Summary: NCQA releases proposed HEDIS changes for MY 2024 and MY 2025

Expansion of race and ethnicity stratification, updates to advance gender-inclusive quality measurement, changes to diabetes-related measures, and several measure retirements are among the changes just proposed to the HEDIS^® program by the National Committee for Quality Assurance (NCQA). Health plans can now comment on the potential updates to Measurement Year (MY) 2024 and MY 2025 through Monday, March 13, 2023. Here, we summarize what health plans need to know.

Proposed expansion of race and ethnicity stratification

With the goal of “[advancing] health equity by leveraging HEDIS to hold health plans accountable for disparities in care among their patient populations,” NCQA is looking to add at least five measures to its existing list of 13 measures that are stratified by race and ethnicity. This stratification program first introduced in MY 2022. Potential candidates for inclusion in race and ethnicity stratification include the following:

• Follow-Up After Emergency Department Visit for Mental Illness (FUM)
• Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS-E)
• Depression Screening and Follow-Up for Adolescents and Adults (DSF-E)
• Follow-Up After Hospitalization for Mental Illness (FUH)
• Prenatal Depression Screening and Follow-Up (PND-E)
• Postpartum Depression Screening and Follow-Up (PDS-E)
• Risk of Continued Opioid Use (COU)
• Use of Opioids at High Dosage (HDO)
• Use of Opioids from Multiple Providers (UOP)
• Cervical Cancer Screening (CCS-E)
• Childhood Immunization Status (CIS-E)
• Prenatal Immunization Status (PRS-E)
• Kidney Health Evaluation for Patients With Diabetes (KED)
• Eye Exam for Patients with Diabetes (EED)
• Follow-Up After Emergency Department Visit for People With Multiple High-Risk Chronic Conditions (FMC)

For members whose race is unknown, NCQA would add an “Unknown” source category to the two existing categories, “Direct” and “Indirect.”

Proposed measure changes to advance gender inclusivity

To support care for transgender and nonbinary members, NCQA proposes to revise the measure description for Breast Cancer Screening (BCS) and Cervical Cancer Screening (CCS) as follows:

NCQA notes that currently, members who are not identified as a woman with their health plan, such as transgender men and nonbinary members assigned female at birth, are excluded from the measure even if their clinical traits warrant these screenings. For Breast Cancer Screening (BCS), members assigned male at birth who have participated in gender-affirming estrogen therapy for at least five years would also be included in the measure.

Proposed diabetes measure updates

NCQA is looking for public comment on two specific diabetes measures as well as denominator changes that would impact all seven HEDIS measures related to diabetes.

Denominator changes

NCQA’s proposed changes include:

• When identifying diabetes from claim/encounter data, plans should:
  • Check for two diagnoses of diabetes on different dates of service in the measurement year (MY) or prior year (PY).
  • No longer check for specific event type codes along with the diagnosis code (e.g., inpatient, outpatient).
• When identifying diabetes from pharmacy data, in addition to validating that the member was dispensed insulin or hypoglycemics/antihyperglycemics in the MY or PY:
  • The member must also have at least one diagnosis of diabetes in the MY or PY. Previously, a diagnosis was not also needed.
  • This allows for the addition of Glucophage/metformin to the Diabetes Medications list, formerly excluded due to being used to treat non-diabetes conditions.

• Removing the required exclusion for polycystic ovarian syndrome, gestational diabetes, or steroid-induced diabetes in the MY or PY with no diagnosis of diabetes. Both denominator identifiers for diabetes now require a diagnosis of diabetes, so this exclusion is no longer needed.

Changes to Hemoglobin A1c Control for Patients With Diabetes (HBD)

The measure would be renamed Glycemic Status Assessment for Patients With Diabetes (GSD) with the following changes:

• Replacing references to HbA1c in the measure with “glycemic status.”
• Adding a new glucose management indicator (LOINC code 97506-0) to allow for glucose monitor results to be used toward compliance. Compliance would still be based on the last available reading in the MY, but can now be an HbA1c test result or a glucose monitor reading.
• If both glucose monitor readings and HbA1c are available on the same day, the measure would prioritize HbA1c test results over glucose monitor readings.
• Renaming the numerators:
  • Adequate HbA1c Control would become Glycemic Status <8%
  • Poor HbA1c Control would become Glycemic Status >9%

Updates to Eye Exam for Patients With Diabetes (EED)

Hybrid reporting would be removed from the measure, which would transition to administrative only. The numerator criteria for bilateral eye enucleation would be moved to a required exclusion.

Proposed measure retirements

With the stated goal of reducing reporting burden and enabling plans to shift their resources to electronic clinical data systems (ECDS) measures and digital quality operations, NCQA proposes to retire six measures for MY 2024:

• Ambulatory Care (AMB)
• Inpatient Utilization—General Hospital/Acute Care (IPU)
• Non-Recommended Cervical Cancer Screening in Adolescent Females (NCS)
• Antidepressant Medication Management (AMM)
• Medical Assistance with Smoking and Tobacco Use Cessation (MSC)
• Use of Spirometry Testing in the Assessment and Diagnosis of COPD (SPR)

For MY 2025, NCQA proposes to retire the Care for Older Adults (COA) – Pain Assessment indicator, stating that “There is no evidence that asking someone annually about pain, without a clinical indication that acute or chronic pain is occurring, will initiate appropriate pain management and improve quality of care.” In seeking public comment, NCQA asks respondents to consider whether it should explore the creation of a new pain-focused measure instead.

Transitions to ECDS-only reporting

While not up for comment during this public comment period, NCQA will transition the following measures to ECDS-only reporting for MY 2024 and is considering transitioning three additional measures for MY 2025:

Additional MY 2025 changes not for public comment

Pediatric measure changes 

NCQA will no longer count telehealth visits for Well-Child Visits in the First 30 Months of Life (W30) and Child and Adolescent Well-Care Visits (WCV), removing the temporary changes made in response to the COVID-19 pandemic.

Specification measure template changes

Noting that it represents “the first large formatting change to the HEDIS measure specifications in over 20 years,” NCQA will write all measures in a new template to align with their digital direction, including:

• Implementing a more table-focused structure (similar to the existing structure of ECDS measure specifications) with more simplified language
• Adding the General Guidelines text into each applicable measure specification
• Noting whether the measure is person or event-based and the attribution bases of the measure (e.g., enrollment, claim/event)
• Listing the data types that the value set codes may be found within (e.g., the Mammography value set may be found in claim and observation data)

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