Medicare Advantage (MA) is the growing public/private form of Medicare that now over half of Medicare beneficiaries are enrolled in. The quality of MA programs is rated using Star Ratings, with 1 being the lowest score and 5 the highest. MA plan payment is tied to Star Rating performance, so plans have a strong incentive to aim for high Star Rating scores.
Star Ratings are determined by performance against a set of measures, the Healthcare Effectiveness Data and Information Set or HEDIS. These track performance on key aspects of care and service. HEDIS measures are managed by the National Committee for Quality Assurance, NCQA. Measure development and updates follow a rigorous development and evaluation process that includes a public comment period and input from advisory panels.
Over the last few years, there have been two encouraging developments with HEDIS and serious illness care:
Advance care planning (ACP) – In 2022, ACP was added as a new HEDIS measure. That means providers can be reimbursed for having discussions regarding ACP with MA members. C-TAC has long promoted ACP as a way to help people prepare for current and future decisions about their medical treatment, plans and even place of care, so this was an encouraging development.
The added ACP HEDIS measure is to be used with MA members 66 to 80 years of age with:
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- Advanced illness,
- An indication of frailty, OR
- Who are receiving palliative care, AND
- Adults 81 years of age and older who had advance care planning during the measurement year
[kp_table table_title=”From a billing standpoint, the following codes should be included in ACP claims:”]
| Code | Definition | Code System |
|---|---|---|
| 99483 | Assessment of and care planning for a patient with cognitive impairment | CPT |
| 99497 | Advance care planning, including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed) provided by the physician or other qualified health care professional | CPT |
| 1123F | Advance care planning discussed and documented advance care plan or surrogate decision maker documented in the medical record (DEM) (GER, Pall Cr) | CPT II |
| 1124F | Advance care planning discussed and documented in the medical record, patient did not wish or was not able to name a surrogate decision-maker or provide an advance care plan (DEM) (GER, Pall Cr) | CPT II |
| 1157F | Advance care plan or similar legal document present in the medical record (COA) | CPT II |
| 1158F | Advance care planning discussion documented in the medical record (COA) | CPT II |
| S0257 | Counseling and discussion regarding advance directives or end of life care planning and decisions, with patient and/or surrogate (list separately in addition to code for appropriate evaluation and management service) | HCPCS |
| Z66 | Do not resuscitate | ICD10 |
[/kp_table]
Advanced Illness Exclusion – In 2019, HEDIS began excluding MA members with advanced illness and frailty from HEDIS measures not pertinent to that population. This acknowledged that measures designed and intended for a general adult population may not always be appropriate for those with limited life expectancy or advanced illness and frailty. The following measures now exclude individuals 65 and older who have an advanced illness and frailty or who live long-term in nursing home settings or those age 80 and older with frailty:
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- Breast Cancer Screening
- Colorectal Cancer Screening
- Controlling High Blood Pressure
- Osteoporosis Management in Women Who Had a Fracture
- Comprehensive Diabetes Care
- Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis
- Persistence of Beta-Blocker Treatment After Heart Attack
- Statin Therapy for Patients with Cardiovascular Disease
- Statin Therapy for Patients with Diabetes
Annual Updates – To make sure HEDIS measures stay current, the NCQA reviews them each year. Any changes are open for public comment and recently C-TAC commented on these measures:
Proposed Changes to Existing Measures – Acute Hospital Utilization – expand to Medicaid
C-TAC supported expanding this measure to the Medicaid program as acute hospital utilization is often a marker of progression in a serious illness and an opportunity to identify patients who could benefit from also getting palliative care services. There is evidence that palliative care can reduce the need for acute hospitalizations and, since more states are exploring adding a palliative care benefit to their state Medicaid programs, including this important measure in those programs will allow states to gauge their performance on it. Acute hospitalization is also a quality-of-life issue as most people would prefer not to need to be hospitalized, so adding it also speaks to people’s quality of life.
Follow-Up After Emergency Department Visit for Mental Illness and Follow-Up After Hospitalization for Mental Illness – expand types of mental illness covered
C-TAC supported broadening the kinds of mental illnesses that should be included in this measure to ensure it meaningfully measures the range of mental health issues members are experiencing. We have all become more aware of and concerned about the prevalence of mental health issues and agree that follow-up from any hospitalization for them should include all possible members involved.
Cross-Cutting Items – Gender-Inclusive Measurement in HEDIS
C-TAC supported this effort to both fully capture all eligible individuals for interventions and as a sign of gender inclusion and affirmation. We support applying this approach to all other appropriate measures in the Medicare program as we believe that will help address disparities and improve access to care
