The What, Why, and How of NCQA's Strategic Roadmap for Digital Quality Measures

Roxanna Cross
Thr 18 Jan 2024
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NCQA quality measures evaluate health plans on their effectiveness, patient experience, access to care, and care coordination. These measures ensure that healthcare payers deliver high-quality care, leading to better health outcomes for enrolled individuals.

The measures assess health plans on a range of evidence-based metrics, including preventive screenings, managing chronic diseases, and using medications appropriately. By doing so, they gauge the level of quality health plans achieve in catering to their members' needs. Patient experience measures also evaluate crucial aspects of care delivery like communication with providers, ease of access to care, and overall satisfaction, thereby ensuring that healthcare payers prioritize patient-centered care.

However, the existing structure of the quality measures creates some challenges.

In a recent blog post, NCQA highlighted some of the quality measurement barriers that need to be addressed.

  • Error-prone: When inputting measures into health plans' IT systems, human error is likely to occur. Interpreting the extensive HEDIS Volume 2 publication, which is over 800 pages, is a challenging task and often leads to mistakes.

How can we minimize human error?

  • Unwanted variations: Users sometimes modify measures to target specific populations. However, this flexibility and harmonization have limitations.

How can we maintain the clinical intent of measurement while making it more flexible?

  • Delayed and retrospective: The process of developing and implementing measures for public reporting is time-consuming, spanning several years. It also takes a significant amount of time to distribute quality results to payers and providers who rely on them.

How can we improve the speed and forward-looking nature of measurement?

Changing Waves: The Recent Changes in the Regulations

NCQA's Commitment to a Fully Digital Ecosystem

NCQA has made a momentous commitment to establish a fully digital ecosystem by 2030, with ongoing initiatives already in motion. These initiatives include the development of Digital Quality Measures (DQM), the adoption of the ECDS reporting format, the implementation of Clinical Quality Language (CQL) for HL7, and the creation of HEDIS® core implementation guides.

To address existing inefficiencies within the system, NCQA aims to standardize data, improve access to diverse data sources, and enhance data accuracy. This will not only lead to better quality outcomes but also streamline the process of quality assessment and reporting for health plans.

NCQA's target is to complete the full digitalization process by 2025, meaning that health plans must adapt to the digital landscape well before the 2030 mandates are introduced.

In this blog, we will explore NCQA's specific initiatives and provide insights on how health plans can navigate this digitalization journey.

NCQA’s Roadmap

All of the NCQA’s initiatives are focused on improving one or more of the following areas:

NCQA estimates that inefficiencies in the mentioned areas cost $10 billion annually. These health system pillars are not currently aligned or optimized to fully support the digital transformation of quality measures.

Digital Quality Measures (dQMs): Enhancing Standardization and Data Quality

Digital Quality Measures (dQMs) offer a digital format for HEDIS® measures, aiming to increase standardization, improve data quality, and expand access to diverse data sources. By harnessing digital technology, dQMs facilitate a more comprehensive and standardized approach to quality measurement in healthcare. Unlike traditional measures, dQMs can accommodate data from a wider range of sources, making them more versatile and inclusive.

Advantages of dQMs include:

  • Easier transfer of measures into your IT system
  • Less interpretation, re-coding, and human error
  • Harmonization with industry standards

CMS is enhancing its digital strategy in several ways. This includes adopting FHIR-based standards and APIs for exchanging clinical information. They are also leveraging AI to identify quality issues, developing APIs for quality measure data submission and interoperability, and accelerating the transition to fully electronic measures.

HEDIS® measures are growing in significance for health plans and consumers. The National Committee for Quality Assurance (NCQA) aims to digitize all HEDIS® measures within five years, making them digital quality measures (dQMs).

Improving the transfer of human-readable, narrative descriptions of HEDIS® measures into health systems' IT systems, reducing interpretation, recoding, and human error, and aligning with industry standards are all crucial benefits of achieving interoperability.

According to the NCQA, their "dQMs align closely with interoperability and data exchange standards, making it easier to deploy the measures and share knowledge across the entire continuum of care." As healthcare undergoes digital transformation, it is evident that interoperability is not only essential for health plans to enhance the member experience and provide quality care, but also to meet the rapidly changing requirements and standards of the industry.

How Does It Impact Payers?

The NCQA encourages health plans to integrate data sources beyond claims in order to gain a comprehensive view of patient health and the quality of care provided. By utilizing this data, health plans can significantly enhance their quality performance and competitiveness. Currently, many health plans primarily rely on claims data for their operations. However, the introduction of dQMs emphasizes the importance of also considering clinical, EHR, labs, and HIE data, although it is not mandatory.

The NCQA encourages health plans to adopt real-time data measurement from multiple sources, rather than relying solely on retrospective techniques. By utilizing real-time data, health plans can make informed decisions that improve the quality of care and patient outcomes. This approach reduces the risk of data loss and creates a comprehensive database that accurately depicts patient health and the quality of care provided.

The NCQA plans to release over 70 digital quality measures and expects health plans to familiarize themselves with them by 2025. Compliance requirements are changing, and health plans will eventually need to digitize their reporting methods by 2030, as outlined in the NCQA's roadmap.

Here is a depiction of expectations NCQA has for health plans and providers on how they should accommodate ongoing and upcoming changes.

The Current Landscape of Payers Regarding These Regulations

During the Health Innovation Summit 2023, the NCQA highlighted the following points based on its experiences so far:

  • Utilizing Implementation Guidelines (IGs) that are based on multiple underlying IGs
  • Considering constraints based on the specific use case and data source

In addition, the NCQA emphasized the need to move beyond retrospective measurement by:

  • Expanding allowable adjustments
  • Adopting person-centered measurement
  • Aligning clinical decision support, clinical practice guidelines, and quality measurement

In a recent blog post, we discussed the benefits of prospective plans and connected data that bring functions closer to the point of care. This enables doctors to access data more quickly, improving patient monitoring, diagnostics, and treatment planning. These initiatives also promote stronger provider coding, ensure that encounter data aligns with the medical record, bridge future gaps, and enhance provider-member engagement. Ultimately, this leads to a superior member experience and improved quality of care.

Preparing for Regulatory Changes: What Should Payers Do?

Establishing a strong data readiness foundation is crucial for long-term transformation in health plans. Data readiness goes beyond data exchange; it ensures that data is usable, leading to improved health outcomes and enabling enhanced human experiences. By focusing on data readiness, health plans can drive consumer engagement initiatives and gain valuable insights from clinical analytics, performance metrics, and operational analytics. More than just giving members access to their records, this approach empowers the entire organization with actionable data.

Failing to prepare data leads to coding gaps, incorrect reporting, and inefficient workflows. Learn about the four steps to attain data readiness in Overcoming Healthcare’s Data Readiness Crisis.

How Can Innovaccer Help Payers Prepare for Implementation of Changes?

Improving quality measure outcomes relies on the provider-member relationship. Innovaccer works with payers to speed up gap closure and make a positive impact on patient care. Our NCQA-certified, interoperable process enables engagement with providers at the point of care. We offer seamless claims and clinical data ingestion for HEDIS®, Stars, QRS, care outcomes, and reporting.

Innovaccer's Quality Management solution ensures high-quality healthcare through measurement, public disclosure, and government compliance programs for Commercial, Medicare Advantage, ACA Commercial, and Medicaid populations. This leads to effective compliance and improved quality ratings.

With Innovaccer, payers can gain deeper insights while reducing costs and improving security. Our unique offering includes comprehensive certified measures, gap closure analytics, REST APIs, and bulk APIs for easy integration. Results are accessible through a unified data model.

Innovaccer helps payers streamline their quality initiatives by consolidating multiple programs like HEDIS, Stars, QRS, P4P, PQA, ACO, and MIPS into one integrated system. Our FHIR interoperability and UDM are well-equipped to support digital quality journeys and facilitate dQMs for payers.


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Tags: Digital Quality Measures
Roxanna Cross
Director - Product Management

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