NCQA releases proposed HEDIS MY 2025 updates
Each year, the National Committee for Quality Assurance (NCQA) publishes a list of measure updates, additions, and deletions for future HEDIS? measure years for public comment. For Measurement Year (MY) 2025, NCQA has proposed adding five new measures, revising five existing measures, and making additional updates related to gender inclusivity and race-ethnicity stratification. The organization has also shared finalized changes to expect for MY 2025 that are not up for public comment.
Here, we offer a summary of NCQA’s proposed changes, which Cotiviti will discuss in our next Quality Decoded webinar, as NCQA seeks feedback from health plans by March 13, 2024.
Proposed new measures for MY 2025
Acute Hospitalization Following Outpatient Surgery (HFO)
For Medicare Advantage beneficiaries, this risk-adjusted utilization measure would capture the percentage of select outpatient procedures that were followed by an unplanned acute hospitalization for any diagnosis within 15 days, and the predicted probability of an acute hospitalization. This would include four rates:
Blood Pressure Control for Patients With Hypertension (BPC-E)
This would measure the percentage of members for all product lines from 18–85 years old who had a diagnosis of hypertension and whose most recent blood pressure was at the following levels during the measurement period:
?BPC-E would be an electronic clinical data systems (ECDS) measure intended to eventually replace the hybrid Controlling High Blood Pressure (CBP) measure. The draft measure expands on the CBP denominator by adding members who have a diagnosis of hypertension and at least one dispensed anti-hypertensive medication, and includes race and ethnicity stratifications (RES).
Documented BI-RADS Assessment after Mammogram (DBM-E)
This would measure the percentage of mammograms for members 40–74 years old from all product lines that have a documented breast imaging reporting and data system (BI-RADS) assessment within 14 days of the procedure. DBM-E would be an ECDS measure.
Follow-Up After Abnormal Breast Cancer Screening (BCF-E)
This would measure the percentage of inconclusive or high-risk BI-RADS assessments that received appropriate follow-up care within 90 days for members 40–74 years old from all product lines. BCF-E would be an ECDS measure.
Cervical Cancer Screening Follow-Up (CCF-E)
This would measure the percentage of commercial and Medicaid members from 21–64 years old with possible or confirmed higher-risk cervical cancer screening results who receive follow-up care within 90 days. CCF-E would be an ECDS measure.
Proposed measure changes for MY 2025
Acute Hospital Utilization (AHU)
This measure would be added to HEDIS reporting for Medicaid plans for members 18–64 years old. ? Medicaid members with six or more inpatient or observation stay discharges during the measurement year would be excluded as outliers.
Adult Immunization Status (AIS-E)
To improve vaccination rates, an indicator would be added to this measure to assess hepatitis B vaccination rates for members 19–59 years old. This numerator would be made compliant by the presence of either the childhood or adult Hepatitis B vaccine series, evidence of anaphylaxis due to the Hepatitis B vaccine, or a positive result for Hepatitis B prevaccination blood testing.
In addition, updates to lower the oldest age stratification from 66+ to 65+ years old are proposed for the influenza, Td/Tdap, zoster, and pneumococcal immunizations. The herpes zoster live vaccine would also be removed from the zoster immunization indicator as it is no longer available in the United States.
Follow-Up After Emergency Department Visit for Mental Illness (FUM) and Follow-Up After Hospitalization for Mental Illness (FUH)
For both measures, additional diagnoses would be added to the denominator including:?
Any diagnosis position would be allowed for intentional self-harm diagnoses, while the principal position requirement would be maintained for other mental health diagnoses.
In the FUH measure’s numerators, to acknowledge the shortage of mental health providers, follow-up care performed by any care provider rather than solely by a mental health provider would be allowed if accompanied by a mental heath diagnosis..
For both measures’ numerators, the mental health diagnosis would be allowed in any diagnosis position on the follow-up claim, rather than just in the principal position, and psychiatric residential treatment, as well as peer support services and occupational therapy for a mental health diagnosis, would be included as options for follow-up care.
Potentially Harmful Drug-Disease Interactions in Older Adults (DDE)
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Medications would be updated to align with recommendations in the updated AGS Beers Criteria, adding anticholinergics to the History of Falls Rate. The Total Rate would be retired based on feedback suggesting that it is not clinically meaningful.
Other proposed changes for MY 2025
Gender inclusive measurement
As NCQA continues to adapt the HEDIS program to be more inclusive of transgender and gender-diverse members, it notes that the Chlamydia Screening in Women (CHL) measure currently excludes members whose gender is not listed as “woman,” even if they are recommended for routine screening. As such, NCQA proposed to rename the measure to Chlamydia Screening in Adolescents and Adults (CHL) and update the description as follows:
The percentage of members 16–24 years of age recommended for routine chlamydia screening who were identified as sexually active and who had a chlamydia test within the measurement year.
This update would follow a similar pattern to the recent updates to BCS-E and CCS-E, using Sex Assigned at Birth of female and Sex Parameter for Clinical Use of female-typical as additional methods of identifying eligible members. NCQA is also proposing to include members who have a Sex Assigned at Birth of male with a history of vaginoplasty.
Race and ethnicity stratification (RES)
As of MY 2024, 22 HEDIS measures will be stratified by race and ethnicity as part of NCQA’s ongoing efforts to improve health equity and reduce disparities in care. For these measures, plans are currently required to report the data source for each race and ethnicity value, whether it’s direct data (self-reported by the member), indirect data (alternate data sources such as the American Community Survey), or unknown. However, stakeholder feedback indicates that this requirement has been burdensome for plans due to the number of indicators it requires them to report. As such, NCQA proposes to eliminate this requirement from the RES stratifications and only report the data sourcing details via the Race/Ethnicity Diversity of Membership (RDM) measure.?
Measure changes for MY 2025 not up for public comment
Use of High-Risk Medications in Older Adults (DAE)
Medications will be added, removed, and regrouped to align with recommendations in the updated AGS Beers Criteria.
Breast Cancer Screening (BCS-E)
Members 40–49 years old will be added to the measure and performance will be stratified by ages 40–49 and 50–74 for all product lines.
Well-Child Visits in the First 30 Months of Life (W30) and Child and Adolescent Well-Care Visits (WCV)
Telehealth visits will be removed from consideration for measure compliance.
Childhood Immunization Status (CIS), Immunizations for Adolescents (IMA), and Cervical Cancer Screening (CCS)
In a recent update to the public comment materials that were originally posted, NCQA has now confirmed that CIS, IMA, and CCS will transition to ECDS-only reporting for MY 2025, retiring administrative and hybrid reporting for these measures.
Register for Cotiviti’s Quality Decoded webinar series as we present a collection of short webinars designed to keep you informed about pivotal updates, measure changes, and announcements from NCQA and the Centers for Medicare & Medicaid Services (CMS) throughout the year.
Our March 6 webinar will address the annual request for public comment on proposed HEDIS measure changes, giving plans the opportunity to weigh in on the significance and feasibility of proposed changes and ask questions of relevant stakeholders.
Join us as we: ?
About the author
Samantha is the HEDIS program manager supporting Cotiviti’s Quality Intelligence solution. She has over 10 years of experience working in HEDIS and is primarily responsible for bridging her knowledge of HEDIS requirements to inform product roadmap, operations, and client collaboration, guiding the organization through the annual HEDIS update cycle.
Director, Access Marketing & Strategy (Oncology), Bayer Pharmaceuticals
8 个月Encouraging continuing efforts on #cancerscreening #qualityoflife and hopefully #healthequity data capture as well