HEDIS 2019 — What To Expect

Nicole Cooney Healthcare Consulting

HEDIS 2019

As we close out HEDIS 2018, Medical Advantage is working hard with our practices and physicians to close gaps to improve the quality of care and patient outcomes. At the same time, we are looking forward to HEDIS 2019 and the opportunities that a new year brings. For HEDIS 2019 the National Committee of Quality Assurance (NCQA) has changed two cross-cutting topics that affect multiple measures as well as implemented four new measures and changed four existing measures1. The following provides a breakdown of each of these changes and how they may affect patient care.

Cross-Cutting Topics


Telehealth had previously been implemented for some behavioral health measures and for HEDIS 2019 telehealth has been implemented for 14 additional measures. Telehealth may include services conducted via real-time interactive audio and video, telephone visits and online assessments and is becoming a more widely used and accepted method of providing health care services. As you can imagine, there are many potential benefits to telehealth such as making healthcare available to patients that live in rural communities or those that have limited mobility, time or transportation. It allows the patient to have access to specialists and provides the patient the ability to manage their own health through patient portals, virtual appointments, remote monitoring and personal health applications.

Excluding Members with Advanced Illness

NCQA has added exclusion criteria to 10 measures to account for members with advanced illness. These are typically patients with a limited life expectancy or who have an advanced illness and are unlikely to benefit from these services. Previously this may have been addressed by removing patients that were in hospice care or for Medicare patients that were living in a long-term nursing home setting. The amended measures do not fall in line with what is considered important to patients with these conditions and excluding them from the measures allows them to focus on those that do such as improving care transitions, getting follow-up after acute care episodes, or avoiding preventable hospitalizations2.

New Measures for HEDIS 2019

NCQA implemented the Electronic Clinical Data Systems (ECDS) reporting method for HEDIS 2016 and new measures are added for this type of reporting every year. The goal of EDCS reporting is to encourage health plans and providers to use electronic clinical data to document high-quality patient care. The following two measures have been added for ECDS reporting for HEDIS 2019:

Prenatal Immunization Status

This measure was created per the clinical guidelines of The Advisory Committee on Immunization Practices (ACIP). It focuses on protecting the health of mothers and their infants through prenatal vaccination by looking at the percentage of deliveries in which the woman received the required immunizations. It is reported as three rates4.

  1. The percent of women who received a tetanus, diphtheria and pertussis (Tdap) vaccine. The Tdap vaccine is recommended during the early part of the pregnancy regardless of prior vaccination status and timing.
  2. The percent of women who received an influenza vaccine. The influenza vaccine is recommended for each annual flu season, from July 1st of the year prior to the measurement period and the delivery date.
  3. A combination rate that includes both vaccines.

Education of the physician as well as the patient will be important to ensure success of the measure. A primary patient concern is the safety of the fetus, but patients may also have concerns about their safety, side effects and general mistrust of the vaccine. Physicians will have to be prepared to address these concerns as well as be prepared to administer the vaccines. Vaccinations may not be a part of their practice, so they may need to implement a process for administering vaccines, become educated enough to address patient concerns, handle patient refusal, track patient vaccination status and other issues that they have not previously had to address5.

Adult Immunization Status

This measure seeks to protect adults from vaccine-preventable diseases. It looks at the percentage of adults 19 years and older who are up to date on recommended routine vaccines. The measure includes five rates:

  1. Percent of adults age 19 and older who received an influenza vaccine.
  2. Percent of adults age 19 and older who received a Td or Tdap vaccine.
  3. Percent of adults age 50 or older who received a Herpes Zoster vaccine to prevent shingles.
  4. Percent of adults age 65 or older who received a pneumococcal vaccine. This measure is for the Medicare population only.
  5. A composite measure of all required vaccines.

Healthy aging includes a healthy diet and exercise, and immunizations are just as important for the prevention of infectious diseases and their complications. Older adults typically have lower immunity and vaccinations may be less effective, but new vaccinations are being developed to be stronger and last longer for aging adults6. Along with preventive services, immunizations are a big part of a healthy lifestyle.

Hospitalization Following Discharge from a Skilled Nursing Facility

This measure targets Medicare members and evaluates the percentage of skilled nursing facility discharges that were followed by an unplanned hospitalization within 30 or 60 days from the date of discharge. As more members require skilled nursing services, measuring the outcomes for these patients is becoming necessary. The measure assesses the coordination of providers and services to support a successful transition to the community from a skilled level of care across Medicare Advantage plans1.

The transition from a skilled nursing home is not always easy but there are things that can be done to ease the transition. Skilled nursing facilities play an important role and should provide discharge plans for every member and care plans for the return home. Unfortunately, there is variation in the quality of plan development and execution of care, so it is important for members and/or their advocates to understand their rights and ask the appropriate questions. Having an effective discharge plan can help decrease the chances of being admitted to the hospital and can help with recovery.

Risk of Continued Opioid Use

NCQA has added a new measure to complement the two existing opioid measures which addresses use at high dosage or from multiple providers. The new Risk of Continued Opioid Use measure identifies the percentage of members 18 years and older who have a new episode of opioid use that puts them at risk for continued use. For this measure, a lower rate indicates better performance and includes two separate rates:

  • The percentage of members whose new episode of opioid use lasts at least 15 days within a 30-day period.
  • The percentage of members whose new episode of opioid use lasts at least 31 days within a 62-day period.

The U.S. Department of Health and Human Services states that opioid overdoses accounted for more than 42,000 deaths in 2016 and in 2017 they declared the opioid epidemic a public emergency8. As opioid deaths and overdoses continue to rise, these measures will require health plans and providers to implement new and existing strategies to monitor opioid use such as health plan reporting, use of prescription drug monitoring programs and treatment plans which can help physicians and patients cut back on overuse.

HEDIS 2019 Updates to Existing Measures

Controlling High Blood Pressure

One of the most significant changes this year is with Controlling High Blood Pressure which now allows reporting of the measure through administrative data. Previously this measure required confirmation of the hypertension diagnosis through an obligatory medical record review. Now the population is defined through claims data where a member has at least two visits with a diagnosis of hypertension. This eliminates the need to confirm the diagnosis and will provide more timely and up-to-date information, while reducing some of the administrative burden9.

NCQA also eliminated the different thresholds based on population. The flag to identify diabetic members has been eliminated and the measure now looks for a blood pressure target of <140/90 for all hypertensive members age 18-85, which is in line with clinical recommendations.

Follow-Up After Emergency Department Visit for Mental Illness

A principal diagnosis of intentional self-harm has been added to the denominator. A principal diagnosis of intentional self-harm with a secondary diagnosis of mental health disorder has been added to the numerator.

Follow-Up After Hospitalization for Mental Illness

A principal diagnosis of intentional self-harm has been added to the denominator.

Plan All-Cause Readmissions

NCQA is publishing the changes for this measure in HEDIS 2019, but they will not actually be implemented until HEDIS 2020 due to the extent of the changes. The measure will now include observation stays as index hospitalizations and readmissions events for all product lines. The measure also will remove individuals with high frequency hospitalization from the risk-adjusted readmission rate and report a rate of these outlying individuals among the plan population for all product lines. NCQA added a separate readmissions rate among index hospitalizations discharged to a skilled nursing facility for the Medicare product line4.

The Future of HEDIS

NCQA’s vision for long-term quality improvement centers around digital measures and reporting through ECDS. For HEDIS 2019, NCQA is including four ECDS measures in addition to the two new immunization measures mentioned above and over the next three years NCQA will be working to convert 20 to 25 measures each year to ECDS110. The hope is that electronic measures will help to align measures, reduce reporting burdens and maintenance costs, help to ensure that reporting is valid and accurate, enhance the values of the measures to those that use them and build a strong foundation for future measures.

About Medical Advantage

Medical Advantage, a wholly owned subsidiary of  The Doctors Company, is an innovator in maximizing health plan and physician clinical and financial performance in value-based contracting. With 20 years of experience managing cost and quality for physician practices, our hands-on approach drives change and positive returns on investment. Through collaboration and guidance, we provide practices, health plans, and delivery systems with customized, actionable solutions to decrease the cost of care and improve quality.


  1. http://blog.ncqa.org/hedis-2019/
  2. http://blog.ncqa.org/improving-care-advanced-illness-frailty/
  3. https://www.ncqa.org/news/ncqa-updates-quality-measures-for-hedis-2019/
  4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4962946/
  5. https://www.ncbi.nlm.nih.gov/pubmed/29338438
  6. https://www.cdc.gov/drugoverdose/epidemic/index.html
  7. https://www.hhs.gov/opioids/about-the-epidemic/index.html
  8. https://healthpayerintelligence.com/news/how-payers-can-succeed-under-updated-2019-hedis-measures
  9. https://www.ncqa.org/hedis/the-future-of-hedis/
  10. https://healthpayerintelligence.com/news/ncqa-seeks-stakeholder-comments-on-updated-hedis-measures