Quality Metrics Tool for Schizophrenia

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 2020, HEDIS consists of 90+ measures across multiple domains of care that include preventive care services and chronic disease management.¹

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

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

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

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

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

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

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

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: NCQA
• Applicable to: Medicaid only
• Covers ages 18 and older

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

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

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

• Measure Steward: NCQA
• Applicable to: Medicaid only
• Covers ages 18 to 64

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

Description: The Star Ratings strategy is aligned with CMS' Three Aims: better care, healthier people/healthier communities, and lower costs through improvements. CMS Star measures for Medicare plans cover the following categories:

• Outcomes
• Intermediate outcomes
• Patient experience
• Access
• Process

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

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

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

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

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