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Johns Hopkins Health Plans

SPC - Statin Therapy for Patients with Cardiovascular Disease

Product Lines:
Advantage MD, EHP, Priority Partners, and USFHP.

Eligible Population:
Males 21-75 years of age and females 40-75 years of age as of December 31 of the measurement year. This includes HealthChoice Performance Measure reporting for Priority Partners. 

Definition:
The percentage of males 21-75 years of age and females 40-75 years of age as of December 31 of the measurement year, diagnosed with clinical atherosclerotic cardiovascular disease (ASCVD) and were dispensed at least one high or moderate-intensity statin medication during the measurement year.

The following rates are reported:

  1. Received Statin Therapy. Dispensed at least one medication during the measurement year.
  2. Statin Adherence 80%. Remained on medication for at least 80% of the treatment period.

Total Rate:  Report two age/gender stratifications and a total rate. 

  • Males 21–75 years as of December 31 of the measurement year. 
  • Females 40–75 years as of December 31 of the measurement year. 
  • Total.

*NOTE: All numerator compliant for Rate 1 must be used as the eligible population for Rate 2 (regardless of the data source used to capture the Rate 1 numerator).

Continuous Enrollment:

  • The measurement year and the year prior to the measurement year.

Best Practice and Measure Tips

The treatment period is defined as the earliest prescription dispensing date in the measurement year for any statin medication of at least moderate intensity through the last day of the measurement year.

  • Consider prescribing a high or moderate intensity statin, as appropriate.
  • Member must use their insurance card to fill one of the statins or statin combination medications through the last day of the measurement year.
    • Gap closure is depended on pharmacy claims.
    • Encourage member to obtain 90 days supplies at their pharmacy. 
    • Consider adding directives to prescriptions instructing the pharmacy to run it through the patient’s pharmacy benefit. The use of discount programs, paying cash for medication and medication samples will not count toward gap closure.
  • Educate members: Statin use should always be accompanied by lifestyle modifications focused on diet and weight loss to improve a patient's lipid panel.
  • Experiencing adverse effects:
    • Instruct patients to contact their practitioner if they are experiencing adverse effects.
    • Document any adverse effects from statin therapy.
    • Determine if the signs/symptoms qualify as an exclusion.
    • Try reducing the dose or frequency or consider trying a different statin medication.
  • Members are identified by event or diagnosis.
    • Event: Discharged from an inpatient setting with a myocardial infarction (MI Value Set) and/or old myocardial infraction (Old Myocardial Infarction Value Set) on the discharge claim. CABG, PCI or any other revascularization in any setting the year prior to the measurement year.
    • Diagnosis: Identify members as having ischemic vascular disease (IVD) who met at least one of the following criteria during both the measurement year and the year prior to the measurement year:
      • At least one outpatient visit, telephone visit, e-visit or virtual check-in with an IVD diagnosis.
      • At least one acute inpatient encounter with an IVD diagnosis without telehealth.
      • At least one acute inpatient discharge with an IVD diagnosis on the discharge claim.
  • Mail Order Pharmacy Program
    • Advantage MD Mail Order Best Practices
      • One of the most important ways to improve the health of our members is to make sure they receive and take their medications as you prescribe. Our mail order pharmacy, CVS Caremark, can help. CVS Caremark sends a three month supply of maintenance medications in one fill, making it easier for the patient only having to fill four times a year. In addition, a three month supply of maintenance medication on Tier 1 through 4 is available through CVS Caremark mail order at a reduced copay. This means your patient can fill a 100-day supply of Tier 1 medication and a 90-day supply of Tier 2 through 4 medication for only 2 times the retail copay—saving them an equivalent of four retail copays per year. Talk to your patients today about mail order pharmacy with CVS Caremark for better health and health care spending. Doctors and staff can contact CVS Caremark by calling the number below, 24 hours a day, seven days a week.
    • EHP CVS Caremark® Mail Service Pharmacy (mail order prescriptions):
      • This service offers a convenient and cost-effective option for obtaining medications on an ongoing basis. Members receive up to a 90 day supply of chronic use medications, delivered to their door.
      • Provider can send an electronic prescription to CVS Caremark® Mail Service Pharmacy. This is the easiest way to get started – Member can expect to get their medication in 7 to 10 business days.
      • For more information visit CVS Caremark.
    • US Family Health Plan
      • Home delivery is available to USFHP members for up to a 90-day supply of approved medications through Walgreens pharmacy. Home delivery is best suited for medications you take on a regular basis. 
      • Members who live in Maryland: 
        • To obtain prescription through home delivery complete the Maryland mail order form and send it in with your valid prescription. 
        • Refills: recommend members to reorder at least two weeks before supply runs out to ensure members receive their refill on time.
          • Walgreens Pharmacy
          • 2700 Remington Ave.
          • Baltimore, MD 21211
          • Phone: 410-235-2128
          • Fax: 410-889-1609
      • Members who live outside of Maryland:

Measure Exclusions

Required Exclusions:

  • Members 66 years of age and older as of December 31 of the measurement year (all product lines) with frailty and advanced illness.
  • Myalgia or rhabdomyolysis caused by a statin any time during the member’s history through December 31 of the measurement year.

Any time during the measurement year or the prior year:

  • Members with a diagnosis of pregnancy
  • In vitro fertilization
  • Dispensed at least one prescription for clomiphene
  • ESRD or dialysis
  • Cirrhosis

During the Measurement Year:

  • Myalgia
  • Myositis
  • Myopathy
  • Rhabdomyolysis 
  • Palliative Care
  • Members in hospice or using hospice services.
  • Members who died.
  • Medicare members 66 years of age and older by the end of the measurement period who meet either of the following:
    • Enrolled in an Institutional SNP (I-SNP)
    • Living in Long Term Care 
       

Exclusion Codes

Common diagnosis codes for exclusion:

  • Muscular Pain 
    • Myopathy ICD-10-CM: G72.0, G72.2, G72.9
    • Myositis ICD-10-CM: M60.80, M60.811, M60.812, M60.819, M60.821, M60.822, M60.829, M60.831, M60.832, M60.839, M60.841, M60.842, M60.849, M60.851, M60.852, M60.859, M60.861, M60.862, M60.869, M60.871, M60.872, M60.879, M60.88, M60.89, M60.9
    • Rhabdomyolysis ICD-10-CM: M62.82
    • Myalgia ICD-10-CM: M79.10, M79.11, M79.12, M79.18
  • Cirrhosis 
    • ICD-10-CM: K70.30, K70.31, K71.7, K74.3, K74.4, K74.5, K74.60, K74.69, P78.81
  • ESRD 
    • ICD-10-CM: N18.5, N18.6, Z99.2

Measure Medications

To comply with this measure, one of the following medications must have been dispensed:

High and Moderate-Intensity Statin Medications

Description Prescription
High-intensity statin therapy
  • Atorvastatin 40-80 mg
  • Amlodipine-atorvastatin 40-80 mg
  • Rosuvastatin 20-40 mg
  • Simvastatin 80 mg
  • Ezetimibe-simvastatin 80 mg
Moderate-intensity statin therapy
  • Atorvastatin 10-20 mg
  • Amlodipine-atorvastatin 10-20 mg
  • Rosuvastatin 5-10 mg
  • Simvastatin 20-40 mg
  • Ezetimibe-simvastatin 20-40 mg
  • Pravastatin 40-80 mg
  • Lovastatin 40 mg
  • Fluvastatin 40-80 mg
  • Pitavastatin 1-4 mg