New guidance from NCQA indicates health plans are facing substantial change in the upcoming 2018 HEDIS® season. There are seven first-year measures. Changes include new and revised behavioral health and chemical dependency measures. A new Transitions of Care measure may be calculated using the hybrid methodology. Additionally, there are new guidelines for measures using Electronic Clinical Data Systems (ECDS), increased use of stratification, inclusion of telehealth as appropriate follow-up care in several behavioral health and chemical dependency measures, and more. The timeline has become more aggressive with an earlier MRRV deadline and an earlier plan lock deadline. This is the time for health plans to work with their HEDIS vendors to review these new measurements, specifications, and timelines and begin making plans to update and enhance data collection and workflow processes.
With such a high volume of change from NCQA, we underscore the need to plan early. Two priorities for refining processes and building new capabilities are:
An increasing focus on behavioral health quality measurement is occurring across the entire healthcare sector. This stems from recognition that mental health impacts population health and healthcare costs. A coordinated approach for mental and physical health is needed. Policymakers and clinicians are working to determine the best approaches to manage this subset of the population. Contributing to the goal of better addressing these issues, NCQA added and revised behavioral health and chemical dependency measures for 2018.
New behavioral health and chemical dependency measures:
Enhanced measures require additional reporting indicators by age and diagnosis:
The measures Use of Opioids at High Dosage and Use of Opioids From Multiple Providers are designed to help address the widely recognized public health crisis of the misuse and abuse of prescription opioid pain relievers. For these measures, the pharmacy claim must capture both prescriber and pharmacy identifiers as well as both dispensed quantity and refill days. This information is used to help identify individuals at high risk of opioid abuse. Health plans may find it challenging to provide complete details for these measures. Thus, plans should assess the data they receive from their pharmacy benefit manager (PBM) to ensure it has all required data elements, and if not, work with their PBM to enhance the data feeds prior to the start of the HEDIS season.
Telehealth is added as an appropriate method of follow up for the behavioral health and chemical dependency measures. Remote access technologies can be used to increase access to care and are a viable means of providing clinical services, especially for those living in rural areas or with decreased mobility. For behavioral health, telehealth visits may be helpful at increasing the success rate of the first visit and in engaging members and preventing relapse. Though the face-to-face method is often preferred, evidence indicates telehealth services may be equally effective. In response, health plans will need to review covered benefits and ensure these align with the telehealth visit procedure codes and modifiers included in NCQA’s value set. In addition, health plans can begin identifying key metrics and testing pilot programs to prepare for more widespread adoption of telehealth.
Many health plans carve out their behavioral health benefits to a behavioral health vendor. Health plans should build strong relationships and data sharing arrangements with these vendors to ensure they are receiving complete and accurate supplemental data to support the calculation of rates for behavioral health measures. This is important for current measures and will be even more crucial as measures continue to be added.
Not only for HEDIS measures but for all quality programs, there is recognition that a better combination of data is needed to adequately measure the delivery of healthcare services. Administrative claims have limitations since their primary purpose is for provider payment. The goal for improved information sources in the healthcare industry is to create a complete view of a member’s encounters with the healthcare system, providing accurate insight into the patient’s diagnoses and health risks, as well as treatments and services delivered. New requirements for HEDIS 2018 support this goal. In response, health plans and vendors must prepare to collect new types of information and define new processes to analyze and visualize data to gain new insights. With this year’s update, many of these adjustments will center on the use of ECDS. Some of the essential data elements will include prescriber and pharmacy data on the pharmacy claim, dispensed quantity and refill days on the pharmacy claim, and ECDS source system of record (SSoR) indicators.
The use of ECDS was introduced by NCQA for reporting in 2017 (2016 measurement year) as a new source of data to be used with specified measures. ECDS 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.
The two measures for which ECDS data were reported in 2017 are Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults and Depression Remission or Response for Adolescents and Adults. Since the use of ECDS data as a new option for healthcare quality reporting is still in the pilot phase, the ECDS data was not widely available for these measures in this reporting season. With the 2018 HEDIS specifications, NCQA continues to embrace ECDS as a data source, promoting the increased use of ECDS as a framework for advancing standardization and encouraging interoperability. Thus, as a health plan, it is important to begin proactively working with your contracted healthcare providers to begin identifying ways to obtain ECDS data for relevant measures.
New measures in 2018 that will use ECDS are:
The increasing use of ECDS will help you obtain more complete and accurate information about your members’ health status and use of healthcare services. You can use this data to develop strategies to perform better with HEDIS as well as population health management. However, retrieving this information may require new arrangements with physicians and other providers. A good first step to being prepared is identifying how your agreements with providers may need to be updated to include requirements for data sharing.
For the 2018 HEDIS season, NCQA is adding layers of stratification for some measures. An example of this is stratifying the measure results based on the type of ECDS used. Additional stratification will increase complexity in the management and reporting of data but will aid in understanding the level of quality provided to different patient populations.
Each ECDS measure will be stratified based on which SSoR was accessed to obtain the measure result. Since member data may come from multiple locations, NCQA created a standard process to allow for the consideration of source when interpreting data. If the same data is found in multiple sources, a hierarchy is applied based on the following priority:
To prepare for the new level of stratification, including ECDS sources and other areas of stratification, health plans will need to begin identifying avenues for new data sources and update reporting processes.
We see substantial opportunities for health plans to accomplish continuous improvement by overcoming obstacles to effectively collecting, managing, and analyzing data. As you look for ways to more efficiently manage the vast details required to measure the numerous aspects of care, we encourage you to update processes early and continue to focus on data completeness, data quality, and leveraging your HEDIS activities for broad population health goals.
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