HEDIS® 2020 – continued focus on today’s health priorities

Tuesday, August 6, 2019 | By Amy Salls, Sr. Director, Revenue and Quality Analytics

HEDIS® 2020 – continued focus on today’s health priorities

For HEDIS 2020, the National Committee for Quality Assurance (NCQA) will introduce additional quality measures and usher in a number of changes to existing measures, while still pursuing efforts to harmonize performance measurement across the industry. This is the first in a four-part blog series in which we’ll be discussing these changes and sharing tips on understanding and incorporating them into your HEDIS strategy.

A subset of the measure changes shows a continued focus on assessing and measuring outcomes for two of the most pressing public health priorities:

  • Measuring and evaluating facility-based utilization
  • Assessing the risk for, and monitoring and treatment of, substance abuse and mental health conditions

Measuring and Evaluating Utilization

NCQA is continuing their effort to identify reporting redundancies and streamline the number of required utilization measures.  Accordingly, the goal over time is to consolidate measures that assess outpatient visits, emergency department visits, and acute inpatient care in general. Where overlap exists in utilization measures, those that are risk-adjusted will be retained, as they can be used to designate and benchmark an expected rate that takes into account an organization’s case mix. A first step for HEDIS 2020 is to remove the Medicare and commercial reporting requirements for the Ambulatory Care and Inpatient Utilization – General Hospital/Acute Care measures.

Additionally, NCQA continues to refine and stratify the measure output. For HEDIS 2019, we saw modifications to outlier definitions, planned stay criteria, exclusion logic, and risk-adjustment calculations, as well as the addition of socioeconomic stratifications.  Specifications for the 2020 Plan All-Cause Readmissions (PCR) measure indicate numerous changes, as might be expected with the preview of specifications provided last year.  The measure assesses the percentage of acute hospital discharges resulting in unplanned acute readmissions within 30 days of discharge. Changes are being made to remove individuals with high frequency hospitalizations so as not to adversely skew the results, and to add observation stays to the assessment, similar to the previous Acute Hospital Utilization measure update.  An industry-wide increase in observation stays has led to the need to reflect this information in discharge and readmission counts and assessments.

Given the substantive nature of the changes to this measure, CMS plans to move it to display for the 2021 and 2022 Star Ratings.  It would return to the 2023 Star Ratings (2021 measurement year data) with a reduced weight of 1. 

Assessing the Risk for and Treatment of Substance Abuse and Mental Health Disorders

Evidence indicates that timely follow-up and continued monitoring of patients with substance abuse disorders can be effective in improving patient outcomes, reducing health care utilization, and decreasing the overall cost of care. Patients who receive appropriate follow-up services tend to have a lower likelihood of relapse and lower utilization of additional intensive services. There are two new measures to address this issue.

  • New Measure: Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)
    Substance Use Disorders (SUDs) contribute significantly to morbidity and mortality in the US and cost the healthcare system billions of dollars each year. Individuals receiving SUD care in these high-intensity settings are especially vulnerable to losing contact with the health care system after discharge. To respond to the diverse needs of this population, this new measure will assess if patients with a SUD diagnosis are receiving timely and adequate follow-up care and services after an acute inpatient hospitalization, residential treatment, or detoxification visit, including follow-up care for a principal diagnosis of SUD delivered in a variety of treatment settings.
    The FUI measure is expected to complement the HEDIS measure, Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence (FUA), introduced in HEDIS 2018 and refined for HEDIS 2019. NCQA envisions that these two Substance Use Disorder measures will work in concert, similarly to the Follow-Up After Emergency Department Visit for Mental Illness and Follow-Up After Hospitalization for Mental Illness measures.
  • New Measure: Pharmacotherapy for Opioid Use Disorder (POD)
    According to the Centers for Disease Control (CDC), prescription and illicit opioids are the driver behind the majority of drug overdose deaths. Despite evidence that suggests pharmacotherapy can improve outcomes for individuals with opioid use disorder (OUD) and the availability of clinical practice guidelines around continuity of pharmacotherapy, it is still an underutilized treatment option.
    In addition to the two opioid measures added in HEDIS 2018 and one added for 2019, NCQA is introducing this fourth POD measure, which represents the percentage of new pharmacotherapy treatment episodes that resulted in 180 or more covered treatment days among members 16 years of age and older with an OUD diagnosis. This new measure introduced by NCQA will allow for the identification of new episodes of OUD pharmacotherapy and will assess adherence to that treatment.

My next blog post is coming soon, where I’ll expand on the HEDIS 2020 Opioid measures.

Your HEDIS vendor is a key partner for a successful strategy. If you’re in the market, contact us for a demo of our NCQA certified HEDIS solution, CareAnalyzer®, and download our HEDIS Timeline: Planning, Milestones, and Deadlines to help stay on track throughout the year



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


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