NCQA Updates Quality Measures for HEDIS® 2019

Changes include four new measures; one addresses opioid use

July 2, 2018

WASHINGTON, DC—The National Committee for Quality Assurance (NCQA) released new technical specifications for the 2019 edition of health care’s most widely used performance improvement tool, the Healthcare Effectiveness Data and Information Set (HEDIS®).

The new HEDIS volume includes four new measures, changes to four existing measures and two cross-cutting topics that address enhancements across multiple measures.

New measures and changes follow a rigorous development process that ensures they are relevant, scientifically sound and feasible for implementation.

New Measures

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

Hospitalization Following Discharge From a Skilled Nursing Facility. The percentage of skilled nursing facility discharges to the community that result in an unplanned hospitalization within 30 days and 60 days.

Intent:A growing number of Medicare Advantage beneficiaries require skilled nursing services, yet there is no measure assessing outcomes for this vulnerable population. This measure assesses the coordination of providers and services to support a successful transition to the community from a skilled level of care across Medicare Advantage plans.

Risk of Continued Opioid Use. The percentage of members 18 years and older who have a new episode of opioid use that puts them at risk for continued use. Two rates are reported:

  1. The percentage of members whose new episode of opioid use lasts at least 15 days in a 30-day period.
  2. The percentage of members whose new episode of opioid use lasts at least 31 days in a 62-day period.

Intent: Continued opioid use for noncancer pain is associated with increased risk of opioid use disorder, opioid-related overdose, hospitalization and opioid overdose-related mortality. This measure assesses members with a new episode of opioid use who are dispensed opioids for a period of time that puts them at an increased risk of continued use.

NCQA has added the following two new measures specified for the HEDIS Electronic Clinical Data Systems reporting method. Data sources include administrative claims, electronic medical records, registries, case management systems and health information exchanges.

Prenatal Immunization Status. The percentage of deliveries on or after 37 gestational weeks in which women received influenza and diphtheria and pertussis (Tdap) vaccines.

Intent: This measure assesses receipt of important prenatal vaccines, which protect women and their infants from influenza and tetanus, diphtheria and pertussis.

Adult Immunization Status. The percentage of adults 19 years and older who are up to date on recommended routine vaccines for influenza, tetanus and diphtheria (Td) or tetanus, Tdap, herpes zoster and pneumococcal.

Intent: This measure assesses routine vaccination against influenza, tetanus, diphtheria and pertussis for all adults, and vaccination against herpes zoster and pneumococcal disease for older adults.

Changes to Existing Measures

Controlling High Blood Pressure. NCQA has revised this measure to reflect a new blood pressure target of <140/90 mm Hg for all adults age 18–85 with hypertension in accordance with updated clinical recommendations. NCQA also has updated the approach to allow for more administrative methods to collect the measure and added telehealth encounters to satisfy certain components of the measure.

Follow-Up After Emergency Department Visit for Mental Illness. NCQA added a principal diagnosis of intentional self-harm to the denominator and a principal diagnosis of intentional self-harm with a secondary diagnosis of a mental health disorder to the numerator.

Follow-Up After Hospitalization for Mental Illness. NCQA added a principal diagnosis of intentional self-harm to the denominator.

Plan All-Cause Readmissions. This measure will now include observation stays as index hospitalizations and readmissions events for all product lines. The measure also will remove individuals with high frequency hospitalization from the risk-adjusted readmission rate and report a rate of these outlying individuals among the plan population for all product lines. NCQA added a separate readmissions rate among index hospitalizations discharged to a skilled nursing facility for the Medicare product line.

NCQA is publishing the revised Plan All-Cause Readmissions measure alongside others released for HEDIS 2019, but delaying implementation until HEDIS 2020. NCQA worked with the Centers for Medicare & Medicaid Services to identify this timeline, given the extent of the measure changes and use of the measure in the Medicare Advantage Star Ratings System.

Cross-Cutting Topics

Telehealth for Physical Health Measures. Telehealth can be an effective, efficient way of delivering health care, and is becoming more widely reimbursed by payers. NCQA introduced telehealth into 14 existing physical health measures for HEDIS 2019, following on previous work to add telehealth services to behavioral health measures last year.

Excluding Members With Advanced Illness.

Quality measures that were designed and intended for a general adult population may not always be appropriate for those with limited life expectancy or advanced illness and frailty. As such, NCQA is implementing cross-cutting exclusions across selected HEDIS measures to help focus on the population who are most likely to benefit from the measured services.

For more information on NCQA’s exclusion work, see this blog post.

For HEDIS 2019, the following nine measures exclude individuals 65 and older who have an advanced illness and frailty or who live long-term in nursing home settings. Four of these measures also exclude those age 80 and older with frailty.

  • Breast Cancer Screening.
  • Colorectal Cancer Screening.
  • Comprehensive Diabetes Care.
  • Controlling High Blood Pressure.
  • Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis.
  • Osteoporosis Management in Women Who Had a Fracture.
  • Persistence of Beta-Blocker Treatment After a Heart Attack.
  • Statin Therapy for Patients with Cardiovascular Disease. 
  • Statin Therapy for Patients with Diabetes.

For more information, refer to the full measure specifications in HEDIS 2019, Volume 2. 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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