NCQA Updates Quality Measures for HEDIS 2018

Changes include seven new measures; two address opioid use

July 11, 2017

WASHINGTON, DC—The National Committee for Quality Assurance (NCQA) released new technical specifications for the 2018 edition of health care’s most widely used performance improvement tool, the Healthcare Effectiveness Data and Information Set (HEDIS).

The new HEDIS technical specifications include seven new measures, changes to four existing measures and two cross-cutting topics that address issues across multiple measures.

New measures and changes follow a rigorous development process that ensures they are relevant, scientifically sound and feasible for implementation. Mindful of stakeholder feedback, NCQA seeks to introduce new measures only where needed and improve measures only when appropriate.

New Measures

The newest additions to HEDIS address emerging health needs and evolving processes in care delivery.

Transitions of Care. The measure assesses percentage of inpatient discharges for Medicare members 18 years and older who had each of the following during the measurement year:

  • Notification of Inpatient Admission
  • Receipt of Discharge Information
  • Patient Engagement After Inpatient Discharge
  • Medication Reconciliation Post-Discharge

Intent: This measure aims to improve care coordination during care transitions for at-risk populations including older adults and other individuals with complex health needs.

Follow-Up After Emergency Department Visit for People With High-Risk Multiple Chronic Conditions. This measure assesses the percentage of ED visits for Medicare members 18 years and older with high-risk multiple chronic conditions and follow-up care within 7 days of the ED visit.

Intent: The purpose of this new measure is to improve the coordination of care for Medicare beneficiaries with multiple chronic conditions who are sent home from the Emergency Room. This follow-up should ensure better coordination of diagnoses, medications, and follow-up needs.

Use of Opioids at High Dosage. This measure assesses the rate of health plan members 18 years and older who receive long-term opioids at high dosage (average morphine equivalent dose >120mg).

Use of Opioids from Multiple Providers.This measure assesses the rate of health plan members 18 years and older who receive opioids from multiple prescribers and multiple pharmacies.

Intent: High dosage, multiple prescribers and pharmacies are all risk factors for dangerous overdose and death. These measures add health plans to the group of stakeholders currently addressing the opioid epidemic.

Depression Screening and Follow-Up for Adolescents and Adults. This measure assesses the percentage of health plan members 12 years and older who were screened for clinical depression and, if screened positive, received follow-up care.

Intent: This completes a set of three measures that address the needs of patients throughout the spectrum of care for depression: screening, ongoing monitoring and response to treatment.

Unhealthy Alcohol Use Screening and Follow-Up. This measure assesses the percentage of health plan members 18 years and older who were screened for unhealthy alcohol use and, if screened positive, received appropriate follow-up care within two months.

Intent:Alcohol misuse is a leading cause of illness, lost productivity and preventable death in the U.S. The U.S. Preventive Services Task Force (USPSTF) has a grade B recommendation that ““clinicians should screen adults aged 18 and older for alcohol misuse and provide persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse.” This measure seeks to assure appropriate screening.

Pneumococcal Vaccination Coverage for Older Adults. This measure assesses the percentage of health plan members 65 years and older who received the recommended series of pneumococcal vaccines: 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine.

Intent: This new measure tracks more closely to updated guidance from the Advisory Committee on Immunization Practices (ACIP). The measure also uses electronic data, and will one day supplant the current survey-based metric.

Changes to Existing Measures

Immunizations for Adolescents. NCQA revised the human papillomavirus (HPV) vaccine rate to align with the updated Advisory Committee on Immunization Practices guidelines, which  now permit a two-dose, rather than three-dose vaccination schedule for adolescents.

Intent: The measure update was required to meet the new ACIP guidance.

Breast Cancer Screening. NCQA added digital breast tomosynthesis (DBT) to the list of acceptable tests for breast cancer screening.

Intent: The breast cancer screening measure is being updated to include recent technology developments.

Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment. NCQA updated this measure to include medication-assisted treatment (MAT) as an appropriate treatment for people with alcohol and opioid dependence. The measure also adds telehealth to treatment options. Additionally, alcohol, opioid and other drug dependencies are added as subgroups for reporting (rate stratification) and the engagement timeframe is extended from 30 to 34 days.

Identification of Alcohol and Other Drug Services. NCQA updated this measure to include MAT as an appropriate treatment for people with alcohol and opioid dependence and reporting of measure rates by alcohol, opioid and other drug dependence diagnosis as subgroups; and for more granular reporting, separates outpatient, ED and telehealth services.

Intent: These two measures that report use and appropriate use of drug and alcohol treatment services, are being updated to reflect the latest guidelines for treatment, Additionally, these measures give providers, consumers and plans better insight regarding access to treatment services and add important and clinically useful information about utilization of services for those with specific substance dependence diagnoses.

Plan All-Cause Readmissions. NCQA developed a strategy extend the existing Plan All-Cause Readmission (PCR) measure to the Medicaid population, essentially becoming a new measure for Medicaid.

Intent: The Plan All-Cause Readmission measure has been valuable in use for Medicare and Commercial populations, now it will have a specific risk adjustment for use with Medicaid populations. We expect this to be especially useful to States for use in assessing quality.

Cross-Cutting Topics

Telehealth for Behavioral Health Measures. Telehealth is an effective, efficient way of delivering health care, and is becoming widely reimbursed by payers such as health plans, states and CMS. NCQA introduced telehealth in seven behavioral health measures for HEDIS 2018.

Intent: NCQA is responding to the growing use of telehealth as an evidence-backed option for behavioral health diagnosis and treatment. Increasingly providers and plans seek to leverage new technologies to bring care to patients. The addition of telehealth codes to HEDIS measures will benefit those who are using this modality already, or who would like to adopt the use of this modality.

Excluding Members in Institutional Care Settings. NCQA is excluding Medicare members enrolled in Institutional Special Needs Plans (I-SNPs) or who live long-term in institutional care settings from the following measures:

  • Breast Cancer Screening.
  • Colorectal Cancer Screening.
  • Osteoporosis Management in Women Who Had a Fracture.
  • Controlling High Blood Pressure.

Intent: The listed HEDIS measures are appropriate for the age-defined general population but not always for people who are frail or have mobility or other functional limitations. NCQA undertook this cross -cutting effort to be sure the measure only includes patients who can actually benefit from the service.

For more information, refer to the full measure specifications in HEDIS® 2018 Volume 2: Technical Specifications for Health Plans. HEDIS publications are available in print and electronically. To order, call 888-275-7585 or visit the NCQA Publications website at

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