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Six Changing HEDIS Measures That Will Affect Your Practice's Quality Incentives

Date: 10/30/19

If you are involved in primary care, you know that HEDIS measures are the key to earning quality incentive payments that can make a big difference for your patients and your practice. Each year, the National Committee on Quality Assurance (NCQA) updates the technical specifications on the Health Data and Information System (HEDIS) measures. Some years, the changes are negligible… but this year has some significant changes that every primary care provider needs to know about.

At Louisiana Healthcare Connections, our quality incentive program focuses on measures that are directly relevant to the health challenges facing our members and our state. Here are the top six HEDIS changes you need to know:

1. Prenatal and Postpartum Care

For 2020, NCQA announced major changes to how quality measures for pregnancy care will be calculated. These changes will have a significant impact on quality measures for providers involved in prenatal and post-partum care.

Timeless of Prenatal Care

Previously, NCQA specifications required that an individual be enrolled with the relevant organization/payor at the time of the prenatal visit. For 2020, NCQA has removed this requirement so a prenatal visit will count toward this sub-measure, regardless of whether the patient changes health plans during the course of her pregnancy.

NCQA requires that the patient has a prenatal visit in the first trimester, on or before the enrollment start date, or within 42 days of enrollment. Other technical specifications remain the same.

Post-partum Care

For the 2020 specifications, NCQA is expanding the timeframe for postpartum care to between 7 and 84 days after delivery. Previously, the requirement was that post-partum visits occurred between 21 and 56 days after delivery. Additionally, NCQA now allows telehealth visits to count toward this measure.

IUD insertion will serve as documentation that the provider conducted a pelvic exam, incision check for cesarean section, and/or wound check.

The following items will all count toward documentation of discussion of women’s health and wellbeing:

  • Screening for depression, anxiety, tobacco use, substance use disorder, or preexisting mental health disorder.
  • Glucose screening for women with gestational diabetes.
  • Discussion of infant care/breast feeding, resumption of intercourse, birth spacing, family planning, sleep /fatigue, resumption of physical activity and attainment of health weight.

Finally, the annual period for both the prenatal and postpartum care measures is changing. Previously, the measurement year ran from November of one year to November of the next. Starting this year, the measurement year is from October 8th until October 7th of the following year.

2. Childhood Immunization Status (CIS)

The new HEDIS specifications for this measure have added live attenuated influenza vaccine (LAIV). This immunization will now count toward the numerator of patients compliant for Childhood Immunization Status.

3. Comprehensive Diabetes Care (CDC)

NCQA has removed “with or without telehealth modifier” language and the telehealth exclusion from ESRD. NCQA has also updated the value sets to identify acute and non-acute inpatient events for the event/diagnosis, as well as updated the value sets used to identify advanced illnesses, IVD acute inpatient events, and thoracic aortic aneurysm inpatient events.

4. Adolescent Well Child (AWC)
5. Well Child Visits in the first 15 months of life (W15)
6. Well Child Visits in the third, fourth, fifth and sixth years of life (W34)

For all three of these well-child measures, NCQA has added instructions intended to ensure these visits are meaningful interactions between the provider and patient:

NCQA specifies that telehealth services may not count as well child visits.

Additionally, they have clarified that handouts given during a visit without evidence of a discussion do not meet criteria for Health Education / Anticipatory Guidance. The discussion with the patient, parent or caregiver must be documented in order to count for these measures.