Abstract
Many of NCQA’s HEDIS® healthcare quality 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. To address these concerns, NCQA developed a set of cross-cutting exclusions for those with advanced illness and frailty to remove them from reporting in selected measures; thereby focusing quality improvement efforts on measures of greater relevance and potential benefit (e.g., improving care transitions, getting follow-up after acute care episodes, or avoiding preventable hospitalizations). These exclusions can focus care on services that are of higher value and importance to individuals with advanced illness while encouraging shared decision making and patient-centered care. NCQA took a multi-step approach to develop these exclusions. After reviewing the literature to identify conditions and service use that may indicate more limited life expectancy, we developed and tested a method of identifying this population using a large Medicare claims database. Overall, a very small percentage of the Medicare population (only 1.6%) met the exclusion criteria. We then reviewed all HEDIS® measures and identified nine where shared decision making should take place for individuals that met the exclusion criteria. Throughout development we received extensive feedback from geriatrics experts, NCQA’s measurement advisory panels and public comment. The cross-cutting exclusions were approved and implemented in the HEDIS® measurement set, to be reported on for the first time in June of 2019.