NCQA Seeks Public’s Help On New and Revised Measures

Hedis®1 Public Comment is February 13–March 13

February 13, 2018

WASHINGTON, D.C.—The National Committee for Quality Assurance (NCQA) invites the public to commenton the Healthcare Effectiveness Data and Information Set (HEDIS®) measures. This is an opportunity for health plans, purchasers, consumers and other stakeholders to weigh in on the relevance, scientific soundness and feasibility of new and revised measures and to provide input on HEDIS guidelines.

NCQA seeks comments on the following:

  • New measures for HEDIS that assess risk of chronic opioid use, hospitalizations following discharge from a skilled nursing facility, health assessments for people with multiple high-risk chronic conditions, adult immunization status and prenatal immunization status.
  • Four new measures that will be part of a new HEDIS volume focusing on organizations that provide or coordinate long-term services and supports (LTSS).
  • Revisions to measures assessing blood pressure control, follow-up after emergency department visits for mental illness and hospital readmissions.
  • Ways to shorten and update the HEDIS Health Plan CAHPS®2(CAHPS 5.0H) survey to reflect current topics of interest to stakeholders.
  • Potential strategies to address issues that apply across multiple measures: exclusions for patients with advanced illness and the use of telehealth in physical health.
  • Two changes to the HEDIS General Guidelines.

About HEDIS and Public Comment

HEDIS comprises measures of clinical quality and patient experience that are based on published clinical guidelines and published scientific evidence. When clinical guidelines change or new evidence becomes available in the scientific literature, NCQA reviews HEDIS measures to determine whether changes may be needed. NCQA convenes multi-stakeholder advisory groups—including independent scientists, clinicians, consumers and purchasers—to ensure that measures meet and balance the high standards of relevance, scientific soundness and feasibility.

Public review and comment is an important part of developing and updating HEDIS measures. NCQA reviews all comments received during public comment and presents results to multi-stakeholder advisory groups and the NCQA Committee on Performance Measurement for deliberation.

NCQA’s HEDIS measures do not constitute clinical practice guidelines, nor should they be used to determine insurance or coverage.

Proposed New Measures

Risk of Chronic Opioid Use: Assesses whether members 18 years of age and older have a new episode of opioid use that lasts for at least 45 days of a 90-day period.

Importance: Research suggests that long-term opioid use often begins with the treatment of acute pain; additionally, there is a relationship between early prescribing patterns and long-term use of opioids. NCQA proposes this measure to assess members with a new episode of opioid use who are at risk of becoming chronic, or long-term, users of opioids.

Hospitalization Following Discharge From a Skilled Nursing Facility:Assesses skilled nursing discharges among Medicare members 18 years of age and older resulting in unplanned acute hospitalizations within a specified time frame.

Importance: Skilled nursing facilities (SNF) provide rehabilitation to ensure a safe and successful transition to the community, and are used most often by older beneficiaries with multiple comorbidities and complex care needs. This proposed new measure assesses the success of the SNF-to-community transition, care coordination and management of care needs in the community following discharge from an SNF.

Health Assessments for People With Multiple High-Risk Chronic Conditions: Assesses whether Medicare members 18 years and older with multiple high-risk chronic conditions received assessments and care management services.

Importance: Research demonstrates that patients with multiple high-risk chronic conditions consume more health care resources and suffer more adverse outcomes than other patients. The services reported in this proposed new measure are evidence-based recommendations that address gaps in care for this vulnerable group.

Adult Immunization Status: Assesses whether members 19 years of age and older are up to date on the following recommended routine vaccines: influenza, tetanus and diphtheria (Td) or tetanus, diphtheria and acellular pertussis (Tdap), herpes zoster and pneumococcal. The measure calculates a rate for each vaccine and a composite rate.

Prenatal Immunization Status: Assesses the percentage of pregnancies during the measurement period when women received influenza and Tdap vaccines.

Importance: These immunizations are intended to protect adults and pregnant women from serious illness and death, and, in the case of prenatal immunizations, provide protection for infants after birth. Despite these recommendations, vaccination coverage levels among adults and prenatal women are low.

Long-Term Services and Supports (LTSS) Measures: This set of measures will provide information about the quality of LTSS for Medicaid plans and case management organizations providing LTSS:

  • LTSS Comprehensive Assessment and Update.
  • LTSS Comprehensive Care Plan and Update.
  • LTSS Shared Care Plan With Primary Care Physician.
  • LTSS Reassessment/Care Plan Update After Inpatient Discharge.

Importance: Person-centered care planning is critical to ensuring that adults with functional limitations and chronic illnesses receive care that helps them live as independently as possible. These proposed new measures, developed with support from CMS and in partnership with Mathematica Policy Research, will encourage transparency and accountability for organizations providing LTSS, including Medicaid plans and community-based organizations.

Proposed Changes to Existing Measures

Controlling High Blood Pressure: NCQA proposes changing the blood pressure target to <140/90 mm Hg for all patients 18–85 years of age with hypertension. This target is appropriate and feasible for use in performance measurement.

NCQA also proposes structural changes to improve the collection and usability of the measure: remove the requirement for medical record confirmation to identify the eligible population, allow selected telehealth modalities and remote monitoring device readings that are transmitted directly to providers.

Importance: The change to a target threshold of <140/90 mmHg for all patients in the measure is based on review of newly released clinical guidelines and feedback from our Cardiovascular, Diabetes and Geriatric Measurement Advisory Panels.

Follow-Up After Emergency Department Visit for Mental Illness: NCQA proposes to add a principal diagnosis of intentional self-harm to the measure.

Importance: NCQA received feedback that individuals with mental illness who go to the ED with intentional self-harm injuries or poisoning are likely to receive a principal diagnosis for the injury or poisoning and a secondary diagnosis for the mental illness condition. For this reason, stakeholders recommend the measure be amended to include individuals with a principal injury or poisoning diagnosis related to intentional self-harm.

Plan All-Cause Readmissions: Given the extent of changes and use of the measure in external programs, NCQA proposes these changes for HEDIS 2020:

  • Include observation stays in the measure numerator and denominator.
  • Classify high-frequency hospital utilizers as outliers, remove them from calculation of the risk-adjusted readmissions rate and report a rate of outliers among the plan population.
  • Discontinue reporting the rate of readmissions among high-frequency hospital utilizers in the Medicaid product line.
  • Introduce reporting of a separate rate of readmissions among index stays discharged to skilled nursing care in the Medicare product line.

In addition, NCQA seeks comment on the advantages and disadvantages of transitioning to a population-based denominator and of maintaining an event-based denominator.

Importance: These changes improve the quality signal of the measure. The inclusion of observation stays mitigates unmerited differences in utilization across health plans and reporting a rate of high-frequency hospital utilizers among a plan population is a more meaningful metric than a readmission rate driven by a population defined by frequent hospitalization. A separate readmission rate among the population discharged to SNF highlights the frequent rehospitalization currently masked by the overall measure rate and provides consumers information on quality of SNF care across plans.

CAHPS Health Plan Survey 5.0H:NCQA seeks feedback on ways to shorten and update the HEDIS Health Plan CAHPS (CAHPS 5.0H) survey to reflect current topics of interest to stakeholders. NCQA is working closely with the AHRQ CAHPS Consortium on possible changes to the CAHPS survey.

Importance: NCQA is committed to including the patient voice in its evaluation of health plan quality.

Cross-Cutting Topics

Exclusions for Advanced Illness:NCQA proposes to exclude members with advanced illness from 11 HEDIS measures that address prevention, screening and disease management.  

Importance: Quality measures designed and intended for the general adult population may not be clinically appropriate, relevant or in line with goals of care for patients with advanced illness and frailty. These exclusions will help focus measures on the intended target population: individuals who are most likely to benefit from the specified services.

Telehealth: NCQA recommends including telehealth in selected HEDIS physical health measures. Recommendations are based on evidence and stakeholder feedback.

Importance: NCQA conducted a review of evidence to determine if telehealth services are appropriate, effective and feasible for use in HEDIS physical health measures. Evidence supports the use of telephone, video conferencing or asynchronous modalities in these physical health measures.

Guideline Update

General Guideline 2: Product-Specific Reportingand General Guideline 19: Self-Insured Members:As coverage contracts evolve, NCQA recommends clarifying the definition of “self-insured/administrative services only.”

Importance: NCQA is addressing changes in the market in health plan definitions and administrative services only (ASO) contracts.

 How to Participate in Public Comment

To read and comment on the proposed changes, visit The public comment period begins at 9:00 AM (ET) on February 13 and ends at 11:59 PM (ET) on March 13. NCQA will review input from public comment and will publish new and updated measures and guidelines in HEDIS.

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