An in-depth look at Aetna’s adult members

Brian Clark:

Well, good morning everyone, and welcome to the first of two webinars this month. The title of today's webinar is, "An in depth look at Aetna's 21 and older female and male members." There are two offerings for this webinar today and tomorrow, April 19th at 2:00 PM Eastern. I ask that if you're not on mute, please go ahead and do so. I hear a little bit of background noise.

Brian Clark:

Now, prior to the webinar today, you received the slides via email from me. Please follow along with us today. I'd like to first welcome Illinois, Maryland, New Jersey, Ohio, Pennsylvania, Texas, Louisiana, Kentucky, Florida, and Michigan to the line today. So glad you could fit this important webinar in your schedule. The webinar will last approximately 50 minutes, and then we'll have some time for questions at the end, as well as during the webinar as well.

Brian Clark:

My name is Brian Clark, and I'm your host. My title is quality translator, and I work in quality management here at Aetna Better Health. My main focus is obviously HEDIS. And then, the other presenters on the line today, their focus is mainly on HEDIS as well. We have three other presenters today. Jacob Stipe, EPSDT coordinator. Diana Charlton, QM nurse consultant, and Debbie Barkley, QM nurse associates. Actually, all three of them work in the Aetna Better Health quality management department as well. Madison Yonlisky will be handling the Q&A box today. Madison is also a quality translator here at Aetna Better Health.

Brian Clark:

The goal of this webinar today, and in all webinars in this series, is to spark conversations with providers in multiple states nationwide while attempting to explore ways to cut down on the burden of medical record review, which is going on right now. We're reaching out for records that were not captured administratively through claims during the measurement year. We'd like to cut down on the burden of reaching out to the office for records by illustrating the HEDIS measures throughout the year, and showing you appropriately codes that can be used to capture care for specific HEDIS measures.

Brian Clark:

Now, we'll go over the agenda for this specific webinar shortly in more depth. Now, during the webinar, we'll be pausing for Q&A. Participation is encouraged. Please utilize the Q&A box. Hover your mouse over the top part of the middle of your screen. Find that option for Q&A and choose the participate dropdown down option. And then, type your question or comment in the white box, and send to all panelists.

Brian Clark:

If you'd like to test that out right now, I ask you to find the Q&A box. In the little white box, maybe just type in, "Hi, Brian, or good morning," or something like that just so I know that we have a live group here, and you're all with us. Or if you didn't get a copy of the slides... Good morning, Larry. If you didn't get a copy of the slides, I sent the slides out to everyone about 30 minutes ago... Hi, Susan. If you didn't get a copy of the slides, say, "Hey, I need a copy of the slides. I didn't get the email," and I'll send a copy of the slides to you.

Brian Clark:

Okay. So, what are we looking at here? This is the good morning. Good morning. A lot of good mornings. A lot of good mornings. I'll get you a copy of the slides, Susan, no problem. So, what we're looking at right here is the Aetna values wheel. Aetna's vision statement or philosophy as to the way we manage healthcare is, you don't join us, we join you. So, by joining you all on the line today in this webinar environment, it's our hope that we're more effectively reaching our Aetna Better Health members.

Brian Clark:

So, on the screen here, you see the Aetna values wheel. At the center of all that we do are the people that we serve. Those are our members and our providers. Our corporate four values are integrity, excellence, inspiration, and caring. As a company, it's our hope that we're acting at all times with integrity, and we all aspire as a company to excel and build a healthier world. That is the goal in mind for our members, and to work with our providers to reach that goal.

Brian Clark:

Today's agenda. Here we go. So, the first thing that we'll do is we will look at HEDIS. Who uses it? What does it measure? Then, the next topic will be meeting HEDIS standards of care. Actually, I think we'll address these in a little bit different of an order, but anyway, those are two agenda topics that we'll look at. Jake will actually start with millennials dropping out of healthcare, and how that can be addressed in the office, how you can address that with patients that are coming in maybe just for a sick visit and encourage them to come back for their annuals and any followup care that's needed.

Brian Clark:

Smartphones and sleep schedules, physical inactivity affecting the USA. We'll look at some challenges and strategies for better meeting HEDIS measures of care, and actually closing gaps that might be out there for your practice or your organization. To piggyback off of that, we'll look at the NCQA approved codes that can capture care for HEDIS purposes, and some useful strategies for improvement. Like I said, that'll be a good portion of the webinar. We'll look at how to meet each measure more effectively.

Brian Clark:

Okay. So, HEDIS is a state requirement. It's collected two ways; claims or other administrative data, medical record review or data collection. Obviously, claims are the fastest and easiest way to collect HEDIS data, but correct coding is very important, which will reduce the burden of medical record review. Currently, right now, we're reaching out for records that were not captured administratively, or might require medical record review after the measurement year has concluded.

Brian Clark:

So, HEDIS was developed, at one point, and is maintained by the national committee for quality assurance. It's a standardized way for health plans to document healthcare services provided to the members. So, it's a really good way just to give us an idea as to whether or not we're meeting the standards when it comes to the HEDIS measures.

Brian Clark:

Now, a note about pay for quality programs, HEDIS scores are related to pay for quality programs. If you meet HEDIS scores, then some states obviously might offer certain pay for quality programs. I would definitely reach out to your point of contact to see if your state offers a program. Some states may offer certain paper quality programs based upon achieved HEDIS rates, such as value based services contracting or quality incentive programs. So, you can see how pay for quality is linked to HEDIS.

Brian Clark:

The public uses HEDIS, regulatory bodies use HEDIS, payers and providers might use HEDIS as well. The payers, definitely the health plan uses HEDIS information to improve the effectiveness of care of our members, and to see if they're receiving the appropriate care. Providers, some of you might utilize HEDIS data for your own internal quality improvement activities using the gaps in care reports to better improve your practice scores, and your rates, and things like that.

Brian Clark:

Some terms that we have been using throughout the series and we'll continue to use, and you will hear these terms, administrative data, hybrid review, and a hit. So, administrative data is healthcare information that's captured by means other than the medical record, like claims or immunization data banks, and historical encounters. Hybrid reviews, what we're going through right now as a health plan, and you providers indirectly are involved with that too because you're sending back records to us. So, that is when administrative data and medical record review are used to satisfy HEDIS guidelines.

Brian Clark:

A hit is when the administrative data and/or medical record meet all the HEDIS requirements for a measure. So, let's just say for instance, a member falls into CDC, comprehensive diabetes care, and the member had an eye exam within the last year or the year before prior indicating no retinopathy. And then also, so the A1C was in control, the blood pressure was in control, and the member also had some sort of nephropathy treatment, a urine test for protein, or the medication list indicates they're on an ACE or an ARB. That's considered a hit. All four sub-measures were met.

Brian Clark:

Let's say the member falls into adolescent well-care and all of the components of a well-visit were addressed during the measurement year, that's considered a hit as well. Just two specific examples of what would constitute as a hit.

Brian Clark:

Challenges and strategies. Okay. So, there are four bullet points I wanted to address here. These are very common issues, and I just wanted to provide you with some strategies to improve these issues that come up. So, members fail to keep appointments, members only seek care when they're ill. Communicating data to the health plan and seeing multiple different providers and coordinating care. I'm sure many people have a lot of good ideas on the line as to how to improve the whole issue of members failing to keep appointments.

Brian Clark:

I'm going to provide you with a couple ways to improve that aspect and that issue, or to address that issue. But if you want to type into the Q&A box how you at your practice address members failing to keep appointments, that'd be great. But here's some ideas. Maybe some text messages that go out prior to the appointment to remind members, "Hey, you have an appointment coming up," Or let's say letters that go out. Or maybe if you have the person's email address, send a quick email, phone calls stating, "Hey, you have an appointment coming up."

Brian Clark:

Or whenever you have the member in the office, let's say they're in for a sick appointment or a well-visit, or something like that, just make sure that you remind them that, "Hey. I saw you were a no-show on X date." Try and figure out what the barrier is to them missing appointments so you can better understand why they're missing these appointments, and provide some feedback as to how to combat their issues that they're having. Members only seek care when ill. So, if you have the member in at a sick visit, encourage them that, "You know, it's important to come in, not just when you're sick." Or while they're in there for a sick visit, make it a comprehensive well-visit and address all items related to that member's care, or their condition that they have.

Brian Clark:

And then, communicating data to the health plan. It's important to submit proper ICD-10 and CPT codes. It's one thing to have a member in and to document in the medical record, but it's ideal if you would send that information via codes to the health plan. And then, finally, seeing multiple different providers and coordinating care. You want to establish a good relationship with all doctors that that member actually goes to, and make sure that all records come back to the PCP home in case the healthcare company at some point needs to reach out to you for those records during hybrid review.

Brian Clark:

Okay. So, I'm going to pause for some questions. I know I sometimes talk a lot, but I hope all that information was useful, helpful, and a little bit of a refresher as to why we are all meeting together for this webinar series. Madison, do we have any questions or comments in the Q&A box?

Madison Yonlisky:

So, there was one question I wanted to bring up because it may depend on the HEDIS measure we're talking about. Somebody asked if this could be applied at all to DME and HME programs. So, like durable medical equipment, home health, things of that nature.

Brian Clark:

You know what? I am going to let you listen to the remainder of the webinar, and if it seems like it is applicable to you, then I would encourage you to please come back. But I would say that this information is very useful and applicable to any practice organization that works with any patient member of Aetna's in any way. So, I would encourage anyone to attend this webinar. So, I hope that that answers your question, because we cover things that are out there outside of the realm of just HEDIS.

Brian Clark:

As you'll see in the next few slides, there are going to be a couple items that we're going to be addressing that are not HEDIS-specific, or coding-specific, or billing-specific, or things of that nature. So, I would encourage all on the line, and anyone of your colleagues, to attend this series. So, the answer would be, in my opinion, yes.

Madison Yonlisky:

This is not a question but just in response to how people or how offices get patients to keep their appointments. Somebody did make a comment that they are called the day before via automatic... it's an automatic system that they use to make a phone call out to their patients the day before to remind them of the appointment. That was just a response to what you had said before.

Brian Clark:

That's great. I like it. Yeah, I welcome those calls because sometimes you just get forgetful sometimes, and you need that additional reminder. Even if it's not a live person calling, that's a good way to ensure that the member makes the appointment. I like it.

Madison Yonlisky:

Somebody did ask, additionally, if we were going to be going over any information on getting prior authorization. That is something that I don't think we'll go over specifically today. Correct me if I'm wrong, Brian, but it is something that if you have questions about, we could always get you in contact with your point of contact. Correct?

Brian Clark:

Yeah, that's right. We're not going to be going over that today. But your point of contact, I'll be introducing everyone to somebody at the health plan that you can reach out to in your state. At the end of the webinar, I'll provide you with their email address. If you have any questions or want to talk about that topic, please go ahead and shoot them an email. So, yeah, we're not going to address that in this webinar today, Madison.

Madison Yonlisky:

I think we are safe to move on.

Brian Clark:

All right, let's do it then. Okay, Jake. Jake is EPSDT coordinator here at the health plan at Aetna Better Health. Well, he's one of them specifically in Pennsylvania, and he will take the ball from here.

Jacob Stipe:

Thank you, Brian. Good morning, everyone. What we're going to do is review these three specific topics based on things that we're seeing, based on surveys and studies. Also, pose questions to those attending on how your provider office or organization addresses these specific that affect those 21 years of age or older. So, we're looking at millennials dropping out of healthcare, smartphone usage and how it affects sleep schedules, and physical inactivity across the nations.

Jacob Stipe:

Let's go to the next slide. I want to just review a recent Zocdoc survey that's available in the prnewswire.com site here, found that Americans are dropping out of healthcare amidst busy lives and a complex healthcare system. Zocdoc is an online tool that's used to find in-network neighborhood doctors, can be used to book appointments, and it can give reminders for upcoming appointments and preventive checkups, and et cetera.

Jacob Stipe:

What they found some interesting information about the millennial population. Millennials is a term that you may hear a lot, especially in the last couple of years, what they're talking about with the millennial generation are those who were born in the early 80s to late 1990s. In some cases, I've seen it go all the way to the early 2000s. So, we're talking about children who are graduating high school up to those who have been in the workforce for some time, maybe new parents. What they found for this age group, for this generation, that nine out of 10 millennials either avoid going to the doctor or don't go to the doctor at all.

Jacob Stipe:

The main barriers that come up are related to things like, "I have to take care of other things before I can take care of myself." So, everyday life is too busy. There's work obligations. There are some situations where they have a hard time scheduling based on some of the provider demographic information that's available to them, things that are online. And then, there is also a relatively new phenomenon called Dr. Google. They are relying on the internet to self-diagnose in a lot of cases, instead of going in and being checked.

Jacob Stipe:

What we're finding out is that there's a lot of aspects to this population where they're being encouraged to be active consumers. It's also something that is encouraged for everyone to be an active consumer when it comes to their own healthcare. We're finding that this is not the case when it comes to this generation of millennials and healthcare. A lot of these things are being pushed back instead of being pursued.

Jacob Stipe:

So, there's more information and we do have this available on the website to find out the survey, and view the infographic on the Zocdoc website that we have posted here. So, go to the next slide. I do want to pose a question to the group. How would you or do you address this millennial perception, or I think maybe another term would be this trend or observation regarding avoidance of care? I'll give you a minute to answer in the chat box or in the Q&A.

Madison Yonlisky:

Hey, we still haven't gotten anything yet, so we'll give it another moment to let people type their answers. Okay, there's an answer. Somebody says that they sent letters asking them to come in for annual wellness, and they make sure that they clarify that it is zero copay, so that might give them a little bit more of a push or, I guess, incentive to come in and get things like that done.

Jacob Stipe:

I see something here from Monica, like an education that they provide kind of a viewpoint here where they say, "If you're not healthy, you're unable to take care of these things that are going on in your life." So, I think there is an educational aspect to that as well. And also, they do make phone calls for reminders as well. So, thank you very much, Monica. Let's move onto the next slide here. Thank you for those who put this information in here. I do see going out to high schools, that's a great thing as well to encourage this, and that'll continue throughout their life.

Jacob Stipe:

The smartphones and sleep schedule. So, information from the Sleep Foundation, there's a recommended amount of sleep for adults of seven to nine hours. They're finding that the average college student gets about six to nine hours of sleep a night. However, lack of sleep can be linked to conditions such as heart attack, obesity, diabetes, high blood pressure, several types of cancers. It puts you at greater risk of infections, colds, flus. It makes it important for young people, young adults, college students, and any new parents to make sure that they're getting enough sleep, and also getting in for those annual well visits that we talked about.

Jacob Stipe:

The smartphones and how they affect that. There's this blue light that's emitted from the smart devices that could be keeping folks up at night. The smartphones right before sleep can delay sleep, or it can manipulate the natural sleep cycle. We see here that 70% of US adults do use a smartphone, so there is this concern then about how smartphone usage can be affecting sleep, especially those who use smartphones at night before they go to sleep.

Jacob Stipe:

So, we do have some links here from Pew Research, from nmbreakthroughs.org sites as well where there's additional information on smartphones and sleep, and their usage. So, I do want to pose this to the group then, similar to what we did on the next slide. How does your practice address sleep and smartphone usage to your patients, especially of this age?

Madison Yonlisky:

While everybody's typing their answers, make sure that you do have, in your Q&A box, that you have the drops down selected to all panelists. Somebody did ask, are you saying using smartphones before sleep can affect how you sleep? The answer to that is yes. It can affect the amount of sleep that you get and the quality of sleep that you get, and therefore can have an impact on your health as well.

Madison Yonlisky:

And then, I don't know if that's something that we had a specific on, Jake, but they did ask. So, when they're talking to members, about how long before going to bed should they stop using their phones? So, that was a question that somebody asked. I'm not sure if we have a specific number on that.

Jacob Stipe:

No, I don't have a specific number on that. That's something that we do leave to medical professionals, sleep professionals. As an educator, it's something that... things that I've read saying half hour, maybe 45 minutes, maybe an hour, but that's something that I would leave to the professionals. So, again, this is just something like how the provider offices would address that. So, I do see that they address the use of smartphones during the encounter, which I think is great.

Jacob Stipe:

Yeah, there's different beliefs in timeframes that I've read just as an educator, but a specific answer, I don't have an answer for what the exact timeframe should be.

Madison Yonlisky:

Right. That would be something we'd have to do a little bit of additional research on. Right. Somebody did answer that, like you said, Jake, address the smart phone during their encounters or their visits in the office. Just making sure that you address that in general during every visit, to answer your question.

Jacob Stipe:

Okay. Another health topic here that is a concern and there's a lot of research on, and it's really physical inactivity in the country. The stateofobesity.org does have an article about physical activity in adults by state. What they found is that looking at inactivity nationwide, 45% of adults are not sufficiently active. The states that had the least active adult population would be Arkansas, Mississippi, Florida. Those that were the most active were Utah, Colorado, and District of Columbia, had the most active adult population. So, well over 100 billion dollars and annual healthcare costs are spent in relation to the lack of physical activity.

Jacob Stipe:

The study also found that 25% of young adults are ineligible to join the military due to weight and lack of physical activity. There's another study that is available too on the State of Obesity looking at the rates for obesity by state and also by age. So, the age groups that they're looking at would be young adults, baby boomer generation, and also seniors. They're finding very similar trends with similar states that show the correlation between obesity and physical inactivity.

Jacob Stipe:

So, just for my last slide here, I do want to pose another question to the group then. How does your practice address physical inactivity to those who are 21 years of age or older?

Madison Yonlisky:

Somebody says that they just suggest things like 30 minutes of walking a day, or even just taking the time to walk your dog makes a big difference. Somebody did say that they discuss the benefits of physical activity and community resources. That's a good one.

Jacob Stipe:

Excellent. Yeah. Especially there's a lot of programs that could be available for those who are on different health plans, those that are available for those who are of an older population may have some sort of additional benefits when it comes to those community resources for physical activity. Also, just educating on the risk of not being physically active and some of the information maybe that you guys have access to from... the links from this presentation would help with educating your patients and our members on that.

Jacob Stipe:

What else do we have here, Madison?

Madison Yonlisky:

Somebody says they tell them the risks. So, somebody said the benefits, this person is saying the risks that they may face if they don't remain active. Somebody said that as preventative care, you can encourage them to participate in physical, things that interest them such as running, walking, things of that nature.

Jacob Stipe:

That's great. Right, thank you all so much for your participation. This is really great. We're going to turn over to Deb Barkley who's going to discuss the HEDIS measures of focus.

Debbie Barkley:

Thanks so much, Jake. And then, in the interest of time, Diana and I are going to share this segment. We're going to move through these rather quickly and just give a high level overview of these HEDIS measures. What you'll find helpful will be the slides that you've received, and those that have requested slides, they'll be coming to you. So, they'll be helpful to you as you take a look at these measures and gather some of the information.

Debbie Barkley:

So, just to take a look, these measures that we're going to cover will cover a wide range of categories like preventative screenings, respiratory conditions, access and availability of care, and some others. Next slide, please. Diana is going to discuss with you some of the Medicare measures that address medication management and care coordination. So, we're going to discuss one in any particular order, but we'll hit all of these rather quickly here and give you some good information, some high points.

Debbie Barkley:

Next slide, please. So, comprehensive diabetes care, this is a major measure that is always covered, and it's a hybrid measure. So, as Brian mentioned to you, medical record review and administrative data is required to satisfy this measure. So, there are four major components that's looked at. That's the eye exam, the attention to nephropathy, blood pressure control, and the hemoglobin A1C. So, this applies to type 1 and type 2 diabetics.

Debbie Barkley:

Next slide, please. Now, here's some codes that are related to the hemoglobin A1C testing. These CPT II codes are indicator of values for A1C. Next slide, please. Next, we see some codes that are available for attention to nephropathy and the diabetic dilated retinal exam. Just a reminder, those retinal exams are done by eye professionals, and so we will receive those codes that most tests were done. It is important that those providers get those results back to the primary care physician. So, a good relationship with those organizations, those eye-care professionals is really important.

Debbie Barkley:

Next slide, please. A part of comprehensive diabetes care is the blood pressure. We're going to talk about blood pressure actually twice in this presentation. One is a standalone measure, and then there is a piece here in the diabetes measure. So, here are some CPT II codes for values for systolic and diastolic blood pressure.

Debbie Barkley:

Next slide, please. So, here's some strategies for improvement. I think I'll touch on this a little bit more later, but we all know as professionals for care for diabetics, the hemoglobin A1C is extremely important, and it's done every two to three months. Having that documentation and having it in the chart, and also codes can be used for that. One thing to keep in mind for hemoglobin A1C and for the blood pressure with this measure, for adherence to the measure, it's the last blood pressure and the last hemoglobin A1C of the measurement and here that is captured for this measure. So, if the member has more than one encounter, multiple encounters, just remember what's going to be extracted from the record is the last hemoglobin A1C and the last blood pressure of the year.

Debbie Barkley:

Next slide, please. Attention to nephropathy. What I'd like to highlight here, in addition to any dipstick test or microalbumin that are sent off to the lab, another way that attention to nephropathy is captured in the record is through the medication list. So, any documentation of ACE inhibitors or ARBs in on that medication lists can be indicators for attention to nephropathy. We already touched on the diabetic retinal exam and having that information in the record.

Debbie Barkley:

Next slide, please. So, I told you we'll talk about the controlling high blood pressure measure. So, as you can see, there's a wide range of age that this measure is looked at, and essentially, HEDIS defines control for HEDIS purposes as any blood pressures that's below 140 over 90 for the wide range of age. The only exception to this is those that are 60 to 85 years of age who do not have diabetes as a diagnosis. That is a blood pressure below 150 over 90.

Debbie Barkley:

We know, as professionals, that our targets for blood pressure control is actually much lower than that. It's below 120 over 80. However, what's accepted for HEDIS is 140 over 90, and 150 over 90. Next slide, please. Once again, this is another hybrid measure, and here are the codes that can be used for controlling high blood pressure.

Debbie Barkley:

Next slide. As a strategy for improvement, one thing that most of us are familiar with is like white coat syndrome. So, sometimes members may come into the office and they have a blood pressure taken. Sometimes it's necessary to retake that blood pressure because of the initial ones, that's high just because of the anxiety of being in the office or getting to the appointments. So, any documentation or documentation of all blood pressures during an encounter is important because we can extract from that record those blood pressures and give a reading for systolic and diastolic that are acceptable.

Debbie Barkley:

Next slide, please. The next measure we're going to talk about is adult BMI assessment. So, this is measures that have a two year look back. It is a hybrid measure. So, that means that medical record review is required for this particular one. There's two strategies that are looked at for this measure, those that are 21 and under, and those that are over the age of 21.

Debbie Barkley:

The important thing to remember about this is that those that are under 21, what you're going to be documenting is the BMI percentile, just like you would do for your adolescents and your children. They're coming for well-care, you are going to capture the BMI percentile. So, that's like using a growth chart, a BMI "growth chart". Not a normal growth chart that just measures height and weight, but a BMI percentile chart. For those that are over 21 is going to be capturing the actual BMI value. Once again, that's a two year look back on that one.

Debbie Barkley:

Next slide, please. Here are the codes that can be used. On the left are those for under 21, and on the right are for those that are over 21. Next slide. Next measure that we're going to take a look at is medical management for people with asthma, and some percentage of people, as you can see, wide range of age five to 64 who were identified as having persistent asthma and how they use their medication. So, we're looking at whether they use their controllers 50% of the time or 75% of the time.

Debbie Barkley:

Here are some codes that can capture that. This is an administrative data measure. So, it's totally captured by pharmacy codes. So, just keep that in mind. So, it's kind of passed before the provider, except for the fact that your responsibility would be just to make sure that the member has the medication that they need, however, that information is captured administratively. Next slide, please. Do we have any questions so far before I continue on?

Madison Yonlisky:

Deb, we do not have any questions at this time.

Debbie Barkley:

Okay, so I'm going to pass it off to Diana. Diana?

Diana Charlton:

Thank you, Deb. My name is Diana Charlton, and I'm one of the nurses in the QM department. Today I'm going to be discussing the Medicare only HEDIS measures for this age group. The next slide, please. The first measure is care for older adults. This is the percentage of members that are 66 years of age and older that have each of the following components addressed during the measurement year. So, there's care planning, which would include items such as an advanced directive, or looking for a medication review to be done.

Diana Charlton:

Functional status assessment, which would include a review of your ADL, or activities of daily living. These are sometimes referred to as your basic ADL. These are the tasks that are learned in the early stages of life, such as walking, feeding, toileting, and bathing. We also have the IADLs, or the instrumental activities of daily living. These are those items that are learned. It's usually in adolescence. Things such as managing money, prepping meals, cleaning your house. They're not necessarily for fundamental functioning, but they enable the individual to live independently. Also, we're looking for a pain assessment to be done.

Diana Charlton:

Next slide. Here are the CPT and CPT II codes for each of the components for the COA, or care of older adult measure. Let's leave this up here for a second. I want to note also that the codes for the medication review and medication list must be submitted on the same claim to close out the gap for the medication assessment component of the measure.

Diana Charlton:

Next slide. The next measure for the Medicare only population is the medication reconciliation post discharge. So, for members that are 18 years of age and older, following a discharge from the hospital, we're looking for them to have medication reconciliation completed with their PCP within 30 days after discharge. If they are discharged and that's followed by a readmission or direct transfer to an acute facility or non-acute facility, we would take the last date of discharge from that facility they were transferred to. Here at the bottom, you can see the medication reconciliation codes that are in the CPT and CPT II classes.

Diana Charlton:

Next slide. We have the transitions of care measure, so this is the percentage of discharges for members 18 years of age and older. Then we're looking to have each of the following components addressed. So, did the member receive a notification of inpatient admission? This would be during the day of the admission or the following day. That they received a discharge information. This should be on the day of discharge or the following day as well.

Diana Charlton:

Patient engagement after inpatient discharge, we're looking for documentation of patient engagement. This could be office visits, visits to the home, telehealth provided within 30 days after discharge. Basically, we want to see how that patient's doing. We're also looking for medication reconciliation post discharge to be done 30 days after discharge.

Diana Charlton:

Next slide. So, here are some examples for the transitions of care measure. You'll notice that the first two components of the measure, we don't have administrative reporting, so we would likely go to the medical record for these. But we do have CPT codes for patient engagement after discharge, and also for the medication reconciliation. So, we're looking at CPT and CPT II code classes.

Diana Charlton:

Next slide. The next measure for Medicare only would be colorectal cancer screening, and this is the percentage of members between the ages of 50 to 75 to have appropriate screening for colorectal cancer. You can see any of the following would meet criteria. So, we look for a fecal occult blood test, flexible sigmoidoscopy, colonoscopy, CT colonography, and the fit-DNA test. I want to note that each of these has a different look back. So, you could see that the one test, the fecal occult, is only during the measurement year, but the other test we can go back further either in claims or the medical record to close the gap for this measure as we find those tests.

Diana Charlton:

Next slide. Here, there's NCQA coding tips for colorectal cancer screening. We also included, on the slides for you, the look back period as well, and their CPT II code classes. I would want to note that these are just some of the examples for the codes for these measures that we've discussed today. So, for the fullest thing, we want you to go to ncqa.org to get all the coding tips for closing gaps administratively.

Diana Charlton:

Next slide. So, at this point, do we have any questions before I pass the ball back to Deb?

Madison Yonlisky:

There was a question, and I did ask for clarity because I wasn't sure exactly what they meant, but they asked if we could clarify about administrative data and pharmacy codes. I wasn't sure though if they meant did they need clarity on what the administrative data actually is, or do they need clarity on how that has an impact on HEDIS measures? So, that was what I was a little unclear about, but I haven't gotten a response back as to what exactly they needed clarity on for it.

Diana Charlton:

Okay. Well, I can try to best answer. I see the question here. Can you please clarify that the administrative data slash pharmacy [inaudible 00:46:17]. One of the measures such as the AMM, which is the asthma medication measure... no, that's MMA, is a medication measure for people with asthma. AFM is also an example of an administrative-only measure, which would be the antidepressant medication management. So, for those measures, the way we close the gap specifically through pharmacy codes that are submitted when the member picks up their medication. We look at those codes and we're able to identify at that point if the member is adherent to their medication and staying on them during the treatment period based on the measure.

Diana Charlton:

If I didn't completely answer your question, we definitely save this chat box and get your point of contact follow up with you and go over the administrative and the pharmacy codes in more detail.

Madison Yonlisky:

That's all the questions we had for now.

Diana Charlton:

All right. Thank you very much, everyone. I'm going to pass the ball back to Deb.

Debbie Barkley:

Thanks, Diana. Everyone, as I go along here, we're going to talk a little bit more about administrative data. Let's just go ahead and cover that real quickly. Administrative data, as Brian mentioned at the beginning, refers to information that's collected other than the medical records. That's usually through claims, or also it can be through historical records. Sometimes information can be collected at free events and through documentation being made a part of the medical record, and then also be made a part of administrative data. So, it's primarily claims.

Debbie Barkley:

So, when some measures, especially these that I mentioned to you, are administrative data only, either sometimes the administrative data for almost every measure puts the member into the measure and then also satisfying your measure. Sometimes it's merely administrative data. So, just when they the claims come through, NCQA looks at whether or not those services were satisfied through the claims, as Diana already mentioned about medication. Because there is actually no real way to tell if a person is taking their medication. You can't tell, we can't tell because we're not there with them.

Debbie Barkley:

However, indicators are the fact that they are going to get their prescription filled in a timely manner. So, that's what's important, and that's how that information is captured. So, we're going to move ahead. This measure that we're talking about now is AAB. I hope that covers that. If you have any further questions, we'll be glad to address them. So, you can go ahead and type your question to the Q&A box.

Debbie Barkley:

So, AAB is the avoidance of antibiotic treatment in adults with acute bronchitis. So, that ranges from 16... I'm sorry, 18 to 64 years of age. So, this is an inverse measure. It is an administrative-only measure. The bottom line of this measure is to just make sure that there's not overuse of a medication, or a medication is being prescribed appropriately. So, an inverse measure means that the lower the number, the lower the rate, the better.

Debbie Barkley:

Next slide, please. PCE. That's the pharmacotherapy management of CLPD exacerbation. So, it's for people who are 40 years of age and older, and they fall into the measure if they had an ED visit between January 1st and November 30th of the measurements year. What it's looking at is whether or not, through pharmacy codes, that they are taking their systemic corticosteroid. That's usually something like prednisone or their bronchial dilator after they pass this ED or outpatient visit for exacerbation of their CLPD.

Debbie Barkley:

Next slide, please. Next measure we have is FAA. This is the adherence to antipsychotic medication for individuals with schizophrenia, and this age ranges from 19 to 64. In the bottom line here, we're looking to see if people who have been prescribed medication for schizophrenia are remaining on their medication 80% of their treatment time. There are many codes that can be used for this. The NCQA website will be the best source for the codes that are appropriate for this measure.

Debbie Barkley:

I think we've got a few coming up here that'll also help with this. Next slide. Yeah, we've got some CPT and ICD-10 codes. So, the visit coupled with a diagnosis code helps us see those members fall into this measure. So, you'll see an ICD-10 code coupled with a visit of some sort, whether it's inpatient or outpatient visit.

Debbie Barkley:

Next slide. Here's some more codes. ED visit with a diagnosis there. Once again, a visit coupled with a diagnosis code. Next slide. Next measure we're going to take a look at is AMM, and that's the antidepressant medication management. It's looking at members who are 18 years and older who were treated with an antidepressant medication. So, the primary goal of this measure is to take a look and see if people are continuing on their medication. It's an administrative data measure once again, and there are two phases looked at. That's the acute phase when they're first prescribed this medication for those first 12 weeks. And then also, it's being looked at, in a continuation phase, for six months after that.

Debbie Barkley:

Next slide. So, of course, the best strategies for improvement, and just to sum all of this up, is a contact with the member, communication, also scheduling visits and coupled probably with any other behavioral health visits that might be necessary. So, contact with the members is the largest thing, and then also encouraging them to stay on their medication. Next slide. Here are some codes once again for this measure, and they are, once again, coupled with the diagnosis code, ICD-10 code, with either an inpatient ED visit or an outpatient standalone visit.

Debbie Barkley:

Next slide. Do we have any questions before we move on? We are almost near the end of discussion of the HEDIS measures. Yes, Madison.

Madison Yonlisky:

Somebody did ask... I believe this is probably going to need to go towards their point of contact. They asked what are some reimbursable CPT codes for things like counseling for nutrition, weight loss, physical activity. You did also mention that a full list of codes is on the NCQA website as well. That's a really good source though.

Debbie Barkley:

Yes. And then, in addition to that, if you get a chance to attend some of the other webinars, we do present more codes for anticipatory guidance, and for nutrition, and so forth in addition to that information that you just gave, Madison, that the NCQA website is a good source, and also their point of contact. I don't know, Brian may also share some coding tips documents that can be shared. If not, they are available through your point of contact. If there are no other questions, we're going to move ahead. We are almost at the finish line with these measures.

Debbie Barkley:

So, the next one, these measures are applicable to women, and we have the CHL, CCS. We'll talk about them in detail, PPC and BCS. Next slide. The CHL is chlamydia of screening in women, and it's percentage of women that are 16 to 24 years of age, and for some kind of testing done for chlamydia. This is an administrative data measure. Here are some codes that when testing is done either in the office or sent off to a lab, that these codes can be used.

Debbie Barkley:

Next slide. For the CCS, cervical cancer screening, we've got two strategies that are looked at here. We've got 21 to 64 and 30 to 64. Now, as you'll notice here, for the 21 to 64, if cervical cancer screening is done, a pap smear that's done without any code testing, we're looking for a pap smear every three years. If code testing done is done for HPV, not reflex testing, but code testing... The difference between reflex testing and code testing is, with reflex testing, the HPV done is contingent upon what the results of the pap smear. So, it may or may not be done.

Debbie Barkley:

So, the pap smear is done and then either the provider has ordered after you get the results of the pap smear, then see if you need to do an HPV, or the pathologist can say, "Huh, as a result of what we've seen, we're going to do HPV testing." But if the ordering provider orders HPV testing at the same time, we're looking for those pap smears every five years. Here are codes that are applicable.

Debbie Barkley:

Next slide. Just something to note on the other one. You don't have to change the slide, Brian. But for CCS, that is a hybrid measure. BCS, breast cancer screening, this is administrative data measure, and it's looking at a percentage of women that are 50 to 74 years of age who had a mammogram, or the other accepted test now is the DBT. That's the digital breast tomosynthesis. Either one of those tests are acceptable.

Debbie Barkley:

So, the member would be prescribed, or sent, or referred over to imaging for a mammogram. Once the members has that done, we would capture that information and they would be counted adherent for that. Next slide. Our last one. This is about prenatal and postpartum care. Looking at two parts here, and you'll notice that there's a difference in the measurement year, and it starts at the and of the previous year. It starts at the end of 2017 on November 6th, 2017 to November 5th, 2018. We are looking for those women who have received care and have been a part of the health plan for at least 42 days. Have been enrolled with the health plan at least 42 days, and also that postpartum care.

Debbie Barkley:

It's very important to note that timeframe, the 21 to 56 days after delivery. It's extremely important to note that because if that postpartum visit is scheduled after that 56 days, we are so glad that that member had that care, however they won't be counted as adhered for. So, just keep that in mind, and that's a note for schedulers to keep that in mind. I am at the end here, and I am going to pass it off to Brian.

Brian Clark:

All right. Thank you, Deb. Diana, thank you very much for presenting as well. And Jake, thanks a lot. So, I'm going to wrap it up here. I mentioned earlier that I would introduce you all to a point of contact, the rep at the health plan, someone that can help you access your offices or your organizations gaps in care reports when it comes to targeting HEDIS measures of care and closing gaps throughout the measurement year. Someone that you can always turn to if you have a question or a comment.

Brian Clark:

At this time if you would like to... I mentioned earlier that I sent the slides out. If you need to get a copy of the slides, please remember to say, "Hey, I need a copy of the slides." Your point of contact will be in touch with you within 24 hours after the webinar. If we did not get to answer a question that was state specific or a question that we just couldn't get to during the webinar, just look for an email here shortly for your point of contact.

Brian Clark:

If you're from Florida, signing in from Florida, your point of contact is Michelle. There's her email. If you're signing in from Texas, that would be Joanna. Pennsylvania's point of contact is Diana. She was a speaker today. Louisiana, that would be Frank. Michigan, that will be Dante. Illinois, that's Anya or Diana. You can reach out to either one. For Maryland, that will be Don. New Jersey, that's Sami. Ohio, one of two individuals, Sarah or Valerie. Kentucky, that would be Kathy.

Brian Clark:

So, we will be presenting the same webinar tomorrow, I believe, at two o'clock is the time. So, if you want to forward the invitation that was sent to you with the link to register for tomorrow's webinar, please do so if you feel that this would be a beneficial webinar for anyone within your organization. Just to let you know, in the future in may, we'll be focusing on serious mental illness or serious emotional distress.

Brian Clark:

That invite for those two offerings will be going out within the next few days because we're presenting that in early May. We're actually presenting two webinars in May. The second one is coding for all HEDIS measures, both Medicaid and dual eligible measures. We're going to be going over just codes for every single measure that we have been or we'll be discussing throughout this year. So, please, attend both of those offerings. June, that will be takeaways from HEDIS season 2018, project in review.

Brian Clark:

So, the HEDIS medical record review project is going on right now. We're just going to go over some things that we have learned from this season. And then, in July, we'll be focusing on back to school physicals and HEDIS measures affecting zero to 11 year old members with an additional focus on EPSDT. All right? That's the plan for the future.

Brian Clark:

I just want to thank everyone for attending today. We're a little bit over now, so I'll let you all get back to doing what you were doing, and appreciate you attending today. I'm going to leave the Q&A box open for about another 10 minutes. If anyone has any questions or comments, please feel free to type in the Q&A box and send to all panelists. Thanks for attending today, and have a great day.