HEDIS updates address transitions of care

Regulatory update

Opioid usage and telehealth are also key points

Ensuring a smooth continuum of care for discharged hospital patients, curbing opioid usage, and telehealth were all on the minds of the National Committee for Quality Assurance (NCQA), as it issued new technical specifications for the 2018 edition of the Healthcare Effectiveness Data and Information Set, or HEDIS. The specifications include seven new measures, changes to several existing measures and two cross-cutting topics, which address issues across multiple measures.

HEDIS is a tool used by more than 90 percent of America’s health plans to measure providers’ performance on important dimensions of care and service. Because so many plans collect HEDIS data, and because the measures are so specifically defined, HEDIS makes it possible to compare the performance of health plans on an “apples-to-apples” basis.

First established in the late 1980s, HEDIS measures address a broad range of health issues, such as persistence of beta-blocker treatment after a heart attack, controlling high blood pressure, comprehensive diabetes care and breast cancer screening.

Included in HEDIS is the CAHPS® 5.0 survey, which measures members’ satisfaction with their care in areas such as claims processing, customer service, and getting needed care quickly. “CAHPS” is an acronym for “Consumer Assessment of Healthcare Providers and Systems.”

Health plans use HEDIS results to see where they need to focus their improvement efforts. In addition, many health plans report HEDIS data to employers or use their results to make improvements in their quality of care and service. Employers, consultants, and consumers use HEDIS data, along with accreditation information, to help them select the best health plan for their needs. Many plans commonly include HEDIS compliance targets into payment contracts with providers, reports America’s Health Insurance Plans, or AHIP.

HEDIS results are included in Quality Compass, a web-based comparison tool that allows users to view plan results and benchmark information.

New measures
The newest additions to HEDIS are designed to address emerging health needs and evolving processes in care delivery, according to NCQA.

  1. Transitions of care. This measure is designed to improve care coordination during care transitions for at-risk populations, including older adults and other individuals with complex health needs, according to NCQA. It 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.
  1. 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 multiple high-risk chronic conditions and follow-up care within seven days of the ED visit. This follow-up should ensure better coordination of diagnoses, medications and follow-up needs, says NCQA.
  1. 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. The measure is designed to track 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.
  1. 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).


  1. 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. According to NCQA, high dosage, multiple prescribers and pharmacies are all risk factors for dangerous overdose and death.
  1. 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. It completes a set of three measures that address the needs of patients receiving care for depression: screening, ongoing monitoring, and response to treatment.
  1. 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.

Changes to existing measures

  1. 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.
  1. Breast cancer screening. NCQA added digital breast tomosynthesis (DBT) to the list of acceptable tests for breast cancer screening.
  1. 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.


  1. 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, it separates outpatient, ED and telehealth services. NCQA says the measures will give providers, consumers and plans better insight regarding access to treatment services, and add clinically useful information about utilization of services for those with substance dependence diagnoses.
  1. Plan all-cause readmissions. NCQA developed a strategy to extend the existing Plan All-Cause Readmission (PCR) measure to the Medicaid population, essentially becoming a new measure for Medicaid. NCQA expects the measure will especially useful to states as they assess quality.

Cross-cutting topics

  1. Telehealth for behavioral health measures. Telehealth is an effective, efficient way of delivering healthcare, and is becoming widely reimbursed by payers such as health plans, states and CMS, says NCQA. That’s why NCQA introduced telehealth in seven behavioral health measures for HEDIS 2018.
  1. 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.

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, according to NCQA.

Transitions of care

Mary Barton, vice president performance measurement, NCQA, discussed the importance of the “Transitions of care” measure during a video chat on the organization’s website.

For the patient, the days and weeks following discharge can be a vulnerable time, she said. “We’re concerned about medical errors. Maybe the patient’s medications were changed in the hospital; maybe tests had been ordered during the hospital stay, but the results were incomplete by the time of discharge. There is a lot of opportunity for things to get dropped.”

To ensure what Barton referred to as a “clear connection between sites of care,” NCQA will be measuring how frequently – or if – primary care physicians are notified of an inpatient admission of one of their patients. The organization will also measure how complete the patient’s information is on the discharge record, so the next provider (primary care physician, long-term-care facility, etc.) knows what has been done and what needs to be done.

And finally, NCQA will measure how promptly the discharged patient’s physician contacted him or her after discharge, to make a follow-up appointment, if necessary. “We have to close the loop on that patient’s care,” she said. After a hospital stay, with its steady stream of caregivers, a patient can feel alone. He or she needs a primary care support team to guide him or her through the next stage of recovery.

Similarly, the measure “Follow-up after emergency department visit for people with multiple high-risk chronic conditions” is designed to address the continuum of care, said Barton.

“We know there is a subset of patients in Medicare who are over 65, who have multiple chronic conditions,” she said. “They are vulnerable; they may be frail; they often have functional limitations; and when they go to the ED, they may experience a change in their medication, which needs to followed-up.”

Also, there may be a multifactorial set of events that led to that ED visit. “EDs are excellent at taking care of the first thing that brought the patient in,” said Barton. “But they’re not necessarily trained or staffed to do the kind of in-depth communication that a primary care team should do.” For example, the patient may face socioeconomic forces that led him or her to the ED, such as an eviction from their house or apartment.

“We’re looking for evidence that an ongoing care team took note of that ED visit and circled that patient back to the primary care setting.”

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