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 schizophrenia 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 schizophrenia.

Behavioral Health Quality Metrics

Select a health care quality entity to expand and read more.

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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, an 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: Assesses 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

    • Applicable to: Medicaid only
    • Covers ages 18 to 64
  • HEDIS Measure for Diabetes Monitoring for People with Diabetes and Schizophrenia1,2


    Description:
     Assess adults 18 to 64 years of age  with schizophrenia and diabetes who had both an LDL-C test and an HbA1c test during the measurement year

    • Applicable to: Medicaid only
    • Covers ages 18 to 64
  • HEDIS Measure for Cardiovascular Monitoring for People With Cardiovascular Disease and Schizophrenia1,2


    Description:
     Assesses adults 18 to 64 years of age  with schizophrenia and cardiovascular disease, who had an LDL-C test during the measurement year

    • Applicable to: Medicaid only
    • Covers ages 18 to 64
  • HEDIS Measure for Adherence to Antipsychotic Medications for Individuals with Schizophrenia1,2


    This HEDIS measure has been adapted for use from a CMS measure

    Description: Assesses adults 19 to 64 years of age who have schizophrenia and were dispensed and remained on an antipsychotic medication for at least 80% of their treatment period.

    • Applicable to: Medicaid only
    • Covers ages 19 to 64
  • About NQF-Endorsed Measures3


    Description:
     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

  • NQF1879: Adherence to Antipsychotic Medications for Individuals with Schizphrenia4


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

    • Measure Steward: Centers for Medicare & Medicaid Services (CMS)
    • Applicable to: Medicaid only
    • Covers ages 18 and older
  • NQF1927: 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: Centers for Medicare & Medicaid Services (CMS)
    • Applicable to: Medicaid only
    • Covers ages 18 and older
  • NQF1932: Diabetes Screening for People with Schizphrenia 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
  • NQF1933: Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia4


    Description:
     The percentage of patients 18 to 64 years of age with schizophrenia and diabetes who had both an LDL-C test and an HbA1c test during the measurement year

    • Measure Steward: NCQA
    • Applicable to: Medicaid only
    • Covers ages 18 to 64
  • NQF1934: Diabetes Monitoring for People with Diabetes and Schizophrenia4

  • NQF1937: Follow-Up After Hospitalization for Schizophrenia (7- and 30-day)4


    Description:
     The percentage of discharges for individuals 18 to 64 years of age who were hospitalized for treatment of schizophrenia and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner

    Two rates are reported:

    • The percentage of individuals who received follow-up within 30 days of discharge
    • The percentage of individuals who received follow-up within 7 days of discharge
       
    • Measure Steward: NCQA
    • Applicable to: Medicaid only
    • Covers ages 18 to 64
  • About CMS Five-Star Measures3


    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 Health3


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

    • Metric: The percentage of sampled enrollees (denominator) whose mental health status was the same or better than expected (numerator)
    • Applicable to: Medicare only 
  • C19 — Plan All-Cause Readmissions3


    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 unplanned an acute readmission for any diagnosis within 30 days, for members 65 years of age and older using a formula to control for differences in the case mix of patients across different contracts.
    • Applicable to: Medicare 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 plan members who got a timely response when they made an appeal request to the health plan about a decision to refuse payment or coverage.

    • Metric: Percent of appeals timely processed by the plan (numerator) out of all the plan’s appeals decided by the Independent Review Entity (IRE) (includes upheld, overturned and partially overturned appeals) (denominator).
    • Applicable to: Medicare Advantage only
  • D09—Getting Needed Prescription Drugs5


    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


 

References:

  1. National Committee for Quality Assurance. HEDIS® & Performance Measurement—Measuring Performance. http://www.ncqa.org/tabid/59/Default.aspx. Accessed on 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 2018 Part C & D Star Ratings Technical Notes www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/PerformanceData.html. https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/Downloads/2016-Technical-Notes-Preview-1-v2015_08_05.pdf. Accessed on May 4, 2018.


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