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HEDIS 2019 Updates and Their Impact on Health Plans

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Unlike previous years, the 2019 HEDIS updates have introduced significant modifications around how HEDIS measures can be used by health plans. There have also been several changes to HEDIS measure specifications. Through this series of articles, we share our perspective on the HEDIS 2019 changes and the potential impact on your organization.

HEDIS 2019 Adjustment Rules

With HEDIS 2019, NCQA turns a page in the history of the HEDIS program. It acknowledges, and provisions for, the need to use measures beyond plan performance, courtesy its latest addition, “Adjustment Rules”.

Before we dig deeper, lets analyze on how HEDIS measures have been used previously by health plans. While the regulatory requirements are obvious, health plans historically have been modifying HEDIS measures to build contractual and operational rules, manage year-round chases, drive population health and track overall quality improvement. These proxy measures, i.e., HEDIS offshoots, have always been health plan specific and have risked changing the intent of the rules (read the intent of NCQA’s 2019 rule modifications here).

NCQA, with its consumer centric focus, has caught onto this and has changed the HEDIS 2019 program to accommodate these needs. Also, to avoid changing the rule intent, bring standardization and promote reuse of measures, NCQA has published guidelines on how to modify the structure of the HEDIS measures without altering the clinical content. These “Adjustment Rules” provide guidelines that enable health plans to be much more proactive in contract-based engagements with providers, drive care management campaigns and manage year-round HEDIS campaigns while still aligning to the core intent of HEDIS measures. The Adjustment Rules concept also enable HEDIS measures to be adopted at various levels of a healthcare system. For example, quality improvement in a physician practice using clinical codes, or purchaser request for quality information at the health plan. Additionally, rules that need to be modified contractually will now have a common structure that can be used for both payer and provider data.

In the forthcoming series of articles, we will continue to share insights around 2019 HEDIS measures and allowed modifications. You can also find out how you can use CitiusTech's Rules Management Module to easily create and manage your own version of HEDIS measures using NCQA’s new Adjustment Rules.


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