New and Changing HEDIS Measures

The National Committee for Quality Assurance (NCQA) opened the public comment period for items being considered for the HEDIS measurement year (MY) 2025 publication. The comment period is an opportunity for key stakeholders to provide input on the expected changes, review of methodological changes, and give input on new and existing changes. The comment period is open until 5 p.m. EST on Wednesday, March 13. Comments should be submitted to the Public Comment website.

Proposed New HEDIS Measures

NCQA has proposed several new measures to the HEDIS set. Those measures include the following:

Acute Hospitalization Following Outpatient Surgery (HFO)

This measure looks at members 65 years of age and older, the percentage of select outpatient procedures that were followed by an unplanned acute hospitalization (inpatient or outpatient stays) for a diagnosis within 15 days (about 2 weeks), and the predictability of an acute hospitalization. Four rates will be reported:

• Colonoscopy
• General surgery
• Orthopedic procedures
• Urology procedures

Blood Pressure Control for Patients with Hypertension (BPC-E)

This measure looks at the percentage of members 18-85 years of age who had a diagnosis of hypertension and who most recent blood pressure was at the following levels during the measurement period:

• <140/90 mm HG
• <130/80 mm HG

The proposed measure will transition from the hybrid method to the Electronic Clinical Data Set (ECDS) method and data will be reported using administrative claims, electronic health records, case management, and health information exchanges. Scoring for this measure will be stratified by product line, race, and ethnicity for both levels.

Documented BI-RADS Assessment After Mammogram (DBM-E)

This proposed measure will look at the percentage of mammograms for members 40-74 years of age, documented in the form of a breast imaging reporting and data system (BI-RADS) assessment within 14 days of the mammogram.

Follow-up After Abnormal Breast Cancer Assessment (BCF-E)

This proposed measure will look at the percentage of inconclusive or high-risk BI-RADs assessments that received appropriate follow-up within 90 days of the assessment, for members 40-74 years of age.

Cervical Cancer Screening and Follow-up (CCF-E)

This proposed measure will look at the percentage of members 21-64 years of age with possible or confirmed higher-risk cervical cancer screening results who receive follow-up within 90 days.

As with all newly proposed measures, we encourage plans to review the measure details, product lines, and exclusionary criteria when developing their comments. Understanding how these measures will impact your plan's ability to capture the data and meet the measure's intent is valuable.

Proposed Changes to Existing HEDIS Measures

An additional part of the comment period included changes to existing measures. Those measures are as follows:

Acute Hospital Utilization (AHU)

NCQA is looking to add the Medicaid product line to this measure to include members 18-64 years of age. Having six or more inpatient or observation stay/discharges during the measurement year would be considered outliers and those with five or less would be non-outliers.

Adult Immunization Status (AIS-E)

The modifications of the measure should be reviewed closely, as NCQA is proposing several changes. It should also be noted that the AIS measure uses the ECDA methodology for reporting:

• Add Hepatitis B immunization indicator
• Updated age range for pneumococcal immunization indicator
• Remove Herpes zoster live vaccine from the zoster immunization indicator
• Update age stratifications for flu, influenza, Td-Tdap and zoster immunization indicators

Follow-up After Emergency Department Visit for Mental Illness (FUM) and Follow-up After Hospitalization for Mental Illness (FUH)

The intent of these measures is to ensure effective care coordination for members discharged from an inpatient or Emergency Department setting, who are at risk for disengagement from treatment and repeat visits. Change expected for both measures include:

• Denominator revisions related to diagnosis position criteria and additional diagnosis codes
• Numerator revisions related to provider type requirements, diagnosis position criteria follow-up, and added follow-up services and settings

Potentially Harmful Drug-Disease Interactions in Older Adults (DDE)

• The changes proposed for the DDE measure include updating medications to align with AGS Beers Criteria and to retire the total rate indicator

The proposed changes to measures should be reviewed closely to ensure the processes within the health plan are available to meet their intent. Plans should also watch CMS guidance closely for measures that could be codified for future Star Rating measurement periods.

Potential Changes to Cross-Cutting

NCQA has also proposed items related to cross-cutting. Those include:

Gender-Inclusive Measurement in HEDIS

The proposed updates would change the Chlamydia Screening in Women (CHL) from “the percentage of women” to “the percentage of members” and measure would be renamed Chlamydia Screening in Adolescents and Adults (CHL).

Race-Ethnicity Stratification

NCQA is proposing the removal of the data source reporting requirement from HEDIS measures stratified by race and ethnicity. Many plans expressed concerns that numerous indicators increased the burden for reporting.

Within the request for comment, NCQA provided updates to changes related to current HEDIS measures, but not seeking comment on:

MY 2024

• NCQA added codes for pneumococcal conjugate 20 vaccine to the value set directory

MY 2025

• NCQA is removing and adding medications to Use of High-Risk Medications in Older Adults to align with updated AGS Beers Criteria
• NCQA is considering adding individuals 40-49 years of age to the Breast Cancer Screening measures
• NCQA anticipates removing telehealth from Well-Child Visits in the First 30 Months of Life and Child and Adolescent Well-Care Visits

MY 2026

• NCQA is completing a transition to a new template for HEDIS measure specifications in MY 2026

Healthmine’s advanced data collection and stratification capabilities through surveying, vendor integrations and prior health data ingestion allows health plans to get ahead of measure changes. We help health plans strategically engage each member based on individual care gaps and engagement patterns so meeting CMS measures is easier and more efficient.

Due to the tight timeline and already busy season within health plans, we recommend you pull a small team together to review the proposed changes and provide comment to NCQA quickly. At Healthmine, we would be happy to support you in developing your comments or answer any questions you may have about the potential impact of these changes. Contact john.willis@healthmine.com.