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

Measurement Period: January 1–December 31.

Description:
The percentage of persons 21–75 years of age during the measurement period who were identified as having clinical atherosclerotic cardiovascular disease (ASCVD) and met the following criteria. Two rates* are reported:

1. Received Statin Therapy. Persons who were dispensed at least one high-intensity or moderate-intensity statin medication during the measurement period.
2. Statin Adherence 80%. Persons who remained on a high-intensity or moderate-intensity statin medication for at least 80% of the treatment period.

Measure Reporting:
CMS Start Rating Measure.
HealthChoice Performance Measure reporting for Priority Partners.

Improvement Notation:
Increased score indicates improvement.

Data Collection:

• ECDS.

Initial Population:

• Measure Item Count: Person.
• Age: 21–75 years of age as of the last day of the measurement period.
• Benefits: Medical. Pharmacy during the measurement period.
• Continuous Enrollment: The measurement period and the year prior to the measurement period.
• Allowable gap: No more than one gap of ≤45 days during each year of continuous enrollment. No gaps on the last day of the measurement period.

Definition:
IPSD- Index prescription start date: The earliest prescription dispensing date for any statin medication of at least moderate intensity during the measurement period.

PDC- Proportion of days covered: The number of days the person is covered by at least one statin medication prescription of appropriate intensity, divided by the number of days in the treatment period.

Treatment period: The period of time beginning on the IPSD through the last day of the measurement period.

Denominator:

Persons with clinical atherosclerotic cardiovascular disease. Either of the following meets criteria:

• Any of the following during the year prior to the measurement period meet criteria:
  • Discharged from an inpatient setting with a myocardial infraction (MI) on the discharge claim.
  • Coronary artery bypass graft (CABG) in any setting.
  • Percutaneous coronary intervention (PCI) in any setting.
  • Any other revascularization procedures in any setting.
• At least two diagnoses of Atherosclerotic Cardiovascular Disease (ASCVD) on different dates of service during the measurement period or the year prior to the measurement period.

Denominator 1: Received statin therapy.
Persons who meet specified age and clinical criteria—based on qualifying cardiovascular events or diagnoses—and do not meet any denominator exclusion criteria and receives statin therapy.

Denominator 2: Statin adherence 80%.
Persons who meet numerator 1 criteria.

Note: All persons who are numerator compliant for Rate 1 must be used as the denominator for Rate 2.

Numerator:
Numerator 1 - Received statin therapy.
At least one dispensing event for a high-intensity or moderate-intensity statin medication during the measurement period.

Numerator 2 - Statin adherence 80%.
PDC of at least 80% during the treatment period.

Summary of changes:

• This is the first year the measure is reported using ECDS.
• Removed the Administrative Data Collection Method.
• Removed sex-specific age bands.
• Removed the requirement to use the same data source for rate 1 and rate 2.
• Updated the initial population criteria to identify persons with ASCVD diagnosis.
• Expanded ASCVD diagnosis criteria in the initial population to allow diagnosis in the measurement period or the year prior to the measurement period.
• Removed denominator exclusion for persons enrolled in an I-SNP or LTI.

Best Practice and Measure Tips

• 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 period.
  • Gap closure depends on pharmacy claims.
  • Evaluate the appropriateness of prescribing a 90-day supply to optimize medication adherence and reduce refill frequency.
  • Consider including prescribing directives that instruct the dispensing pharmacy to adjudicate the claim through the patient's pharmacy benefit plan. 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 based on qualifying clinical events or diagnoses; ensure claims are submitted with accurate and complete coding to support measure compliance.
• Start the conversation early. Engage your patients in a discussion about the importance of the medication(s) at the first prescription - right from the beginning. Setting the stage early can foster a sense of ownership and responsibility, helping them stay committed.
• Simplify the regimen. Complex medication schedules are a major barrier. Whenever possible, consider prescribing medications that are easier to manage—like once-daily doses, combination pills, or medications that can be taken with food.
• Encourage your patients to utilize technology. Medication reminder apps and digital health tools, in addition to pill boxes, can be incredibly effective in keeping patients on track.
• Monitor and follow up. Don’t wait for patients to report issues—proactively check in with them, whether through a follow-up call or appointment. Early intervention can prevent small issues from escalating into bigger problems.
• Ask about and address barriers head-on. Costs, side effects, and confusion are common barriers to adherence. Be proactive in identifying these issues and work with your patients to find affordable options or solutions to side effects.
• Involve Family and Caregivers. Having a support system can make a world of difference. Involve family members or caregivers in the discussion to help create a consistent, supportive environment for the patient.
• Reinforce Positive Behavior. When patients adhere to their medication regimen, celebrate those small wins. Positive reinforcement helps to build trust and motivates them to stay on course.

Measure Exclusions

Denominator Exclusions:

• Persons who use hospice services or elect to use a hospice benefit any time during the measurement period.
• Persons who died any time during the measurement year period.
• Persons receiving palliative care or who had an encounter for palliative care any time during the measurement period.
• Persons 66 years of age or older by the last day of the measurement period, with both frailty and advanced illness.
• Persons who received in vitro fertilization, had a diagnosis of pregnancy, or were dispensed at least one prescription for clomiphene during the measurement period or the year prior to the measurement period.
• Persons with a diagnosis of ESRD or cirrhosis, or who received dialysis during the measurement period or the year prior to the measurement period.
• Persons with myalgia, myositis, myopathy or rhabdomyolysis during the measurement period.
• Persons with myalgia or rhabdomyolysis caused by a statin any time during the person’s history through December 31 of the measurement period.

*Please note that not all ICD-10-CM and SNOMED CT US Edition codes are listed here. For access to the complete set of codes, contact your Provider Engagement Liaison or email [email protected].

Measure Medications

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

Statin Medications List
High-intensity statin therapy

• Amlodipine Atorvastatin
• Atorvastatin
• Ezetimibe Simvastatin
• Rosuvastatin
• Simvastatin

Moderate-intensity statin therapy

• Amlodipine Atorvastatin
• Atorvastatin
• Ezetimibe Simvastatin
• Fluvastatin
• Lovastatin
• Pitavastatin
• Pravastatin
• Rosuvastatin
• Simvastatin