Blue Review
A newsletter for contracting institutional and professional providers

September 2020

COVID-19 Sparks HEDIS® Changes for Medicaid Pay-for-Performance Measures, Including Telehealth

By: Dr. Derek J. Robinson, M.D., MBA, FACEP, CHCQM, Vice President and Chief Medical Officer, Blue Cross and Blue Shield of Illinois (BCBSIL)

2020 has brought us many challenges and opportunities that continue to rapidly evolve. As we all adapted to the imperative to flatten the COVID-19 curve, the focus on preventive care shifted and many patients postponed routine visits. The delay in non-emergent care and pivot to the use of telehealth have necessitated changes to Healthcare Effectiveness Data and Information Set (HEDIS) measurements. 

This month’s article is focused on providing you with information regarding key updates on quality measures, which may be relative to your practice, both in person and by telehealth. While many of the measures also apply for commercial and Medicare Advantage, we’re spotlighting those that may have an impact on Illinois Medicaid Pay-for-Performance measures.

HEDIS MY 2020 and MY 2021: Key Changes for Medicaid Pay-for-Performance Measures, Including Telehealth
The National Committee for Quality Assurance (NCQA) has made changes to its HEDIS measures for Measurement Year (MY) 2020 and 2021. Below is a summary of changes impacting Medicaid Pay-for-Performance measures. Please note, only select changes have been captured in the list below. For a full list of changes, see the HEDIS Measurement Year 2020 & Measurement Year 2021 Volume 2, Summary Table of Measures, Product Lines And Changes.

Retired Measures

  • Adult Body Mass Index (BMI) Assessment (ABA)
  • Medication Management for People with Asthma (MMA 50% and 75%)
  • Comprehensive Diabetes Care (CDC) – Nephropathy (retired for Medicaid and commercial)

New Measures and Definitions

  • Well-Child Visits in the First 30 Months of Life (W30) – W15 was renamed to W30. Measure now contains two rates: children 15 months of age with 6+ well-child visits and children 30 months with 2+ well-child visits. Note: Hybrid Data Collection Method has been removed for this measure

Measures with Significant Changes

  • Well-Child Visits in the First 30 Months of Life (W30) (Previously W15)
    • W15 was renamed to Well-Child Visits in the First 30 Months of Life (W30)
    • Measure now contains two rates: children 15 months of age with 6+ well-child visits and children 30 months with 2+ well-child visits in the last 15 months
    • Telehealth is eligible for reporting
    • Hybrid Data Collection Method has been removed for this measure
  • Initiation of Alcohol or Other Drug Dependence Treatment (IET)
    • Opioid treatment and services billed weekly or monthly now included in numerator and denominator
  • Follow-Up After Hospitalization for Mental Illness Within 30 Days (FUH)
    • Removed mental health provider requirement for follow-up visits for intensive outpatient encounters, partial hospitalizations, community mental health centers, and electroconvulsive therapy settings
    • Visits in a behavioral healthcare setting added to the numerator
    • Added telephone visits to the numerator
  • Breast Cancer Screening (BCS)
    • Added Donepezil-memantine to the “Dementia combinations” description in the Dementia Medications List
  • Weight Assessment Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC)
    • Member-reported biometric values (BMI, height and weight) are eligible in reporting
  • Prenatal and Postpartum Care (PPC): TOPC and PPC
    • Telephone visits, e-visits, and virtual check-ins are eligible for the Timeliness of Prenatal Care (TOPC) rate 
  • Comprehensive Diabetes Care (CDC)
    • Retired the “Medical Attention for Nephropathy” indicator for the commercial and Medicaid product lines
    • Telephone visits, e-visits and virtual check-ins are appropriate settings for blood pressure (BP) readings
    • BP readings reported or taken by the member are eligible for reporting
    • Clarified that documentation of “HB1c” meets criteria for the Hybrid Specification of the HbA1c testing indicator
    • Clarified that eye exam results read by a system that provides an artificial intelligence (AI) interpretation meet criteria for the Eye Exam sub-measure
  • Controlling High Blood Pressure (CBP)
    • Removed the restriction that only one of the two visits with a hypertension diagnosis be an outpatient telehealth, telephone visit, e-visit or virtual check-in when identifying the event/diagnosis
    • Added Donepezil-memantine to the “Dementia combinations” description in the Dementia Medications List
    • Telephone visits, e-visits and virtual check-ins are appropriate settings for BP readings
  • Statin Therapy for Patients with Diabetes (SPD)
    • Removed the restriction that only one of the two visits with a diabetes diagnosis be an outpatient telehealth, telephone visit, e-visit or virtual check-in when identifying the event/diagnosis
    • Removed the restriction that only one of the two visits with an IVD diagnosis be an outpatient telehealth, telephone visit, e-visit or virtual check-in when identifying the event/diagnosis

Measures with Telehealth Changes

  • Antidepressant Medication Management (AMM): Effective Acute Phase Treatment
    • Added e-visits and virtual check-ins to the event/diagnosis
  • Follow-Up After Hospitalization for Mental Illness Within 7 and 30 Days (FUH)
    • Added telephone visits to the numerator
  • Well-Child Visits in the First 30 Months of Life (W30) (Previously W15)
    • Removed the telehealth exclusion
  • Prenatal and Postpartum Care (PPC): TOPC and PPC
    • Added telephone visits e-visits and virtual check-ins to the Timeliness of Prenatal Care rate
    • Clarified that services provided via telephone, e-visit or virtual check-in are eligible for use in reporting both rates
  • Comprehensive Diabetes Care (CDC)
    • Added telephone visits, e-visits and virtual check-ins as appropriate settings for BP readings
  • Controlling High Blood Pressure (CBP)
    • Removed the restriction that only one of the two visits with a hypertension diagnosis be an outpatient telehealth, telephone visit, e-visit or virtual check-in when identifying the event/diagnosis
    • Added telephone visits, e-visits and virtual check-ins as appropriate settings for BP readings
  • Statin Therapy for Patients with Diabetes (SPD)
    • Removed the restriction that only one of the two visits with a diabetes diagnosis be an outpatient telehealth, telephone visit, e-visit or virtual check-in when identifying the event/diagnosis
    • Removed the restriction that only one of the two visits with an IVD diagnosis be an outpatient telehealth, telephone visit, e-visit or virtual check-in when identifying the event/diagnosis, step 2 required exclusions

Learn more about Dr. Derek J. Robinson

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The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.