Heart disease is a major contributor to the exponential rise in health care expenditures, costing the U.S. billions of dollars each year. As such, effectively managing high cholesterol is among the Centers for Medicare and Medicaid Services (CMS) key strategies to improve health outcomes. High cholesterol is a sneaky and silent health concern that raises the risk for serious conditions like peripheral artery disease, high blood pressure, and stroke.
Based on substantial evidence gathered in 2013 by the National Heart, Lung, and Blood Institute (NHLBI), the American College of Cardiology (ACC) and the American Heart Association (AHA) developed an evidence-based guideline for treating high blood cholesterol in adults to reduce the risk of heart disease and strokes. The main treatment outlined by the panel is a combined approach of promoting healthy lifestyles and the use of statins. These guidelines were used by CMS as a framework while creating three common quality measures related to cholesterol: Medication Adherence for Cholesterol (MAC), Statin Therapy for Patients with Cardiovascular Disease (SPC), and Statin Use in Persons with Diabetes (SUPD).
Medication Adherence for Cholesterol (MAC) – Patients ages 18 and above are included in this measure when the pharmacy dispenses a statin medication two or more times using the patient’s insurance benefit. Prescriptions filled often enough to cover 80% or more of the time a patient is supposed to be taking the medicine is considered compliant for quality reporting purposes.
Statin Therapy for Patients with Cardiovascular Disease (SPC) – Males aged 21-75 and females aged 40-75 with a diagnosis of atherosclerotic cardiovascular disease are included in this measure. A moderate or high-intensity statin filled using the patient’s insurance benefit is considered compliant for quality reporting purposes. The list of exclusions for this quality measure is lengthy.
Statin Use in Persons with Diabetes (SUPD) – Patients aged 40-75 with at least two fills of a diabetic medication are included in this measure. A statin filled using the patient’s insurance benefit is considered compliant for quality reporting purposes. The list of exclusions for this quality measure is lengthy as well, and different from the other statin quality measures.
To effectively manage high performance on statin-related quality measures, routine measuring and monitoring, as well as accurate reporting, is essential. These actions serve as a guide in assessing patients who are receiving statin therapy, those who may be appropriate for therapy, and those who are not candidates for statin therapy. Below are additional strategies and key points to consider when closing the quality gap on these important measures.
Medication Management Strategies
- Reconcile medications at each office visit
- Renew expired prescriptions at annual wellness visits
- If available, utilize pharmacy services for comprehensive medication management and drug information questions
- Initiate statin therapy, or (annually) accurately document and code appropriate statin exclusion codes
- Consider an alternative statin and/or dosage adjustment to reduce adverse effects
- Promote 90-day prescriptions and encourage mail order pharmacies for patients with transportation barriers
- Educate patients on the importance of medication adherence
- Discuss Med Sync for patients on multiple chronic medications
Key points to consider:
- Pharmacy-related quality measures account for a substantial portion of quality measure programs.
- High performance year over year may not keep pace with cut point changes released by CMS each year in October and could impact overall quality performance and associated incentives.
- Every percentage point counts toward the total quality score.
- related quality measures vary in their inclusion, exclusion, and compliance definitions.
- Detailed data analytics and performance dashboards, along with provider education on the nuances of each quality measure provide the foundation for mastering the metrics for quality reporting in parallel with providing evidence-based patient care.