PROVISIONARY MEASURES

CLINICAL DEPRESSION FOLLOW-UP CARE Adequate follow up care is essential in caring for patients identified as experiencing depression. The CBI Program incentivizes PCPs to monitor patients with depression and establish routine follow up care to reduce adverse occurrences and healthcare expenditures.

MEASURE DESCRIPTION: The percentage of patient’s ages 12 years and older, including pregnant and post-partum women, who are screened for clinical depression using a standardized depression screening tool and who, if screened positive for depression, received follow up care within 30 days. Screening should be completed annually in addition to clinical judgment and/or member life events.

MEMBER REQUIREMENT: PCP must have five members that meet the eligible population criteria.

ELIGIBLE POPULATION:

Membership: Linked members enrolled in the Medi-Cal program in Santa Cruz, Monterey or Merced counties, excluding Dual Coverage members.

Ages: All patients 12 years and older

Continuous Enrollment: Rolling 12 months with a 45 day allowable gap

Eligible Member Event/Diagnosis: none, all members meeting above criteria are eligible.

Exclusions:  Members with a diagnosis of Bipolar Depression during the past 24 months  Members diagnosed with Depression during the measurement period (rolling 12 months)  Members enrolled in Hospice services during the measurement period  California Children’s Services (CCS) Members

DENOMINATOR: Members in the Eligible Population who were screened for depression (indicated by G8431 code) as having a positive depression screening

NUMERATOR: Members who receive appropriate follow up care. Follow-up plan MUST include one or more of the following within 30 days. See below for list of qualifying codes.  Follow-up behavioral health encounter, with or without a telehealth modifier, including assessment, therapy, collaborative care, medication management, acute care and telehealth encounters.

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 A follow-up outpatient visit, with a diagnosis of depression or other behavioral health condition with or without a telehealth modifier.  A telephone visit with a diagnosis of depression or other behavioral health condition.  Follow-up with a case manager, with documented assessment of depression symptoms (any encounter that addresses depression symptoms).  Dispensed an antidepressant medication. See medication table below.

TABLE: ANTIDEPRESSANT MEDICATIONS Description Prescription Miscellaneous  antidepressants  Monoamine oxidase  Isocarboxazid inhibitors  Phenelzine  Selegiline  Tranylcypromine Phenylpiperazine  antidepressants  Psychotherapeutic  -chlordiazepoxide combinations  Amitriptyline-perphenazine  -olanzapine SNRI antidepressants  SSRI antidepressants   Fluoxetine  Tetracyclic  antidepressants  Mirtazapine Tricyclic antidepressants  Amitriptyline  (>6 mg) 

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SERVICING PCP SITE REQUIREMENT: Credit is given to the linked PCP site at the end of the measurement period. The linked PCP site does not have to be the provider site who performed the screening.

PAYMENT FREQUENCY: This is a provisionary measure; there is no payment for 2018.

CALCULATION: Number members with documented and appropriately billed depression screening follow up care/total members with positive depression screening.

RESOURCES: Clinical Depression Screening and Follow-up Tip Sheet

Documentation must include a standardized Depression screening tool. Screening tools do not need to be sent to the Alliance. However, please make sure these are maintained in the patient’s medical record. Examples of standardized screening tools include but are not limited to: . Adolescent Screening Tools (12-17 years) PHQ-A . Adult Screening Tools (18 years and older) PHQ-2 followed by PHQ-9 (if PHQ-2 positive) . Older Adults Screening Tool PHQ-2 followed by GDS 5 or GDS 15 . Pregnant and Post-Partum Women EPDS, BDI, HAM-D

DATA SOURCE: Claims

CODE SETS: Clinical Depression Screening Codes We recommend providers report Quality Measure G codes, in addition to their regular encounter codes, to indicate a member was screened for depression using an age appropriate standardized depression screening tool and provide a follow-up plan with a positive result. Clinical Depression Screening Include Code Set Clinical Depression Screening Exclude Code Set

Clinical Depression Follow Up Codes Clinical Depression Follow-up Care Include Code Set Clinical Depression Follow-up Care Exclude Code Set Clinical Depression Follow-up Care Tips Sheet

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FORMULARY MEDICATION UTILIZATION: AIRDUO Within the same pharmacological class there is significant price variation between medications with the same FDA approved indication. In an effort to control pharmaceutical spending the Alliance has developed the Formulary Medication Utilization measures to encourage providers to utilize low cost prescriptions for eligible patients. We are encouraging providers to start eligible patients on AirDuo, and convert patients currently using Advair to AirDuo when possible.

MEASURE DESCRIPTION: This measure rates the performance of providers in utilizing preferred versus non preferred medications.

MEMBER REQUIREMENT: PCP must have five members that meet the eligible population criteria, as defined below.

ELIGIBLE POPULATION:

Membership: Linked members enrolled in the Medi-Cal program in Santa Cruz, Monterey or Merced counties, excluding Dual Coverage members.

Age: 12 years or older on the date of prescription fill

Continuous Enrollment: None

Eligible Member Event/Diagnosis: one paid claim for preferred or non-preferred medication within measurement period.

Exclusions: . Administrative Members at end of the measurement period . Members with other health coverage on date of prescription . Medicare Part D on date of prescription fill . Denied and pending claims . California Children’s Services (CCS) Members on date of prescription fill

DENOMINATOR: # of paid prescription claims for non-preferred medications Advair HFA, Advair diskus and preferred AirDuo Respiclick and the generic equivalent.

NUMERATOR: # of paid prescription claims for preferred AirDuo Respiclick and the generic equivalent

SERVICING PCP SITE REQUIREMENTS: Prescribing history is attributed to the PCP site the member is linked to at the end of the measurement period, regardless of the prescribing provider.

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DATA SOURCE: Pharmacy claims

CALCULATION FORMULA: # of paid prescriptions claims for AirDuo medications / # of paid prescription claims for non-preferred (Advair HFA, Advair diskus) and preferred (AirDuo) medications.

PAYMENT FREQUENCY: This is a provisionary measure; there is no payment for 2018.

RESOURCES: 2018 Programmatic Measure Benchmarks

CODE SET: Preferred and Non Preferred medications are identified using the GCN number associated with the prescribed medications. Non Preferred medications can be in the same GCN class as the Preferred Medication, we are using the GCN code paired with the Manufacturer Code to differentiate Preferred and Non Preferred. See specifications below.

Non Preferred Medication GCN Codes:  GCN Codes 97137, 97135, 97136, 50584, 50594, 50604  GCN Codes 42956, 42957, 42958 without manufacturer code for TEVA SPECIALTY and TEVA

Preferred Medication (Numerator) GCN codes:  GCN Codes 42956, 42957, 42958 with manufacturer code for TEVA SPECIALTY and TEVA

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FORMULARY MEDICATION UTILIZATION: BASAGLAR Within the same pharmacological class there is significant price variation between medications with the same FDA approved indication. In an effort to control pharmaceutical spending the Alliance has developed the Formulary Medication Utilization measures to encourage providers to utilize low cost prescriptions for their eligible patients. We are encouraging providers to start eligible patients on Basaglar, and convert patients currently using Lantus Solostar pens, Lantus vials, Levemir, Levemir Pens to Basalgar when possible.

MEASURE DESCRIPTION: This measure rates the performance of providers in utilizing preferred versus non preferred medications.

MEMBER REQUIREMENT: PCP must have five members that meet the eligible population criteria.

ELIGIBLE POPULATION:

Membership: Linked members enrolled in the Medi-Cal program in Santa Cruz, Monterey or Merced counties, excluding Dual Coverage members.

Age: 21 years or older on the date of prescription fill

Continuous Enrollment: None

Eligible Member Event/Diagnosis: one paid claim for preferred or non-preferred medication within measurement period.

Exclusions: . Administrative Members at end of the measurement period . Members with other health coverage on date of prescription fill . Medicare Part D on date of prescriptionfill . Denied and pending claims . California Children’s Services (CCS) Members on date of prescription fill

DENOMINATOR: # of paid prescription claims for non-preferred medications, Lantus Solostar pens, Lantus vials, Levemir vials, Levemir Pens and preferred Basaglar Kwikpens

NUMERATOR: # of paid prescription claims for preferred Basaglar Kwikpens

SERVICING PCP SITE REQUIREMENTS: Prescribing history is attributed to the PCP site the member is linked to at the end of the measurement period, regardless of the prescribing provider.

DATA SOURCE: Pharmacy claims

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CALCULATION FORMULA: # of paid prescriptions claims for Basaglar Kwikpens medications / # of paid prescription claims for non-preferred (Lantus Solostar pens, Lantus vials, Levemir vials, Levemir Pens) and preferred (Basaglar Kwikpens) medications

PAYMENT FREQUENCY: This is a provisionary measure; there is no payment for 2018.

RESOURCES: 2018 Programmatic Measure Benchmarks

CODE SET: Preferred and Non Preferred medications are identified using the GCN number associated with the prescribed medications. Non Preferred medications can be in the same GCN class as the Preferred Medication, we are using the GCN code paired with the Manufacturer Code to differentiate Preferred and Non Preferred. See specifications below.

Non Preferred Medication GCN Codes:  GCN Codes 13072, 22836, 25305  GCN Code 98637 without manufacturer code: ELI LILLY & CO.

Preferred Medication (Numerator) GCN Codes: . GCN Code: 98637 with manufacturer code: ELI LILLY & CO.

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IMMUNIZATIONS FOR ADOLESCENTS (IMA) . The HPV vaccine protects against most of the cancers caused by the Human Papillomavirus (HPV) infection that can affect male and female patients. HPV infection can cause cervical, vaginal, and vulvar cancers in women and penile cancer in men. HPV can also cause anal cancer, throat cancer, and genital warts in both men and women.

The CBI Program incentivizes PCPs to monitor adolescent vaccines and establish routine preventive care to reduce health care costs.

MEASURE DESCRIPTION: The percentage of adolescents 13 years of age who had one dose of meningococcal conjugate vaccine, one tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine, and have completed the human papillomavirus (HPV) vaccine series by their 13th birthday.

MEMBER REQUIREMENT: PCP must have five members that meet the eligible population criteria, as defined below.

ELIGIBLE POPULATION: Membership: Linked members enrolled in the Medi-Cal program in Santa Cruz, Monterey or Merced counties, excluding Dual Coverage members.

Ages: Adolescents who turned 13 years of age during the measurement period

Continuous Enrollment: 12 months prior to the member’s 13th birthday

Eligible Member Event/Diagnosis: None

Exclusions: . Administrative Members on date of 13th birthday . Members with other health coverage . Medi-Medi Members . Anaphylactic reaction to the vaccine or its components any time on or before the member’s 13th birthday. . California Children’s Services (CCS) Members

DENOMINATOR: The eligible population as defined above

NUMERATOR: Members who received one dose of Meningococcal conjugate, one dose of Tdap, and 2 doses of HPV

SERVICING PCP SITE REQUIREMENT: Credit is given to the linked PCP site at the date when the member turns 13 years old. The linked PCP site does not have to be the provider site who administered

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the vaccinations. We encourage providers to enter all vaccination history, from those vaccines administered at your site, or another provider office, into the immunization registry.

PAYMENT FREQUENCY: This is a provisionary measure; there is no payment for 2018.

DATA SOURCE: Claims and immunization registries (CAIR & RIDE)

CALCULATION FORMULA: Number of members who receive one dose of Meningococcal conjugate, one dose of Tdap, and 2 doses of HPV/total qualifying 13 year olds.

PROVIDER PORTAL: The portal provides a list of your linked members who, according to our records, may not have had a one or more of the vaccinations listed above. This list is based on submitted claims and immunization registry information.

Note: This list is subject to claims lag, and members on this list may include members that have not yet been seen at your office, but who are linked to your practice. We recommend cross referencing this list with your EHR.

RESOURCES: IMA: Immunizations for Adolescents Include Code Set IMA: Immunizations for Adolescents Exclude Code Set Immunizations for Adolescents (IMA) Tip Sheet CAIR Immunization Registry http://cairweb.org/ RIDE (Healthy Futures) Immunization Registry http://www.myhealthyfutures.org/

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