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In early August, the National Committee for Quality Assurance (NCQA) announced updated quality measures for the Healthcare Effectiveness Data and Information Set (HEDIS) in 2019. There are more than 90 current measures that span six domains of care and evaluate if health plans are providing necessary care related to issues including medication adherence, chronic disease management and immunizations. In updating the measures, NCQA has considered new guidelines, a public health crisis, and an aging population. In total, there are four new measures, four changes to existing measures, and two cross-cutting measures.

New Measures

To facilitate better care coordination for the growing Medicare Advantage population, HEDIS will now be tracking hospitalizations that occur within two months of a member being discharged from a skilled nursing facility. The measure will look at unplanned hospitalizations within both 30-day and 60-day windows of discharge from the facility.

Other new HEDIS measures have been developed to help health plans determine if members are at a higher risk of opioid abuse. One measure will take a closer look at adults over the age of 18 who are prescribed an opioid for non-cancer pain. The intent is to monitor those who have been prescribed opioids for an extended period of time, which could put them at higher risk for becoming addicted to the drug. “Extended durations of opioid use are connected with longer term use and abuse, including overdose and opioid overdose-related mortality,” said Barton said. “We think clinicians and health plans can both address the problem by restricting extended prescriptions from the start. A lot can be done to decrease risk by just decreasing people’s access to opioids.”

The final two measures are related to reporting on whether pregnant women and other adults are following appropriate vaccination schedules. Expectant mothers should receive influenza, tetanus and diphtheria vaccines, while adults older than 18 should receive influenza, tetanus and diphtheria (Td) or tetanus, Tdap, herpes zoster and pneumococcal vaccines for older populations. “Payers should use data from multiple sources to ensure vaccination rates are being measured accurately,” said MaryBarton, vice president of performance at NCQA. “State registries or immunization databases and health information exchange networks can contain data on vaccines that may have been performed somewhere other than the patient’s primary care provider, for example.”

Changes to Existing Measures

To fall in line with the new blood pressure guidelines, the measure for controlling high blood pressure now reflects the new target of  <140/90 mm Hg for all adults age 18–85 with hypertension. In addition, NCQA “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.” Furthermore, NCQA made changes to measures for follow-ups to mental health illness emergency department visits and hospitalizations, adding intentional self-harm as a qualifying event and also updated the “Plan All Cause Readmissions” measure. While the latter was updated alongside the 2019 measures, it will not be implemented until 2020.

Cross-Cutting Topics

It is important to note that across the board, NCQA is adding telehealth for physical health measures and also excluding members with advanced illness from selected HEDIS measures in an effort to focus on those who “are most likely to benefit  from the measured services.”

For payers to maintain a competitive edge and succeed under the new HEDIS measures, they need to understand emerging healthcare issues to ensure that they have the capabilities in place to excel in as many performance measures as possible. BioIQ helps health plans meet these measures through configuring and managing scalable health testing and immunization programs. To learn more, contact BioIQ at (888) 818-1594 or


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