Medication management (MM) is proving to be a viable tool for improving medication related quality metrics. More and more, managed care organizations are exploring collaborations between quality and pharmacy staff to improve quality metrics. Pharmacists engaged in MM can do “double duty” to improve key care quality metrics. An added benefit of an MM program is that it provides a ready laboratory for assessing the status of proposed and display measures in a population.
Late in 2015 CMS released a request for comment entitled: Request for Comments: Enhancements to the Star Ratings for 2017 and Beyond. While the request outlined CMS’s plans for all STAR measures, the medication related measures are of particular importance to the MM community. Here is a quick review of CMS’s plans for medication related STAR measures.
What to look for in 2017
- High Risk Medication Targeted for Removal from STARS
The High Risk Medication (HRM) measure calculates the percent of Medicare Part D beneficiaries 65 and older who received two or more prescription fills for the same HRM drug with a high risk of serious side effects in the elderly. The measure is endorsed by the PQA and National Quality Forum (NQF), and the HRM rate is calculated using the PQA specifications and medication list is based on American Geriatrics Society (AGS) recommendations.Recently the AGS released the 2015 update of the Beers Criteria. This update contains a number of drugs in which the decision to avoid or discontinue the medication requires clinical information that would not be available in the prescription drug event data. In addition, CMS felt that HRM use is provider controled and should not be affected by non-clinical beneficiary characteristics, and the HRM measure was not included in CMS’ overall analysis to assess the impact of socio-economic status on the Star Ratings (discussed later).
While CMS continues to be concerned with avoiding inappropriate medications in older adults and considers this a marker of care quality for Medicare beneficiaries, the HRM measure will be removed from the Star Ratings and moved to the display measures for 2017. CMS is encouraging the measure developers to review the HRM measure to better understand the need for clinical data and associations with socio-demographic status. If measure updates are endorsed by the PQA with sufficient lead time CMS may consider adoption for the 2019 display page (using 2017 data).
- Impact of ICD-10 adoption
Measure stewards (PQA and NCQA), are in the process of reviewing measure specifications which required diagnosis information in order to transition from ICD-9 to ICD-10. Once the measure specifications have been updated the changes will be tested and adopted for the Part D Star Ratings and display measures. NCQA has already incorporated the ICD-10 codes in the 2016 Healthcare Effectiveness Data and Information Set (HEDIS). During the transition period both ICD-9 and ICD-10 codes will be used due to the look-back periods for some measures.
- Medication Therapy Management (MTM) Program Completion Rate for Comprehensive Medication Reviews (CMR) measure
CMS will be adding a detailed file during each HPMS plan preview period to list each contract’s underlying denominator, numerator, and Data Validation score since exclusions are applied to the plan-reported MTM data. Additionally, CMS will be implementing additional data integrity checks to assure that bias is not entering into the data used for the CMR rate. CMS program audits will soon include a review of the MTM program. CMS is particularly concerned that activities biasing CMR results may not be detected by routine Data Validation standards. These include activities to restrict MTM eligibility, encouraging beneficiary opt-outs, or including CMRs that do not meet guidance.CMS also takes care to note that the CMR rate measure is an initial measure of MTM service delivery. They go on to further note that they expect to evaluate and incorporate additional MTM measures which are outcomes based as companion measures to the CMR rate.
- Medication Reconciliation Post Discharge
The Medication Reconciliation Post-Discharge (MRP) measure assesses the percentage of discharges from acute or non-acute inpatient facilities for members 66 years of age and older for whom medications were reconciled within 30 days of discharge.NCQA made two changes: 1) expanded the coverage on this measure from Medicare Special Needs Plans only to all of MA, and 2) expanded the age range to members 18 years and older. Both of these changes for HEDIS 2016 are seen as an important step to measure the quality of care coordination post-discharge for MA beneficiaries as well as ensuring patient safety. CMS is planning to include this measure on the 2017 display page and then include it in the 2018 Star Ratings.
- Statin Measures
NCQA has added two sets of statin therapy measures to HEDIS to align with the 2013 ACC/AHA blood cholesterol guidelines. These measures are focused on two of the major statin benefit groups described in the guidelines: patients with atherosclerotic cardiovascular disease (ASCVD) and patients with diabetes.Since some of these HEDIS measures overlap with the measures developed by the PQA, CMS is planning to include only the Statin Therapy for Patients with ASCVD measure on the 2017 display page and then include it in the 2018 STAR Ratings. Specifically, this measure focuses on males 21 to 75 and females 40 to 75 years of age who were identified as having clinical ASCVD and were dispensed at least one high or moderate-intensity statin medication during the measurement year.
The Statin Use in Persons with Diabetes, calculates the percentage of patients between 40 and 75 years old who received at least two diabetes medication fills and also received a statin medication during the measurement period (excluding members enrolled in hospice). CMS is recommending adding this to the SUPD 2017 display page (using 2015 data), and to the 2018 SUPD Star Ratings (using 2016 data).
- Asthma Measures
NCQA has expanded their asthma measures to include older adults. HEDIS 2016 includes two measures for older adults: 1) Medication Management for People with Asthma (the percentage of members 5 to 85 years of age who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period (i.e., first prescription date through end of measurement year)) and 2) The Asthma Medication Ratio (the percentage of members who were identified as having persistent asthma and had a ratio of controller medications to total asthma medications of 0.50 or greater during the measurement year). CMS is planning to include these both on the 2017 display page, but does not have a specific time frame for elevating them for inclusion in STAR Ratings.
Post 2018 measure sophistication will be increasing. Depression will requiring the use of patient self reported symptom scores which must be collected at appropriate intervals. The management of opioid over-utilization will have it’s own set of measures which will eventually morph into a set of measures assessing optimal pain management, and anti-psychotic use will begin to be studied.
- Depression Measures
NCQA has adapted a provider-level depression outcome measure developed by Minnesota Community Measurement for use in HEDIS. Depression Remission or Response in Adolescents and Adults (DRR) uses a patient-reported outcome measure, the PHQ-9 tool, to assess whether patients with depression have achieved remission or have an improvement in their symptoms. The measure assesses the percentage of individuals age 12 and older with depression and an elevated PHQ-9 score (greater than 9) who achieve a PHQ-9 score of less than 5 at six months or have a 50% reduction in their PHQ-9 score. This measure also uses a new data collection methodology for HEDIS, relying on data coming from electronic clinical data systems (e.g., EHRs, clinical registries, case management records). If approved, the new measure would be published in HEDIS 2017.
- Use of Opioids from Multiple Providers or at High Dosage in Persons without Cancer
In the 2016 Call Letter, CMS noted that three opioid overutilization measures were in development by the PQA. CMS further stated that if these measures were endorsed by the PQA prior to the 2017 bid deadline in June 2016 that they may be adopted as future display measures or alternatively be used in the Overutilization Monitoring System (OMS). The measures were endorsed by the PQA in May 2015.PQA’s three opioid measures examine multi-provider, high dosage opioid use among individuals 18 years and older without cancer and not in hospice care.
Measure 1 (Opioid High Dosage): The proportion of individuals receiving prescriptions for opioids with a daily dosage greater than 120mg morphine equivalent dose for 90 consecutive days or longer.
Measure 2 (Multiple Prescribers and Multiple Pharmacies): The proportion of individuals receiving prescriptions for opioids from four (4) or more prescribers AND four (4) or more pharmacies.
Measure 3 (Multi-Provider, High Dosage): The proportion of individuals receiving prescriptions for opioids with a daily dosage greater than 120mg morphine equivalent dose (MED) for 90 consecutive days or longer, AND who received opioid prescriptions from four (4) or more prescribers AND four (4) or more pharmacies.
These measures have been tested using the PQA specifications, and CMS will be developing new opioid over-utilization measure reports (beginning with 2016 dates of service) to provide to Part D sponsors on a monthly basis through the Patient Safety Analysis website, similar to the other patient safety measures. The website also includes the OMS. The reports will allow sponsors to track their performance over time and allow for contract level trending and outlier analyses. These three measures will also be added the 2018 Part D display page (using 2016 data). However, CMS is not recommending the addition of these measures to the Star Ratings at this time due to concerns 1) about the current lack of clinical guidelines regarding the use of opioids to treat chronic, non-cancer pain and 2) pending additional analysis on diagnosis data sources, such as newly available encounter data for Medicare Part C and resolving timing issues of RAPS file updates, which are used to identify exclusions for certain cancer conditions. As an aside NCQA is adapting the three opioid overuse measures developed by the PQA for potential use in HEDIS.
- Appropriate Pain Management
NCQA is exploring opportunities to develop a new measure(s) focusing on appropriate pain management. The intent is to assess the quality of pain management and treatment. There is no definite timeline established for the development of this measure.
- Antipsychotic Use in Persons with Dementia
CMS has been particularly concerned with the unnecessary use of antipsychotic drugs in nursing homes and, as a result, has pursued strategies to increase awareness of antipsychotic use in long term care settings. In addition, the GAO released a report in January 2015 describing the inappropriate use of antipsychotics in Part D beneficiaries with dementia (http://www.gao.gov/products/GAO-15-211)The PQA has endorsed the measure, Antipsychotic Use in Persons with Dementia (APD). CMS tested this measure based on the PQA specifications for all contracts, MA-PDs, PDPs, and at the individual contract-level for all beneficiaries, community-only residents, and both short-term and long-term nursing home residents and results indicate that the measure is reliable.
CMS intends to develop new patient safety APD measure reports to provide to Part D sponsors on a monthly basis through the Patient Safety Analysis website beginning with year of service 2016. They are also recommending the addition of the overall APD measure plus breakout rates for community-only residents, short-term nursing home residents, and long-term nursing home stay residents to the 2018 Part D display measure set (using 2016 data). Eventually CMS plans to replace the Rate of Chronic Use of Atypical Antipsychotics by Elderly Beneficiaries in Nursing Homes display measure with the new APD measure. However, they are not yet recommending adding the APD measure to the Star Ratings pending the resolution of operational issues.
I would be happy to discuss any of these thoughts in greater detail. Feel free to reach out by phone or e-mail.
James Notaro, RPh, PhD