For many people, there is a point in life where frailty or advanced illness begin to impact function and overall quality of life. What’s meaningful or most important for them may be less about preventive screenings or disease-specific medical treatment and more about receiving coordinated care to support maintaining function and quality of life in the face of declining health.
NCQA recognizes that some HEDIS measures don’t necessarily apply to these patients, where the measured services may be of little benefit or not in line with their preferences or goals of care.
This is why NCQA is implementing a set of cross-cutting exclusions to remove those with advanced illness from selected HEDIS measure reporting. This will focus quality efforts for this population on measures that are of greater relevance and potential benefit.
In prior years, NCQA applied a cross-cutting exclusion to remove people receiving hospice care from all HEDIS measures. We then implemented an exclusion for older adults in Medicare living long-term in nursing home settings from a few select HEDIS measures.
Emily Morden, Senior Research Associate in NCQA’s Quality Measurement and Research Group, explains why this is taking place and how these exclusions will impact measure reporting, and more importantly, the care provided to older adults with advanced illness and frailty.
Q: Why should these populations be excluded from these selected measures?
A: Many HEDIS measures are based on clinical guidelines that apply to a general adult or older adult population. For those with limited life expectancy or advanced illness, the services identified in some measures may not be relevant or in line with the patient’s goals of care.
By implementing these exclusions, the frail and advanced illness population can focus on care that’s more appropriate for their conditions and health status. Attention will be focused on quality measures that capture services and care processes that are most relevant for this population (e.g., improving care transitions, getting follow-up after acute care episodes, or avoiding preventable hospitalizations).
Q: How will these exclusions help patients?
A: When quality measures are used in various reporting programs, there can be a strong push to make sure every eligible patient receives the measured services. These exclusions help ensure that quality measures and all associated quality improvement efforts are focused on the population most likely to benefit from the specified service. Exclusions also aim to ensure that frail older adults are not burdened with unnecessary tests or treatments that would benefit them little and may even pose harm. For these individuals, shared decision making should be utilized between patients and their families, caregivers and providers to ensure patient-centered care is delivered.
Q: How did you go about identifying individuals to exclude from selected measures?
A: After reviewing the literature to identify conditions that may indicate more limited life expectancy, we developed and tested a claims-based method of identifying this population for the purpose of exclusion from selected measure reporting. Throughout the development process we received extensive feedback from various stakeholders, including experts in geriatrics, NCQA’s measurement advisory panels, our Committee on Performance Measurement and public comment. This feedback informed both to whom the exclusion should apply and to which measures it should apply.
Q: How will the exclusions help health plans and providers improve care?
A: Refining the selected measures to exclude those with advanced illness allows plans and providers to focus improvement efforts for things like cancer screenings and disease-specific treatment and management on those patients most likely to benefit. To improve care for those with advanced illness, time not spent providing unnecessary services can be used to assess patient goals, support shared decision-making and address care needs that are more relevant and important to this population. For example, the Transitions of Care measure assesses whether activities that support good care coordination are received for patients during and after a hospital stay. Looking at things such as notification for a patient’s primary care provider of an inpatient admission and subsequent hospital discharge, as well as patient engagement and medication reconciliation after a hospital stay. These care coordination activities are important and relevant for those with advanced illness who are admitted to the hospital.
Q: To which measures do these exclusions apply?
|Measures||Exclusion for members|
|≥65 with advanced illness and frailty||≥80 with frailty||≥65 in Medicare living long-term in nursing home|
|Breast Cancer Screening||✓||N/A1||✓|
|Colorectal Cancer Screening||✓||N/A1||✓|
|Controlling High Blood Pressure||✓||✓||✓|
|Osteoporosis Management in Women Who Had a Fracture||✓||✓||✓|
|Comprehensive Diabetes Care||✓||N/A1||✓|
|Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis||✓||✓||✓|
|Persistence of Beta-Blocker Treatment After a Heart Attack||✓||✓||✓|
|Statin Therapy for Patients with Cardiovascular Disease||✓||N/A1||✓|
|Statin Therapy for Patients with Diabetes||✓||N/A1||✓|
1Measure does not include members age 80 and older.
Q: How can people learn more?
- Link to HEDIS Volume 2 for more information.
- Submit technical questions about the exclusions to NCQA’s Policy Clarification Support through MyNCQA.org: https://my.ncqa.org/
- Contact Sierra Alewine at firstname.lastname@example.org for more information on the exclusions work.