Measure Update: Improving care for individuals receiving palliative care

We have a measure update you should know about.

Starting in measurement year 2020, NCQA added a cross-cutting exclusion to 15 HEDIS measures for palliative care patients. People in palliative care are receiving comfort care for the symptoms of a serious illness. Removing these folks from selected HEDIS measure reporting allows us to better focus quality efforts on other measures relevant to their care. This may include measures to improve care transitions, ensure follow-up after acute care, or avoid preventable hospitalizations.

Elderly senior aged patient on bed with geriatric doctor holding hands for trust and nursing health care, medical treatment, caregiver and in-patient ward healthcare in hospital

HEDIS measures created with the general population in mind may not be relevant to all patients, particularly those approaching end of life or with advanced or serious illness. That’s why, over the last several years, NCQA added cross-cutting exclusions to remove certain populations from measures. For example, we exclude patients in hospice care from all HEDIS measures. We also exclude older Medicare members who live long-term in nursing home settings. For other selected measures, we exclude those with advanced illness and frailty. Check out more information on our previous exclusions work in this earlier blog.

Why exclude palliative care?

The palliative care exclusion applies to selected measures covering three categories: inappropriate medication use, screening and prevention, and disease-specific medical treatment.

The focus on comfort in palliative care often includes certain medications that are inappropriate for use in the general population, such as opioids for pain management. Also for patients in palliative care, services identified within the screening/prevention or disease-specific treatment categories may not align with patient goals or may even complicate their care.

It is important to keep in mind that excluding individuals receiving palliative care does not mean they shouldn’t get the care or service defined in the measures; it means that the patient will be able to make shared decisions about their care with their family, caregiver, and provider. At the same time, NCQA exempts providers and health plans from accountability for palliative care patients for the selected measures.

We do not apply the palliative care exclusion across all measures like the hospice exclusion. Palliative care differs from hospice, in that it can be helpful at any stage of a serious illness and people are more likely to transition out of palliative care than hospice. In hospice, the focus is on terminal illness and providing comfort during the last six months of life, whereas a patient receiving palliative care can receive treatments to cure their illness and may only need comfort care for a short period of time.

As part of the process, NCQA developed a method for identifying individuals with palliative care for the purpose of an exclusion. Throughout the process, we gathered feedback from various stakeholders, including measurement advisory panels, our Committee on Performance Measurement and public comment.

The palliative care exclusion has been implemented in the HEDIS Measurement Year 2020-2021. You’ll find it in our annual measures publication. It specifically applies to the following measures:

  • Risk of Continued Opioid Use.
  • Use of Opioids at High Dosage.
  • Potentially Harmful Drug Interactions in Older Adults. 
  • Use of High-Risk Medications in Older Adults.
  • Breast Cancer Screening.
  • Cervical Cancer Screening.
  • Colorectal Cancer Screening. 
  • Osteoporosis Screening in Older Women. 
  • Cardiac Rehabilitation.
  • Comprehensive Diabetes Care. 
  • Controlling High Blood Pressure. 
  • Kidney Health Evaluation for Patients With Diabetes.
  • Osteoporosis Management in Women Who Had a Fracture. 
  • Statin Therapy for Patients With Cardiovascular Disease. 
  • Statin Therapy for Patients With Diabetes.

We know palliative care improves the overall quality of life for those with a serious illness. NCQA recognizes that the use of palliative care is variable. We want to see it used more broadly in the future. As the use of palliative care evolves, we will review and revise the exclusion accordingly. We want to make sure the exclusion remains relevant for the intended population.

Have questions about the exclusions?

  • Link to HEDIS Volume 2 for more information.
  • Submit technical questions about the exclusions to NCQA’s Policy Clarification Support through MyNCQA.org