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Changes to Provider Quality Reports

November 6 Update: The Body Mass Index Measure in the last chart below should have been weighted a "1." The chart has been corrected.

Before the end of the year, you’ll notice several changes to provider quality reports. While some of these changes reflect annual Healthcare Effectiveness Data and Information Set (HEDIS) and Centers for Medicare and Medicaid Services (CMS) updates, others make the reports more meaningful for your practice.

Annual Quality Benchmark Updates

Each year, CMS and the National Committee for Quality Assurance (NCQA) publish updated quality benchmarks. Provider quality reports use these benchmarks to calculate your performance for each measure compared to the 5 Star Cut Point (in percentage) for Medicare, and the national 90th percentile for non-Medicare reporting. These benchmarks remain in effect until the next annual update.

New Quality Measures

Measure Name

Description

Adolescent Well-Care Visit (AWC)

Percentage of enrolled members, 12 – 21 years of age, who had at least one comprehensive well care visit with a primary care provider (PCP) or an OB/GYN practitioner during the measurement year

Asthma Medication Ratio (AMR)

Percentage of members, 5 – 85 years of age, identified as:

  • Having persistent asthma
  • AND a ratio of controller medications to total asthma medications of 0.50 or greater during the measurement year

Statin Therapy for Patients with Cardiovascular Disease (SPC)

Percentage of males, 21 – 75 years of age, and females, 40 – 75 years of age, identified as having clinical atherosclerotic cardiovascular disease (ASCVD) and meeting the following criteria:

  • Received statin therapy – members who were dispensed at least one high or moderate-intensity station medication during the measurement year
  • Statin adherence 80% - members who remained on a high or moderate-intensity statin medication for at least 80% of the treatment period

Statin Therapy for Patients with Diabetes (SPD)

Percentage of members, 40 – 75 years of age, with diabetes who do not have ASCVD and met the following criteria:

  • Received statin therapy – members who were dispensed at least one statin medication of any intensity during the measurement year
  • Statin adherence 80% - members who remained on a statin medication of any intensity for at least 80% of the treatment period

Statin Use in Persons with Diabetes (SUPD)

Percentage of Medicare members, ages 40 – 75, with diabetes who received at least one fill of a statin medication in the measurement year

Well-Child Visits in the First 15 Months of Life (W15)

Percentage of members who turned 15 months old during the measurement year, and had six or more well-child visits with a PCP during their first 15 months of life.

Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life (W34)

Percentage of members, 3 – 6 years of age, who had one or more well-child visits with a PCP during the measurement year.


Changes in Priority Measures

Priority measures have been identified for Medicare, adult (internal medicine), family practice, and pediatric members. You will see metrics showing closed gaps, impending gaps, persistent gaps, and total member attribution, as well as a trending report including the current and previous month, and the Medicare 5 Star Cut Points or the national 90th percentile for each measure (depending on population).

Priority measures for the upcoming year are:

Medicare Measures

  • Medication Adherence for Diabetes Meds
  • Medication Adherence for Hypertension/RAS
  • Medication Adherence for Statins
  • Diabetes HbA1c Poor Control >9%*
  • Adult BMI Assessment
  • Diabetes Care Kidney Disease
  • Rheumatoid Arthritis Therapy
  • Breast Cancer Screening
  • Colorectal Cancer Screening
  • Diabetes Eye exam 

*Diabetes HbA1c Poor control >9% is displayed as an inverted measure. Numerator will be defined as good control less than or equal to 9.0%

Pediatric Measures

  • Follow-Up for Children Prescribed ADHD Medication – Initiation Phase
  • Follow-Up for Children Prescribed ADHD Medication – Maintenance Phase
  • Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents – Nutrition Total
  • Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents – BMI Percentile Total
  • Appropriate Treatment for Children with Upper Respiratory Infection
  • Chlamydia Testing in Women – ages 16-20
  • Well-Child Visits in the First 15 Months of Life – Six or more visits
  • Well-Child Visits in Third, Fourth, Fifth, and Sixth Years of Life
  • Adolescent Well Care 

Adult Measures

  • Breast Cancer Screening
  • Diabetes HbA1c Control <8%
  • Colorectal Cancer Screening
  • Cervical Cancer Screening
  • Medication Management for People with Asthma – 75% rate
  • Pharmacotherapy Management of COPD Exacerbation – Bronchodilator
  • Persistence of Beta Blocker Treatment after a Heart Attack
  • Statin Use in Patients with Cardiovascular Disease – Received Statin Therapy
  • Statin Use in Patients with Diabetes – Received Statin Therapy
  • Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis 

Family Practice Measures

  • Breast Cancer Screening
  • Diabetes HbA1c Control <8%
  • Colorectal Cancer Screening
  • Cervical Cancer Screening
  • Postpartum Care
  • Prenatal Care
  • Statin Use in Patients with Cardiovascular Disease – Received Statin Therapy
  • Statin Use in Patients with Diabetes – Received Statin Therapy
  • Follow Up for Children Prescribed ADHD Medication – Initiation Phase
  • Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

The following two changes affect ONLY ACO and large group reports: 

  • A change in the methodology for calculation of the Medicare Stars score
    The overall Star rating shown in a box near the upper left corner of your summary report is calculated on 11 measures based on CMS weight Previously, High Risk Medication was included in this calculation. High Risk Medication has been changed to a display measure for 2018, and will no longer be included in this calculation.

 

Measure

Weight

Breast cancer screening

1

Body mass index (BMI)

1

Rheumatoid arthritis measure (ART)

1

Diabetes HbA1c poor control

3

Diabetes – eye exam

1

Diabetes care kidney disease

1

Colorectal cancer screening

1

Osteoporosis management in women who had a fracture

1

Medication adherence for statins (Part D)

3

Medication adherence for hypertension/RAS (Part D)

3

Medication adherence for diabetes meds

3

  • Commercial summary score
    A summary score will be added to non-Medicare reports. The score will be shown in a box that mirrors the same formatting of the Star Ratings box on Medicare reports. This score is calculated using the average measures compared to national percentile. Calculations are limited to measures with denominators greater than or equal to 30. All measures will be weighted a “1.”