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HEDIS 2020: Navigating Digital Measurement Shift

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Standardization, Stability and Digital Innovation Journey are the key underlying messages that were highlighted in the NCQA HEDIS 2020 Summary of Changes. Altogether, the changes occur across few broad areas – Digital Measure Compatibility, Allowable Adjustment Rules, Measure Ruleset, Reporting, and Process changes. Introduction of ‘Allowable Adjustments’ across all clinical HEDIS measures should assist in greater adoption of HEDIS measures across industry entities and beyond usage of submission. With the enhanced share of ECDS measures in overall HEDIS program (along with wider adoption of ‘Digital Measure Compatibility’ through extended clinical value-sets) will further strengthen aggregation of clinical data as an alternate source, while balancing the overarching dependency on claims data.

The recently introduced 2020 first year measures are directed at arresting rising health issues such as women mental health during pregnancy, opioid and substance abuse amongst the generalized population. NCQA’s expressed interest to release measure definition 11 months ahead of HEDIS season will enable better planning and measure stability overtime. These changes should create a significant shift from traditional regulatory and operational reporting to a better holistic patient health quality management approach.

Summary of Measure Changes

HEDIS 2020 summary of changes released in July 2019 from NCQA introduces 96 Measures spread across all Medicare, Medicaid and Commercial lines of businesses. Except for survey-based measures, all HEDIS measures have undergone modifications.

  • 5 new measures for ECDS:
    • Breast Cancer Screening (BCS-E)
    • Colorectal Cancer Screening (COL-E)
    • Follow-up Care for Children Prescribed ADHD Medication (ADD-E)
    • Prenatal Depression Screening and Follow-Up (PND)
    • Postpartum Depression Screening and Follow-Up (PDS)
  • 2 new measures for Opioid and Substance Abuse:
    • Pharmacotherapy for Opioid Use Disorder
    • Follow-Up After High Intensity Care for Substance Use Disorder
  • 43 measures have undergone measure Ruleset changes, where measure eligibility, denominator, numerator or exclusion criteria will undergo alterations (e.g., For appropriate testing for pharyngitis - changing the member based denominator to an episode-based denominator, revision of episode date definition such as – removal of the IESD definition and addition of negative co-morbid condition history and negative competing diagnosis definition, exclusion of out-patient visits etc.)
  • 18 measures have been updated to meet Reporting changes, including revision of data elements in the reporting table, e.g.., appropriate treatment for upper respiratory infection will have revision of data elements in the reporting table.
  • 3 measures have been retired for hitting the performance ceiling or being accommodated in other alternative measures:
    • Standardized Healthcare Associated Infection Ratio
    • Annual Monitoring for Patients on Persistent Medications
    • Use of Multiple Concurrent Antipsychotics in Children and Adolescents
  • 29 Measures were influenced through inclusion and expansion of ‘telehealth’ as a legitimate data source, including the behavioral and physical health measures. Telehealth is getting more popular amongst patients and providers specially in the area of chronic condition management for extending clinical accessibility and guidance for health monitoring. Asynchronous modalities or self-paced programs, which are being widely adopted over Telehealth platforms, are promoting it as a significant data source for clinical outcome measurement.
  • All 2019 CMS HEDIS Star Measures for MA Population will undergo changes as part of HEDIS 2020

NCQA’s recommended and proposed changes for HEDIS 2020 are enlisted across few significant areas such as:

  • Digital Measure Compatibility
  • Allowable Adjustments and
  • Process and Reporting Changes

Digital Measure Compatibility Changes

NCQA is following a two-prong strategy to actively pursue their Digital Innovation vision for defining HEDIS 2020.

  1. Expand ECDS share in HEDIS program
  2. Standardize value-sets to include clinical codes like SNOMED and RxNorm codes across broad set of Clinical measures

ECDS measures promote expanded use of clinical data beyond traditional claims data and actively contribute towards meaningful clinical outcome measurement. Beyond 2020, the share of ECDS measures in HEDIS program could further rise. Currently there two significant quality programs that are managed with overlapping clinical measures:

  1. NCQA for health plan reporting and
  2. CMS for provider reporting

Collaborative efforts are underway where both NCQA and CMS are working towards a common standardized ground through the introduction of Quality Data Model and Clinical Quality Language for a standard format for quality measure interpretation and implementation. Inclusion of clinical codes with traditional value-sets will expand the opportunities for clinical data acquisition and processing without the need to maintain complex crosswalks, thereby easing the data operations management.

HEDIS Allowable Adjustments

Another key area is ‘Allowable Adjustments’ which will accommodate about 66 measures with new set of rules for modification and allow flexibility in altering the specified items as applicable for localized population scenario (e.g., enrollment criteria, changing the product line criteria, measurement period, population subsets).

Traditionally HEDIS specifications have been closely integrated for NCQA HEDIS program to prevent other industry entities like states, providers and government bodies from direct adoption and measurement, while representing the ecology of local population. Consequently, HEDIS like measures were created by other industry entities who adopted HEDIS measures with modified eligibilities and included value-sets to represent local needs while retaining measure clinical structure. With the introduction of ‘Allowable Adjustments’, the prevailing limitation and rigidness will be removed, and measures will become flexible for wider industry adoption without altering redundant duplication of HEDIS specification.

This will enable measure standardization across entities by retaining the measure clinical intent undisrupted while allowing multiple versions of HEDIS-like measures. Measures with added flexibility of “Allowable Adjustments” will be an important yardstick for industry wide performance benchmarking.

Process and Reporting Changes

In the coming years, NCQA is proposing a schedule change to release the complete measure specs 11 months before the current timeline. Another significant proposed change is the redesign of the HEDIS IDSS submission file to make it available in two formats – XML (existing) and CSV format


  • HEDIS 2020 has introduced changes to majority of the measures, making it essential for payers to start their reporting priorities in advance, since significant time would be needed to validate performance results against prior year.
  • A detailed analysis of HEDIS 2020 data requirements against 2019 data model is crucial. With significant number of measures undergoing measure logic changes, performance shifts are expected when compared against performance measured in 2019.
  • Root cause analysis of the recorded shifts and audit registry maintenance will help resolve clarifications during HEDIS audit season. ‘Allowable Adjustment’ rules will make room for simple, though, complex validation scenarios.
  • Working with your vendor while supporting the adequate set of necessary data beyond NCQA Sample and Test Deck will ensure higher success rate during actual performance measurement.
  • The focus on clinical data aggregation makes it necessary to plan and execute comprehensive prospective program with close monitoring and a view of continuous improvement (especially in the areas of preventive screening, women and childcare and opioid usage)

The HEDIS 2020 Journey begins now.


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