased risk of cardiovascular illness. Consider expanding the cardiovascular measures to anyone treated with atypical antipsychotic medications, regardless of diagnosis. Discuss recommendation with Mathematica.
NAMI Support. NAMI strongly endorses extension of these measures to bipolar disorder in the denominator. As with schizophrenia, bipolar disorder is a complex mental disorder with multiple phases and a diverse pathology of symptoms--mania, extreme mood swings, depression, anxiety, mixed state and, in some instances, psychotic features. Treatment for bipolar disorder is often complex and can involve prescribing of multiple compounds. As with schizophrenia, treatment adherence is often challenging for many individuals living with bipolar disorder. In fact, a number of the existing atypical antipsychotic compounds listed in the draft adherence measure are approved by the Food and Drug Administration for treatment of bipolar disorder (e.g., mood stabilizing agents). Likewise, persons with bipolar disorder experience many of the complex medical comorbidities (including cardiovascular disease, diabetes and cervical cancer) of individuals living with schizophrenia. In addition, they have nearly identical needs with respect to follow-up care after a hospital admission. Finally, they also utilize EDs for a diverse array of needs that often associated with failure to access treatment. For these reasons, NAMI urges that NCQA extend all 6 measures for schizophrenia to bipolar disorder. Support. NCQA will share these thoughts with Mathematica.

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