HEDIS^® Measurement Year 2027 Post-Public Comment Summary Report

Overall, commenters supported the new measure concept. Major themes were as follows:

1. While some commenters noted that assessing continuous glucose monitoring (CGM) utilization would encourage more complete documentation and adoption of CGM, and supported stratification by race and ethnicity to identify disparities, others expressed a preference for outcome-based measures and raised concerns about the actionability of a utilization measure.
2. While some commenters confirmed that CGM utilization data is available across claims and clinical sources, others raised concerns about inconsistent documentation, incomplete data, cross-source reconciliation and data accuracy, including device variability, calibration requirements and challenges capturing utilization due to over-the-counter purchases, unfilled prescriptions and unstructured data.
3. Commenters provided feedback on the measure design, including suggestions to expand the age range to include children and support for the diabetes type stratifications, with some feedback on their definitions.
4. Commenters raised concerns about health plan reporting for those without CGM coverage, noting variation across product lines and states, as well as reporting requirements tied to inclusion of the measure in programs.

1. NCQA maintained the race and ethnicity stratifications and retained the measure as a utilization measure to support initial implementation and feasibility. NCQA will continue exploring CGM outcome measurement, with CGD-E intended to assess utilization as an initial step.
2. To support feasibility, NCQA maintained the focus on documented utilization (rather than metrics) and retained multiple pathways across data sources and code systems to identify CGM use. NCQA did not adopt the suggestion to count unfilled orders as CGM use.
3. NCQA updated the diabetes type stratification criteria based on testing and stakeholder input. The 18–75 age range was retained to align with existing HEDIS diabetes measures focused on adults, though NCQA will continue to evaluate opportunities to expand to additional populations.
4. NCQA added a pharmacy benefit requirement in addition to the medical benefit requirement in response to stakeholder feedback on variation in CGM coverage and related reporting concerns.

Decision: Add the CGD-E measure for MY 2027.

Overall, commenters supported the new measure concept. Major themes were as follows:

1. Commenters noted the importance of timely follow-up for stool-based tests, and that screening is not complete without this crucial step.
2. Some commenters expressed concerns about data feasibility and the ability to capture positive stool-based test results. Commenters noted challenges with access to structured laboratory data and linking results to follow-up colonoscopy.
3. One commenter proposed NCQA consider excluding individuals with prior colonoscopies.
4. There was majority support on the follow-up timeframe. Most comments supported the 180-day timeframe as feasible, while a few commenters recommended shorter timeframes to reflect clinical urgency or longer timeframes to address access constraints.
5. There was mixed feedback on including and stratifying adults ages 76–85. Some supported the stratification to maintain visibility in older adults, while others raised concerns about clinical appropriateness and alignment with guidelines.
6. Commenters raised concerns about the denominator definition, including distinguishing screening from diagnostic tests and the exclusion of certain FDA-approved screening modalities.

1. NCQA agrees with stakeholder feedback about the measure’s importance.
2. NCQA acknowledges that current reportability may be limited but notes that data feasibility should improve over time.
3. NCQA added an exclusion for individuals that receive a colonoscopy in the year prior given expert feedback.
4. NCQA maintained the proposed 180-day time frame.
5. NCQA will remove the 76–85 age stratification in the final version of the specification.
6. NCQA added an exclusion for stool-based test results that occur during an inpatient, ED or observation stay.

Decision: Add the COF-E measure, with the 45–75 age stratification only, for MY 2027.

Overall, there was mixed support for the new measure concept. Major themes were as follows:

1. Commenters supported integrating the CUES framework, with some viewing it as essential, but some raised concerns about data capture, electronic health record (EHR) integration and maintaining confidentiality.
2. Commenters were split around the follow-up window timing, with many favoring a 30-day window for feasibility and alignment with other measures, while others urged a 7-day window to reflect urgency; some recommended tracking both.
3. Meaningful concerns were raised about patient safety, data privacy and underreporting due to fear of disclosure, especially given potential access to records by abusers or third parties.
4. Commenters noted that inadequate resources, training and infrastructure may hinder effective implementation, risking unsafe or impractical expectations for providers.

Based on stakeholder feedback, NCQA will consider whether additional testing is needed and may include an updated version of the PVS-E measure in a future volume of HEDIS.

Decision: Delay inclusion of PVS-E in HEDIS.

• Person-Centered Outcome – Goal Identification (GID-E)
• Person-Centered Outcome – Goal Follow-Up (GIF-E)
• Person-Centered Outcome – Goal Achievement (GIA-E)

Overall, there was mixed support for the new measure concepts. Major themes were as follows:

1. Commenters recommended a phased or incremental approach to implementation, and a substantial number of commenters supported delaying public reporting of the GIA-E measure to allow time for workflow development, access to relevant data systems and performance monitoring.
2. There were some concerns expressed by commenters around feasibility, interoperability challenges, additional provider burden and duplication of existing processes.
3. Some commenters highlighted concerns about potential gaming of the measures and variations in performance, emphasizing the need for safeguards to ensure that goal difficulty and progress ratings accurately represent meaningful change.

1. Based on stakeholder feedback, NCQA decided to recommend approval of all three measures for HEDIS MY 2027, with a decision to keep the GIA-E measure in first year reporting status for at least two years.
2. To support implementation, NCQA will publish the annual measure specifications and supporting implementation guidance, including clarifications on alignment with Model of Care requirements.
3. NCQA has established audit guidelines that assess the appropriateness of both the selected goals and the scaling used to measure progress. NCQA will continue to monitor feasibility, administrative burden and potential unintended consequences (including gaming) during first-year reporting and make any necessary refinements to the measure specifications.

Decision: Add the GID-E, GIF-E and GIA-E measures for MY 2027.

Overall, commenters supported the new measure concept. Major themes were as follows:

1. Commenters expressed concern with plans’ ability to access syphilis screening results. Commenters that indicated they had access to syphilis screening results stated they were not mapped onto SNOMED codes.
2. Commenters were largely supportive of a future version of the measure including additional rescreening time points to align with current clinical guidelines. Commenters suggested phasing in additional rescreening criterion pending measure implementation.
3. Some commenters suggested this measure may not be most appropriate at the plan-level, given many determinants of prenatal syphilis screening and follow-up occurs outside of direct plan control.
4. Some commenters questioned whether the measure offers sufficient opportunity for improvement given prenatal syphilis screening rates are already high and expressed concerns about small-denominator issues, particularly for follow-up after positive results.

1. NCQA acknowledges concerns with data limitations regarding access to syphilis screening results and small denominator concerns for the follow-up rate. In response to stakeholder feedback, NCQA has removed the follow-up indicator from this measure.
2. NCQA appreciates the support for the inclusion of additional screenings, as aligned with ACOG guidance for syphilis screening during pregnancy. NCQA will continue to assess data feasibility and will consider phasing in additional screenings when appropriate.
3. NCQA acknowledges the challenge in accurately assessing follow-up for health plans given limitations of lab data. NCQA is no longer proposing to include follow-up to a positive syphilis screen in the measure.
4. Although syphilis screening is a recommended component of routine prenatal care, there is still room for improvement, especially considering the growing burden of prenatal syphilis nationally. There is currently no standardized national measure to assess and monitor screening performance across healthcare organizations.

Decision: Add the PSY-E measure, without the follow-up indicator, for MY 2027.

• Expand the denominator age range (≥50 years of age).
• Add stratification for individuals 50–64 years of age.

Overall, commenters supported the proposed updates to the AIS-E pneumococcal indicator. Major themes were as follows:

1. Several commenters raised concerns about ongoing immunization data capture and reporting challenges and their impact on measure performance.
2. Vaccine hesitancy was flagged as a potential measure reporting and accountability challenge. A few commenters noted that individuals at the younger end of the updated age range (50–64) may be less motivated to receive recommended vaccines and suggested adding an exclusion for documented patient refusals.
3. Commenters expressed concern about how this update would impact benchmarking and indicator performance rates. Several commenters suggested that NCQA delay implementation of the proposed updates to allow plans time to encourage newly eligible members to receive the vaccine. Some commenters also recommended removing the measure from public reporting until the impact of the updates is understood.

NCQA will include the updated AIS-E pneumococcal indicator specifications in HEDIS for MY 2027.

1. While NCQA acknowledges the challenges associated with immunization data capture and reporting, these issues affect all AIS-E indicators and other HEDIS immunizations measures. NCQA has specified AIS-E with ECDS methodology to support collection of immunization information from multiple sources and includes self-reported immunizations. NCQA will continue to work with stakeholders to improve immunization registry interoperability to support data availability.
2. The intent of NCQA’s immunizations measures is to encourage plans and providers to engage in best practices for immunizations, which includes continued patient engagement after a refusal. While NCQA appreciates commenter feedback, we believe that a patient refusal exclusion may unintentionally reduce opportunities for providers and plans to educate patients and encourage recommended immunizations. Additionally, recent testing efforts suggest that the data used to calculate the measure does not reliably capture patient refusals. NCQA plans to continue exploring the feasibility of incorporating patient refusals in future measure updates.
3. While NCQA understands the potential performance shifts associated with the expanded denominator age range, implementing these updates for MY 2027 is reasonable given that the relevant updated guidelines for pneumococcal vaccination have been in place for over a year. Further, NCQA acknowledges that performance reductions may result from the updated age range but underscores that these likely reflect gaps in immunization coverage that plans should work to address. Lastly, NCQA plans to include information in the MY 2027 HEDIS Trending Memo to support appropriate rate change interpretation.

Decision: Include the changes to the pneumococcal indicator in the AIS-E measure for MY 2027.

• Add the Medicaid product line for ages 18–64.

Overall, commenters supported the proposed changes for HEDIS MY 2027. Major themes were as follows:

1. Commenters expressed concern that, without additional adjustment for non-clinical risk factors, such as income or education level, plans serving higher risk or rural populations may be unfairly penalized.
2. Many commenters emphasized that emergency departments (EDs) often serve as the most accessible point of care for Medicaid members, particularly in rural areas, regions served by Critical Access Hospitals, areas with shortages of healthcare providers or areas with limited after-hours primary care and urgent care availability.
3. A few commenters questioned whether the proposed Medicaid outlier threshold of nine or more ED visits per member per year is appropriate or meaningful for identifying high utilization in the Medicaid population, particularly given that the thresholds for Medicare and commercial plans are set at a lower number of visits.

1. NCQA acknowledges the impact of non-clinical risk factors on health care utilization and outcomes; however, NCQA does not risk adjust for these factors because we believe health plans should provide the same level of care to all patients regardless of non-clinical factors.
2. NCQA recognizes that access to timely primary care and urgent care services varies across communities and that ED use may reflect broader system-level access challenges. NCQA appreciates this feedback and will consider how to incorporate this in the future.
3. NCQA will keep the proposed threshold of nine ED visits for the Medicaid product line. This threshold reflects observed utilization patterns in the Medicaid population, which is materially different from other populations in visit frequency, and is intended to identify members with exceptionally high ED use. The approach taken to determine the threshold among Medicaid plans was similar to the approach for Medicare and commercial plans, where NCQA calculated two standard deviations above the mean number of ED visits among members with at least one ED visit to determine the outlier threshold.

Decision: Add the Medicaid product line to the EDU measure for MY 2027.

• Add exclusion for individuals with asthma.
• Update the denominator to capture members with either in the MY:
  • One or more inpatient or observation stay with a COPD diagnosis in any claim position; or
  • Two or more ambulatory care visits (any combination): ED visit, urgent care visit, or ambulatory care visit with a COPD (exacerbation) diagnosis in any claim position.
• Update the numerator to capture dispensing events during the MY for a Short-Acting Beta Agonist (SABA) or Short-Acting Muscarinic Antagonist (SAMA); a Long-Acting Beta Agonist (LABA); and a Long-Acting Muscarinic Antagonist (LAMA).

Overall, comments supported proposed changes for HEDIS MY 2027. Major themes were as follows:

1. Most commenters supported adding an exclusion for individuals with asthma given different treatment approaches between asthma and COPD.
2. While some commenters supported using COPD diagnoses in any claim position to capture COPD exacerbations, others were concerned that these criteria would unintentionally capture COPD comorbidities as well.
3. Some commenters expressed concern that the medications required for the updated numerator would be inappropriate for some denominator members, particularly if the updated denominator was too broad and unintentionally captured members with COPD comorbidities (versus true COPD exacerbations).
4. A few commenters recommended accounting for prior or overlapping fills for SABA and SAMA medications using a lookback period that goes beyond the measurement year.

1. NCQA agrees with stakeholder feedback about the asthma exclusion.
2. Based on advisory panel expert and public comment feedback, NCQA revised the denominator to capture events with either a COPD diagnosis in the principal claim position or a COPD exacerbation diagnosis in any claim position. The denominator now more precisely identifies members with true COPD exacerbations (versus COPD comorbidities).
3. By revising the denominator to more precisely identify members experiencing COPD exacerbations, NCQA ensured that the “triple therapy” required by the numerator would be appropriate for the population included in the measure.
4. NCQA did not add a lookback period to account for prior and overlapping SABA and SAMA medications. Incorporating this specification component would require a higher continuous enrollment threshold that would limit reporting feasibility for minimal potential performance improvements.

Decision: Add the proposed changes, with a revised denominator, to the PCE measure for MY 2027.