The healthcare industry is on the cusp of a significant transformation with the shift to digital quality measurement. As the National Committee for Quality Assurance (NCQA) sets a 2030 deadline for transitioning to a digital-only state, health plans will be required to use standardized interoperable data for all reporting programs, requiring digitization of all Health Effectiveness Data and Information Set (HEDIS®) measures by the same deadline.
Currently, 90% of health plans in the United States utilize HEDIS measures to assess how well they are meeting the needs of their member population. However, traditional methods are largely claims-based and rely heavily on manual coding of medical records, which can be cumbersome and prone to errors. In addition, the retrospective nature of traditional HEDIS measures often delays the response to the needs of member populations.
NCQA aims to streamline and standardize this process by offering pre-coded measures. These can eliminate the need for plans and vendors to interpret measure specifications manually. This digital approach will not only ensure consistency but may also significantly reduce the time required for vendors to achieve certification. With digital measurement, health plans will have more timely access to performance data and the ability to proactively deliver specialized services for screenings like cancer and diabetes, helping to improve overall care.
Despite the impending deadline, many health plans lack a concrete strategy to transition to digital measures. During a recent Cotiviti webinar, over 70% of participants said they do not have a plan or are not yet discussing the need to use Fast Healthcare Fast Healthcare Interoperability Resources (FHIR®) to exchange healthcare information for quality reporting. Without FHIR, which NCQA mandates, digital measurement by 2030 is unattainable.
The stakes are high. Quality measures reported through NCQA HEDIS submissions or to CMS directly impact Star Ratings and quality bonus payments. Falling below a four-star rating can result in significant revenue losses, potentially amounting to hundreds of millions of dollars annually. State Medicaid pay-for-performance programs also offer similar financial incentives, underscoring the critical nature of this transition.
Preparation for this transition can begin now as plans familiarize themselves with proactive steps to meet digital measure standards by 2030. Interoperability initiatives under the 21st Century Cures Act provide a foundation, but leveraging this technology for quality use cases is essential. Plans can start by budgeting for new technology and working with partners to evaluate a path to digital data readiness.
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The move to digital quality measurement represents a profound shift in healthcare, promising improved accuracy, efficiency, and patient outcomes. By preparing early, health plans can ensure they are ready to tackle unforeseen challenges with flexibility.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).