2018 CBI Tech Specs

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. 2018 CBI TECHNICAL SPECIFICATIONS | CCAH P a g e | 55 of 72 Version 2018.5 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 Bupropion antidepressants Vilazodone Vortioxetine Monoamine oxidase Isocarboxazid inhibitors Phenelzine Selegiline Tranylcypromine Phenylpiperazine Nefazodone antidepressants Trazodone Psychotherapeutic Amitriptyline-chlordiazepoxide combinations Amitriptyline-perphenazine Fluoxetine-olanzapine SNRI antidepressants Desvenlafaxine Duloxetine Levomilnacipran Venlafaxine SSRI antidepressants Citalopram Escitalopram Fluoxetine Fluvoxamine Paroxetine Tetracyclic Maprotiline antidepressants Mirtazapine Tricyclic antidepressants Amitriptyline Amoxapine Clomipramine Desipramine Doxepin (>6 mg) Imipramine Nortriptyline Protriptyline Trimipramine 2018 CBI TECHNICAL SPECIFICATIONS | CCAH P a g e | 56 of 72 Version 2018.5 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 2018 CBI TECHNICAL SPECIFICATIONS | CCAH P a g e | 57 of 72 Version 2018.5 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. 2018 CBI TECHNICAL SPECIFICATIONS | CCAH P a g e | 58 of 72 Version 2018.5 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 2018 CBI TECHNICAL SPECIFICATIONS | CCAH P a g e | 59 of 72 Version 2018.5 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

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