Multiple different quality measurement systems are currently in use to evaluate health plans’ quality performance: the National Committee for Quality Assurance’s (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS®) measures[1], the Center for Medicare & Medicaid Services’ (CMS) Quality Rating System (QRS), and the CMS Star Ratings system, among others. Optimizing your plan's quality performance is crucial for whichever system is used to assess your plan’s quality performance. Quality measure data may:

• Have potentially significant financial repercussions; in some instances, CMS uses quality data to determine bonus payment amounts
• Be used to qualify for NCQA’s Health Plan Accreditation—which may influence consumers’ enrollment decisions
•   Act as a tool to assist potential enrollees in evaluating and comparing health plans to choose one suited to their needs
• Provide a tool to monitor provider performance

However, between evolving regulations, policy changes, and updates to measure requirements, preparing for the new quality reporting season may seem formidable.

At its essence, optimizing quality measure performance requires clean, complete data—but collecting the right type and amount of data for quality measures requires a thorough understanding of current reporting requirements and both short- and long-term changes. In this article, we’ll examine some challenges you may face when optimizing your organization’s quality measure performance and some strategies to help you overcome them!

Importance of clean & complete data

Your top priority for optimal quality measurement performance is clean, complete data. That’s why your first step should be communicating with your HEDIS vendor to identify potential issues or data gaps prior to the initial measurement year (MY) submission data load and then proactively address them.

Some common data issues to prevent include referential integrity, such as referring to providers in claims not included in the provider data; including supplemental data that does not use the same member ID as the rest of the dataset; not including the correct lookback period for data; or incorrectly identifying providers’ specialties.

The value sets, containing the clinical codes used in quality measures, can change from one year to the next, which means you need to confirm that codes used for supplemental data in previous years are still valid and will generate the expected results. There are also many measures that use codes in value sets, particularly for exclusions, that have lookback periods longer than the typical number of years of claims sent to HEDIS vendors. Creating a historic claims file to capture these codes and ensure members are correctly excluded from measures can be beneficial.

Understanding MY 2024 reporting needs

It’s also crucial to ensure you and your vendor understand what needs to be reported in the MY 2024 submission(s). For instance, do you have new submissions or changes to how Medicaid or Special Needs Plan (SNP) subgroups are broken out?

You may be required to report surveys such as the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Health Plan Survey or the Qualified Health Plan (QHP) Enrollee Survey. For Commercial, Medicaid, and ACA lines of business, these surveys are conducted by third-party vendors; however, the health plan must provide a sample frame for each survey.

The sample frame is essentially a list of individuals who are eligible because they had continuous enrollment during the specified interval and are still enrolled so that a sample can be selected from them by the third-party vendor for participation in the survey.

Another factor to check: Does your State require additional fields to be added to Medicaid CAHPS survey sample frames? If so, the resources creating the sample frame need to be given advance notice of this requirement.

Preparing for 2025

Data created during 2025 will obviously impact future MY 2025 reporting, making it crucial to anticipate and proactively address known changes. For instance, quality measures are updated annually, meaning you need to understand new measures and changes to existing measures to adjust data collection strategies appropriately.

For the 2025 Star Ratings, CMS is implementing several minor updates but no significant methodological changes. However, 3 new measures will be implemented beginning with the 2026 Star Ratings, as well as changes to multiple measures.

Three new HEDIS measures will be introduced for MY 2025, as well as changes to existing measures; are you collecting the data needed to report them?

NCQA continues to work towards making electronic clinical data systems (ECDS) reporting standard, with the goal of transitioning to fully digital measurement by 2030. In the meantime, HEDIS measure updates will significantly reduce hybrid measure reporting, with only 8 hybrid measures remaining for 2025. Hybrid measures allow for a sample of members in a measure to potentially be made compliant by combining claims data with data abstracted by Medical Record Review (MRR).

Be sure to evaluate the logic used to select providers—for instance, making sure that specialties specific to certain measures, e.g., primary care provider, are included in the chase logic for those measures and that the provider demographic information is accurate.

Veradigm Quality Suite

The NCQA-certified Veradigm Quality Suite can help you optimize your plan’s quality performance. Veradigm Quality Analytics identifies gaps in HEDIS®, QRS, Star Ratings, and more, enabling you to maximize your financial impact by targeting interventions according to performance potential. Comprehensive Submissions—Quality supports the annual MY submission as well as provides the ability to drill down into member and claims data year-round. The Strategy, Trending, and Review tool supports the analysis of rates, trends, and improvement strategies, including the ability to create “what-if?” scenarios to assess where resources and attention should be focused.

To prepare for MY 2025, there are changes you may need to make starting as early as January 1 of the new year—and at Veradigm, we’re looking ahead so we can help you prepare for the future.