Quality Metrics Tool

Review Healthcare Effectiveness Data and Information Set (HEDIS), National Quality Forum (NQF) endorsed, and Centers for Medicare & Medicaid Services (CMS) Five-Star measures for bipolar disorder all in one easy-to-use tool.

A number of quality metrics focused on behavioral health care have been developed by various national organizations. The measures created by these health care quality entities focus on different aspects of population health management and vary in scope from process-related to clinically-focused metrics, as well as medication adherence and other aspects of health care quality measurement.*

*This tool provides summaries from select, nationally-recognized, quality entities. Note: Other quality organizations may offer additional measures for individuals with bipolar disorder.

Behavioral Health Quality Metrics

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  • About National Committee for Quality Measures (NCQA) HEDIS Measures1

    HEDIS is a standardized set of measures used by more than 90% of United States health plans to measure performance in different areas of care and service.1

    NCQA developed HEDIS as a means to:

    • Provide the managed care industry with a way to compare performance among plans
    • Allow health plans a way to obtain information on specific areas that need improvement
    • Assist consumers in selecting the health plan that best meets their needs


    HEDIS measures are reviewed and updated on an annual basis. As of 2018, HEDIS consists of 94 measures across 7 domains of care that include preventive care services and chronic disease management.1

  • HEDIS Measures Related to Mental Health


    HEDIS measures have focused on mental health since before 2012, including aspects of care coordination, medication management, and overall mental health care utilization. In reports, the NCQA has indicated that behavioral health is a common, but sometimes hidden, driver of health care costs. Treatment can present a quality challenge, such as increased risk for diabetes and other metabolic diseases in individuals who take antipsychotic medications. As such, HEDIS measures related to mental health measures have expanded in recent years.

  • HEDIS Measure for Follow-up After Hospitalization for Mental Illness1,2


    Description: Assesses adults and children 6 years of age and older who were hospitalized for treatment of selected mental health disorders and had an outpatient visit, and intensive outpatient encounter or a partial hospitalization with a mental health practitioner. The measure identifies the percentage of members who received follow-up within 7 days of discharge and within 30 days of discharge.

    • Applicable to:
      • Commercial insurance, Medicaid, and Medicare
      • Covers ages 6 and over
  • HEDIS Measure for Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications1,2


    Description: Assess adults 18 to 64 years of age with schizophrenia or bipolar disorder, who were dispensed an antipsychotic medication and had a diabetes screening test during the measurement year

    • Measure Steward: NCQA
    • Applicable to: Medicaid only
    • Covers ages 18 to 64
  • About NQF-Endorsed Measures3


    NQF endeavors to promote and ensure patient protections and health care quality through measurement and public reporting. The federal government relies on NQF-defined measures or health care practices as the best, evidence-based approaches to improving care. In addition to the federal government, states and private-sector organizations use NQF’s endorsed measures, which must meet thorough criteria, to evaluate performance and share information with patients and their families.3 

  • NQF 1880: Adherence to Mood Stabilizers for Individuals With Bipolar I Disorder4


    Description: Percentage of individuals at least 18 years of age as of the beginning of the measurement period with bipolar I disorder who had at least two prescription drug claims for mood stabilizer medications and had a Proportion of Days Covered (PDC) of at least 0.8 for mood stabilizer medications during the measurement period (12 consecutive months)

    • Measure Steward: Centers for Medicare & Medicaid Services (CMS)
    • Applicable to: Medicaid and Medicare
    • Covers ages at least 18 years
  • NQF 1927: Cardiovascular Health Screening for People With Schizophrenia or Bipolar Disorder Who Are Prescribed Antipsychotic Medications4


    Description: The percentage of individuals 25 to 64 years of age with schizophrenia or bipolar disorder who were prescribed any antipsychotic medication and who received a cardiovascular health screening during the measurement year

    • Measure steward: National Committee for Quality Measures (NCQA)
    • Applicable to: Medicaid only
    • Covers ages 25 to 64
  • NQF 1932: Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications4


    Description: The percentage of patients 18 to 64 years of age with schizophrenia or bipolar disorder, who were dispensed an antipsychotic medication and had a diabetes screening test during the measurement year

    • Measure steward: NCQA
    • Applicable to: Medicaid only
    • Covers ages 18 to 64
  • NQF 0003: Bipolar Disorder: Assessment for Diabetes4

    Percentage of patients treated for bipolar disorder who are assessed for diabetes within 16 weeks after initiating treatment with an atypical antipsychotic agent

    • Measure steward: Center for Quality Assessment and Improvement in Mental Health (CQAIM)
    • Applicable to: 
    • Covers ages 18 and older
  • NQF 0112: Bipolar Disorder: Level-of-Function Evaluation4


    Description: Percentage of patients treated for bipolar disorder with evidence of level-of-function evaluation at the time of the initial assessment and again within 12 weeks of initiating treatment

    • Measure steward: CQAIM
    • Applicable to: 
    • Covers ages 18 and older
  • About CMS Five-Star Measures5


    Description: The Five-Star Ratings strategy is aligned with CMS’ Three Aims: better care, healthier people/healthier communities, and lower costs through improvements. CMS Five-Star measures for Medicare plans cover the following categories:

    • Outcomes
    • Intermediate outcomes
    • Patient experience
    • Access
    • Process
  • C05—Improving or Maintaining Mental Health5


    Description
    : Percent of all plan members whose mental health was the same or better than expected after 2 years

    • Metric: The percentage of sampled Medicare enrollees 65 years of age or older (denominator) whose mental health status was the same or better than expected (numerator)
    • Applicable to: Medicare Advantage only 
  • C21—Plan All-Cause Readmissions5


    Description
    : Percent of senior plan members discharged from a hospital stay who were readmitted to a hospital within 30 days, either for the same condition as their recent hospital stay or for a different reason

    • Metric: The percentage of acute inpatient stays during the measurement year that were followed by an unplanned acute readmission for any diagnosis within 30 days, for members 65 years of age and older using a the formula to control for differences in the case mix of patients across different contracts
    • Applicable to: Medicare Advantage only 
  • C22—Getting Needed Care5


    Description
    : Percent of the best possible score the plan earned on how easy it is for members to get needed care, including care from specialists

    • Metric: This case-mix adjusted composite measure is used to assess how easy it was for a member to get needed care and see specialists. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) score uses the mean of the distribution of responses converted to a scale from 0 to 100. The score shown is the percentage of the best possible score each contract earned.
    • Applicable to: Medicare Advantage only 
  • C32—Plan Makes Timely Decisions About Appeals5


    Description
    : Percent of the best possible score the plan earned on how easy it is for members to get the prescription drugs they need using the plan

    • Metric: This case-mix adjusted measure is used to assess the ease with which a beneficiary gets the medicines their doctor prescribed. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) score uses the mean of the distribution of responses converted to a scale from 0 to 100. The score shown is the percentage of the best possible score each contract earned.
    • Applicable to: Medicare Advantage only 
  • D09—Getting Needed Prescription Drugs5


    Description
    : Percent of senior plan members discharged from a hospital stay who were readmitted to a hospital within 30 days, either for the same condition as their recent hospital stay or for a different reason

    • Metric: The percentage of acute inpatient stays during the measurement year that were followed by an unplanned acute readmission for any diagnosis within 30 days, for members 65 years of age and older using a the formula to control for differences in the case mix of patients across different contracts
    • Applicable to: Medicare Advantage only 


 

References:

  1. National Committee for Quality Assurance. HEDIS® & Performance Measurement—Measuring Performance. http://www.ncqa.org/tabid/59/Default.aspx. Accessed May 4, 2018.
  2. National Committee for Quality Assurance. 2017 State of Health Care Quality—HEDIS Measures of Care. www.ncqa.org/report-cards/health-plans/state-of-health-care-quality/2017-table-of-contents. Accessed May 4, 2018.
  3. National Quality Forum. NQF’s History. www.qualityforum.org/about_nqf/history. Accessed on May 4, 2018.
  4. National Quality Forum. NQF-Endorsed Measures. www.qualityforum.org/QPS/QPSTool.aspx. Accessed on May 4, 2018. 
  5. Centers for Medicare & Medicaid Services. Medicare 2016 2018 Part C & D Star Ratings Technical Notes  www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/PerformanceData.html.


HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). To purchase copies of this publication, contact NCQA Customer Support at 888-275-7585 or visit www.ncqa.org/publications