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California Health & Wellness is no longer a Medi-Cal plan starting January 1, 2024. Regardless of the county you live in, your Medi-Cal service and benefits will not be impacted by the health plan changes since you will be assigned to a new health plan. The county you live in determines your new health plan. Learn more

What's New in HEDIS Performance Measures?

Date: 01/02/19

The Healthcare Effectiveness Data and Information Set (HEDIS®) is a set of standardized performance measures updated and published annually by the National Committee for Quality Assurance (NCQA).

NCQA released the following 2019 new technical specifications for HEDIS measures:

New measures

  • Risk of continued opioid use. This measure assesses the percentage of members ages 18 and older who have a new episode of opioid use that puts them at risk of continued use.
  • Prenatal immunization status. This addition assesses the percentage of deliveries at 37 gestational weeks or more in which women received influenza, and diphtheria and pertussis (Tdap) vaccines.
  • Adult immunization status. This measure tracks the percentage of adults ages 19 and older who are up to date on vaccines for influenza, tetanus and diphtheria (Td) or tetanus, Tdap, herpes zoster, and pneumococcal disease.

 

Changes to existing measures

  • Well-child visits and adolescent well-care visits. Notations in the patient’s medical record, such as "well-developed" or “appropriate for age,” do not meet the criteria for the physical or mental developmental history components of these measures.
  • Controlling high blood pressure. The measure was updated to align with clinical guidelines. The provider tip sheet Controlling Blood Pressure is available on the California Health & Wellness Plan (CHWP) provider website under the Quality Improvement section.
  • Follow-up after emergency department visit for mental illness. Patients going to the emergency room with intentional self-inflicted injuries may receive a principal diagnosis for the injury and a secondary diagnosis for mental illness. Because of this, NCQA added a principal diagnosis of intentional self-harm to the denominator and a principal diagnosis of intentional self-harm with a secondary diagnosis of a mental health disorder to the numerator.
  • Follow-up after hospitalization for mental illness. NCQA added a principal diagnosis of intentional self-harm to the denominator.
  • Plan all-cause readmissions. This measure will now include observation stays as index hospitalizations and readmissions events for all product lines. It will also remove patients with high-frequency hospitalization from the risk-adjusted readmission rate and report a rate of these outlying individuals among the plan population. Implementation of this measure is delayed until 2020.

Cross-cutting topics

NCQA instituted two changes across multiple measures. These are the introduction of telehealth into 14 measures and the exclusion of members with advanced illness from certain measures, including cancer screenings and some cardiovascular measures.

HEDIS is designed to provide purchasers and consumers with the information they need to reliably compare the performance of health care plans. Final HEDIS rates are typically reported to NCQA, the Centers for Medicare & Medicaid Services (CMS), and state agencies once a year. Through HEDIS, NCQA holds CHWP accountable for the timeliness and quality of health care services (acute, preventive and mental health) delivered to its diverse membership. CHWP also continually reviews HEDIS rates and looks for ways to improve.