May 23, 2018
TO: Interdepartmental Serious Mental Illness Coordinating Committee
FROM: National Committee for Quality Assurance
DATE: May 23, 2018
RE: Opportunities for Quality Measurement in SMI/SED
Thank you for the opportunity to provide comments on ways to improve care for adults with serious mental illness (SMI) and youth with serious emotional disturbances (SED). Improving care for these populations is a high priority for the National Committee for Quality Assurance (NCQA).
Although quality measurement has been critical for improving care for chronic conditions such as diabetes and cardiovascular disease, evidence shows that quality measurement for behavioral healthcare lags behind physical health measures and shows less improvement over time. Challenges to measuring the quality of behavioral healthcare include lack of standardization in treatment protocols, limited standardized data sources to capture outcomes and lack of linked electronic health information.
The Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC) aims to increase federal coordination in using data to improve quality of care and outcomes, ensuring that quality measurement efforts include mental health. ISMICC can rapidly advance its goal by using NCQA’s proven strategies.
Proven NCQA measurement strategy
NCQA has developed behavioral health measures for the SMI/SED populations that address medication adherence, follow-up care after hospitalization and emergency room visit, diabetes and cardiovascular screening, monitoring and outcomes (Appendix A). Some of these measures are in the Healthcare Effectiveness Data and Information Set (HEDIS®[1]) for reporting by health plans to NCQA. HEDIS is the industry standard for measuring health plan performance required by federal, state and private purchasers. Other measures are in Medicaid Core Set and Certified Community Behavioral Health Clinics demonstration program for reporting by states and providers. The consistent use of measures by federal agencies, states, health plans and providers in national reporting programs and value-based payment models increases shared accountability and quality improvement efforts.
NCQA further pursues a measurement strategy focused on high-need, high-cost populations such as individuals with SMI/SED and substance abuse. We seek opportunities to expand SMI/SED measures to develop a package of tools or modules that allow payers to require (and organizations to demonstrate) high-quality care for specific populations, including SMI/SED and substance abuse. These specialized measurement modules could help ISMICC, federal agencies, states and consumers clearly identify high-quality providers.
Demonstrated roadmap for delivery system transformation
The delivery system for specialty SMI/SED services is complex and fluctuating. Recent legislation has offered opportunities for states to make changes in public sector delivery systems. Many states have been using Medicaid 1115 waivers to improve payment and redesign delivery systems. Some have exercised a limited-time opportunity, provided in the Affordable Care Act, to get a higher Medicaid match for “behavioral health homes.” In January 2017, CMS selected eight states to participate in a two-year demonstration program for Certified Community Behavioral Health Clinics to provide comprehensive, integrated behavioral health and primary care services.
Successful delivery system transformation requires proven roadmaps in provider capacity development. NCQA implements a behavioral health integration distinction program to recognize primary care practices that have structure, processes and teams in place to address the needs (screening, brief counseling, medication management, care planning) of patients with behavioral health conditions. NCQA explores opportunities to develop roadmaps for providers across the care continuum, to build competencies for providing high-quality care for the SMI/SED and substance abuse populations.
Move toward patient-reported outcomes
NCQA envisions providers using patient- and family-reported data on key outcomes to support clinical care, patient engagement, care monitoring and quality improvement, and to allow quality reporting. Symptoms, functioning, employment, housing and criminal justice involvement are important outcomes for the behavioral health population, yet outcome data are not routinely documented and are fragmented across service sectors. By working together, health care, public and social service sectors, providers and registry and EHR vendors can advance the capability to track patient-reported outcomes.
NCQA’s work, especially concerning the provider-capacity requirement on monitoring patient recovery and outcomes, will help provider organizations establish and use health information systems (e.g., registries, EHRs) to capture patient-reported outcomes. NCQA is working on several measure development projects that use alternative tools to capture patient-reported data and that will inform future patient-reported outcome measurement.
In summary, concerted quality improvement efforts begin by aligning measurement. The consistent use of standardized quality measurement across service sectors and care settings increases shared accountability of all federal agencies, as well as joint efforts between public and private sectors.
Thank you again for the opportunity to share our thoughts on this critical issue. If you have questions, please contact Paul Cotton, Director of Federal Affairs, at 202-955-5162 or at cotton@ncqa.org, or Junqing Liu, Research Scientist, at 202-955-3546 or at liu@ncqa.org.
| Measure | Data Source | Denominator | Numerator | Included in HEDIS? |
| Diabetes screening for people with schizophrenia or bipolar disorder who are using antipsychotic medications | Claims | Members 18–64 years of age with schizophrenia or bipolar disorder and dispensed an antipsychotic medication. | Members who had a glucose test or HbA1c test during the measurement year. | Yes |
| Diabetes monitoring for people with diabetes and schizophrenia | Claims | Members 18–64 years of age with schizophrenia and diabetes. | Members who had an HbA1c test and an LDL-C during the measurement year. | Yes |
| Cardiovascular monitoring for people with diabetes and schizophrenia | Claims | Members 18–64 years of age with schizophrenia and cardiovascular disease. | Members who had an LDL-C test performed during the measurement year. | Yes |
| Adherence to antipsychotic medications for individuals with schizophrenia | Claims | Members 19–64 years of age with schizophrenia and who were dispensed antipsychotic medications. | Members who achieved a proportion of days covered of at least 80% for their antipsychotic medications. | Yes |
| Metabolic monitoring for children and adolescents on antipsychotics | Claims | Members 1–17 years of age who had two or more antipsychotic prescriptions. | Members who had both of the following during the measurement year. · At least one test for blood glucose or HbA1c. · At least one test for LDL-C or cholesterol. | Yes |
| Alcohol Screening and Follow-up for People with Serious Mental Illness (SMI) | Claims | Members 18 years of age and older with at least one inpatient visit or two outpatient visits for schizophrenia or bipolar I disorder, or at least one inpatient visit for major depression during the measurement year. | Members who were screened for unhealthy alcohol use and received two events of counseling if identified as an unhealthy alcohol user. | No |
| Tobacco Use Screening and Follow-up for People with Serious Mental Illness or Alcohol and Other Drug Dependence | Claims | · SMI: Members 18 years of age and older with at least one inpatient visit or two outpatient visits for schizophrenia or bipolar I disorder, or at least one inpatient visit for major depression during the measurement year. · AOD: All members 18 years of age or older as of December 31 of the measurement year with any diagnosis of alcohol or other drug dependence during the measurement year. | · SMI: Members who were screened for tobacco use and received follow-up care if identified as a current tobacco user. · AOD: Members who were screened for tobacco use and received follow-up care if identified as a current tobacco user. | No |
| Body Mass Index Screening and Follow-up for People with Serious Mental Illness | Claims | Members 18 years of age and older with at least one inpatient visit or two outpatient visits for schizophrenia or bipolar I disorder, or at least one inpatient visit for major depression during the measurement year. | Members who had calculated body mass index documented and were provided two events of follow-up care if body mass index was greater than or equal to 30 kg/m2. Follow-up includes: · Two events of counseling, on different dates, for weight management (such as nutrition or exercise counseling) or · One event of counseling and one fill of medication (Orlistat) for weight management. | No |
| Controlling High Blood Pressure for People with Serious Mental Illness | Claims | Members 18–85 years of age with at least one acute inpatient visit or two outpatient visits for schizophrenia or bipolar I disorder, or at least one inpatient visit for major depression during the measurement year AND a diagnosis of hypertension. | Members whose most recent blood pressure (BP) was adequately controlled (after the diagnosis of hypertension) based on the following criteria: · Members 18–59 years of age whose BP was <140/90 mm Hg. · Members 60–85 years of age and flagged with a diagnosis of diabetes whose BP was <140/90 mm Hg. · Members 60–-85 years of age and flagged as not having a diagnosis of diabetes whose BP was <150/90 mm Hg. | No |
| Comprehensive Diabetes Care for People with Serious Mental Illness: Hemoglobin A1c (HbA1c) Testing | Claims | Members 18–75 years of age with at least one acute inpatient visit or two outpatient visits for schizophrenia or bipolar I disorder, or at least one inpatient visit for major depression during the measurement year AND diabetes (type 1 and type 2). | Members who had an HbA1c test performed. | No |
| Comprehensive Diabetes Care for People with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) | Claims | Members 18–75 years of age with at least one acute inpatient visit or two outpatient visits for schizophrenia or bipolar I disorder, or at least one inpatient visit for major depression during the measurement year AND diabetes (type 1 and type 2). | Members whose most recent HbA1c level was greater than 9.0% or was missing a result, or for whom an HbA1c test was not done. | No |
| Comprehensive Diabetes Care for People with Serious Mental Illness: Medical Attention to Nephropathy | Claims | Members 18–75 years of age with at least one acute inpatient visit or two outpatient visits for schizophrenia or bipolar I disorder, or at least one inpatient visit for major depression during the measurement year AND diabetes (type 1 and type 2). | Members who received a nephropathy screening test or had evidence of nephropathy. | No |
| Comprehensive Diabetes Care for People with Serious Mental Illness: Blood Pressure Control (<140/90 mm Hg) | Claims | Members 18–75 years of age with at least one acute inpatient visit or two outpatient visits for schizophrenia or bipolar I disorder, or at least one inpatient visit for major depression during the measurement year AND diabetes (type 1 and type 2). | Members whose most recent blood pressure screening result was <140/90mm Hg. | No |
| Comprehensive Diabetes Care for People with Serious Mental Illness: Hemoglobin A1c (HbA1c) Control (<8.0%) | Claims | Members 18–75 years of age with at least one acute inpatient visit or two outpatient visits for schizophrenia or bipolar I disorder, or at least one inpatient visit for major depression during the measurement year AND diabetes (type 1 and type 2). | Members whose most recent HbA1c level was less than 8.0%. | No |
| Comprehensive Diabetes Care for People with Serious Mental Illness: Eye Exam | Claims | Members 18–75 years of age with at least one acute inpatient visit or two outpatient visits for schizophrenia or bipolar I disorder, or at least one inpatient visit for major depression during the measurement year AND diabetes (type 1 and type 2). | Members who received an eye exam. | No |
[1]HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).