HEDIS® Guide 2019 Additional Measures for Today's Health Priorities

In the upcoming 2019 HEDIS season, the National Committee for Quality Assurance (NCQA) continues to usher in sizable change. Four additional and two revised measures introduce a great number of new data and measurement challenges. Even so, as a health plan, you may be encouraged to note that NCQA is keeping the same general direction building on changes from recent years and continuing a steady course of harmonizing performance measures across the industry. Efforts and progress are still underway to identify the optimal use of electronic data to increase efficiency in data retrieval. As NCQA continues in this direction, efforts to enhance multiple dimensions of care and service and adopt new approaches in data capture will position you for success in quality performance now and in the future.

Many of the new and revised measures for the 2019 HEDIS season reflect NCQA’s response to some of the most pressing healthcare needs recognized industrywide as today’s public health priorities:

  • Addressing needs in behavioral health, including chemical dependency.
  • Reducing hospital re-admissions.

NCQA and other stakeholders are working together to align measurement approaches for these domains of care as well as other population health priorities. This is reflected in the many HEDIS measures adopted into other quality programs, such as the Medicare Advantage Star Ratings system. As NCQA and the Centers for Medicare & Medicaid Services (CMS) work together and with other stakeholders to identify the most meaningful measures for the industry, we expect to see even greater measurement harmonization over time.

Addressing Needs in Behavioral Health

The importance of behavioral health quality measurement is recognized across the entire healthcare sector. Health plans are increasingly supporting a coordinated approach to improve mental and physical health. Contributing to this goal, NCQA added and revised behavioral health measures for 2019.

New Measure: Risk of Chronic Opioid Use

The two opioid measures added in the 2018 HEDIS season and this new measure added for 2019 are designed to help address the public health crisis related to the misuse and abuse of prescription opioid pain relievers. Since long-term opioid use often begins with the treatment of acute pain, this new measure will assess the percentage of members 18 years of age and older who have a new episode of opioid use that lasts for at least 15 days in a 30-day period and the percentage of members 18 years of age and older who have a new episode of opioid use that lasts for at least 31 days in a 62-day period.

Revised Measure: Follow-Up After Emergency Department Visit for Mental Illness

NCQA is updating this existing measure to capture another population. The current measure assesses the percentage of emergency department visits for members 6 years of age and older with a principal diagnosis of mental illness that were followed up with a visit within 7 and 30 days of the ED visit. For the 2019 HEDIS season, this measure will be enhanced to also include members with a primary diagnosis of intentional self-harm.

Reducing Hospital Re-admissions

New measure: Hospitalization Following Discharge from a Skilled Nursing Facility

This new measure emphasizes a continuing focus on improving care coordination and reducing hospital readmission. For many adults, care in a skilled nursing facility is essential to safely transitioning back to home. These individuals generally have several illnesses and use multiple medications. Health plans are responsible for the entire episode of care, which includes care prior to the admission, during the stay, and after discharge. NCQA identified ways health plans can reduce hospital re-admissions for members in this population:

  • Strengthen care transitions (for example, share medication reconciliations and diagnostic workups) between hospitals and skilled nursing facilities.
  • Promote admissions to skilled nursing facilities that have appropriate staffing levels and technical capabilities.
  • Support members with complex care needs by coordinating follow-up care with primary care providers.

This new measure assesses the number of skilled nursing care episodes during the measurement year that were followed by an unplanned acute hospitalization within 30 and 60 days for any diagnosis. It also assesses the predicted probability of an acute hospitalization using a formula to calculate risk adjustments based on comorbidity, age, and gender. Data are reported in the following categories:

  • Count of skilled nursing episodes (denominator).
  • Count of 30-day hospitalizations (numerator).
  • Count of expected 30-day hospitalizations.
  • Count of 60-day hospitalizations (numerator).
  • Count of expected 60-day hospitalizations.

Revised measure: Plan All-Cause Re-admissions

This measure assesses the percentage of hospital discharges that result in unplanned hospital readmissions within 30 days of discharge. NCQA and CMS are working together to refine this measure with several revisions that impact the definition of the denominator, numerator, and risk adjustment model for data collected in 2019. Revisions include:

  • Stratification to separate those individuals with high frequency of index hospital stays.

Keeping with the goal of harmonization, NCQA and CMS are collaborating and delaying implementation of the changes outlined for this measure. NCQA published measure revisions for the HEDIS 2019 season but will delay implementation until HEDIS 2020. For Star Ratings, the revisions would be part of the display page for 2020 and 2021 and would be proposed through rulemaking for the 2022 Star Ratings.

The Move Toward Greater Use of Electronic Data

In addition, NCQA is actively identifying meaningful and accessible data sources. Through refinements to measure requirements and pilot programs, NCQA along with other healthcare policymakers and stakeholders, seeks to answer the question: How can we best use data to measure and inform the care that is provided? Across the industry, NCQA, along with other stakeholders, are learning where data is best captured and which electronic sources yield data for analytics that can provide the most meaningful insights.

The use of electronic clinical data systems (ECDS) for performance measurement remains in a learning stage for all parties. Introduced by NCQA in 2017 (2016 measurement year) as a new source of data to be used with specified measures, these data streams include any information about member health or experiences with healthcare that comes directly from healthcare provider electronic systems. Examples include electronic health records (EHRs), member eligibility files, clinical registries, health information exchanges, administrative claims systems, electronic laboratory reports, electronic pharmacy systems, immunization information systems, and disease or case management registries. Two performance measures added for the 2019 HEDIS seasons that will use ECDS are: Adult Immunization Status and Prenatal Immunization Status. These two measures add to the year-to-year refinements in HEDIS measurement and reporting that are propelling health plans toward greater use of electronic data.

In the near term, an increasing number of measures and evolving electronic data requirements compound the reporting challenges for health plans. Eventually, in the three- to five-year time frame perhaps, performance measurement will become less burdensome. As clinical systems become more integrated and health plans and providers share member/patient health data, the process of gathering, analyzing, and reporting data will become increasingly automated. This will ease the burden of completing medical record review for different measure sets. Thus, through application of lessons learned, advances in interoperability, and greater use of electronic data sources, efficiency in measurement and data reporting will greatly increase.


The numerous changes for the 2019 HEDIS season continue NCQA’s year-to-year progress toward improving quality outcomes and efficiency in performance measurement. This brief summary highlights a few key updates from NCQA but does not include all changes. Looking forward to the 2019 HEDIS season, you will have many opportunities to achieve higher rates for HEDIS measures by overcoming obstacles to effectively collecting, managing, and analyzing data. As you look for ways to more efficiently manage the vast amount of information required to measure the numerous aspects of care, we encourage you to update processes early and focus on efficiency in capturing data and enhancing the completeness and quality of data. Your success with HEDIS activities will help strengthen your ability to achieve improvements in the overall health of your member population, including some of today’s most pressing population health priorities.

* HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA)

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