Behavioral Health at Heart of Recommended Medicaid Measures From National Quality Forum

When the National Quality Forum (NQF) recently issued a series of reports recommending new measures that would improve the health of Medicaid patients, they boiled down to this: keep better tabs on patients’ behavioral health, and especially the way it affects diabetes and cardiovascular care.

NQF’s recommendations in the 3 reports to HHS, known as the Measure Applications Partnership or MAP reports, are designed to provide insight into how the department can improve healthcare quality to the 70 million adults and children now enrolled in Medicaid, a program that is growing as it expands under the Affordable Care Act.

Because Medicaid is delivered as a partnership between the federal and state governments, there is variety in funding and design from state to state, so the Core Sets of measures—one each for adults, children, and those dually eligible (who receive both Medicaid and Medicare) —are designed to track how well care is delivered across the states. Starting 4 years ago, NQF began providing guidance to HHS on improving the care for dual eligibles; it began advising on adults the following year and on children the year after that.

"An important goal of NQF's work on behalf of the Medicaid program is to help foster greater alignment across measures and use of the same measures across states," said NQF President and CEO Christine K. Cassel, MD. "In doing so, we would acheive better benchmarks and a strengthened ability to compared results across states while reducing the measurement burden on providers."

Recommendations for new measures in NQF’s 3 recent reports track trends in both mental health and diabetes care: a recognition of the interplay between diabetes and behavioral health, and how failing to address mental health problems can manifest itself in higher glycated hemoglobin (A1C) and cardiovascular effects. Accountable care organizations are required to identify how they are addressing behavioral health needs.

The need to jointly address both physical and mental health needs has been on the agenda at both the American Psychiatric Association and the US Psychiatric and Mental Health Congress; in 2014, a speaker at the latter meeting said psychiatrists should become familiar with the basics of prescribing diabetes medications, since so many of the therapies for serious mental illnesses cause side effects that make patients gain weight or develop diabetes.

As reported previously by The American Journal of Managed Care, the late Wayne Katon, MD, was a pioneer in the collaborative care movement, which seeks to embed behavioral health providers into primary care practices to ensure that diabetes and mental health issues are addressed together. Under this model, patients are more likely to show up at appointments and take medication, both physical and mental health symptoms improve, and the model ultimately saves money. Katon and his co-authors reported their findings in a landmark study in the New England Journal of Medicine; before he passed away in March 2015, Katon said the collaborative care concept had received more attention since the ACA passed than it had in his entire career.

NQF’s recommendations on adults reflect this concept as well as the recent attention from CDC and HHS Secretary Sylvia Mathews Burwell to opioid abuse, which she discussed directly with the nation’s governors at the summer meeting of the National Governors’ Association in West Virginia. CDC recently released data showing the death rate from heroin has quadrupled in a decade, with most of the increase coming in the past 5 years. Prescription opioid abuse is widely recognized as a common gateway to heroin addiction.

Recommendations for adults. There were recommendations for adding 9 and removing 1 measure. Recommendations reflect the fact that the working age population—the segment growing most rapidly—is not in good health. In this group, 57% are overweight, have diabetes, hypertension, high cholesterol or a combination of these conditions, according to the report. Recommended new measures to the Adult Core Set include:

· Controlling high blood pressure for persons with serious mental illness.

· Cardiovascular health screening for persons with schizophrenia or bipolar disorder who are prescribed antipsychotic medications.

· Two measures for use of opioids for multiple providers at high dosage in persons. without cancer: multiple provider, high dosage and multiple prescribers/multiple pharmacies. Of note, many states are passing laws to track and prevent these abuses.

· Effective postpartum contraception access, and use of contraception for women aged 21-44 years of age.

· Medication management for people with asthma.

Recommendations for children. NQF recommended 6 new measures, some of which amplified recommendations in the report for adults. These include:

· Infants under 1500g not delivered at the appropriate level of care.

· Use of multiple antipsychotics at the same time in children and adolescents.

· Effective postpartum contraception access, and effective contraception access for adolescents 15-20 years of age.

· Audiological evaluation no later than 3 years of age.

· A pediatric all-condition readmission measure.

Recommendations for Dual Eligibles. The unique needs of the population who receive both Medicaid and Medicare resulted in recommendations for 18 new measures, many of which involved behavioral health and comorbidities. Care coordination received attention as well, as lack of attention here drives much of the cost for these 10 million Americans, who account for 34% of Medicare spending, or $340 billion each year. Recommendations for new measures here include:

Behavioral Health:

· Suicide risk assessment for adult major depressive disorder and bipolar disorder.

· Substance abuse screening/prevention composite.

· Alcohol screening/follow-up for those with serious mental illness.

· Tobacco screening/follow-up for those with serious mental illness.

· Follow-up after discharge from emergency room for mental health or alcohol/drug dependence.

Diabetes/Cardiovascular and Behavioral Health:

· Body Mass Index/follow-up for those with serious mental illness.

· Controlling high blood pressure for those with serious mental illness.

· Diabetes care for those with serious mental illness: attention for nephropathy care.

· Diabetes care for those with serious mental illness: A1C testing.

· Diabetes care for those with serious mental illness: A1C control > 9.0%.

· Diabetes care for those with serious mental illness: A1C control < 8.0%.

· Diabetes care for those with serious mental illness: eye exam.

Care Coordination/Other Readmission:

· Rehospitalization during first 30 days of home health.

· Medication reconciliation: number of unintentional medication discrepancies per patient.

· All-cause unplanned readmission measure for 30 days post discharge from inpatient rehabilitation facilities.

· Emergency department use without hospital readmission during first 30 days of home health.

· Skilled nursing facility 30-day all-cause readmission measure.

· All-cause unplanned readmission measure for 30-days post discharge from long-term care hospitals.