The Clock is Ticking: Priority Measures for MA and Medicaid Prospective HEDIS review

This month we are taking a look at hybrid method retirement and new measures for the Medicare Advantage Star program, as well as where Medicaid measurement programs (especially those that are common withhold measure) are going. The pace of change is dizzying and likely to speed up over the next few years. By now, most health plans with MA and Managed Medicaid programs are already developing their year-round, prospective HEDIS programs to align with the future changes. Those who have adopted an NLP platform like Astrata’s Chart Review will definitely have an edge as they adapt to this dizzying pace of change.

Beyond their current NLP-powered prospective programs, where do we advise leaders to keep an eye out and consider opportunities and tactics before these measure changes land? We’ve divided our advice into three sections – what to do immediately for 2024, how to prep quickly for 2025, and what to start working on now so that you don’t fall farther behind in 2026.

All Hands on Deck for 2024

Probably the most pressing issue facing most health plan HEDIS teams in 2024 is the retirement of colorectal cancer screening (COL) from the hybrid methodology this year. MY24 impacts Star Ratings for 2026 and this should be a main focus of efforts between Stars and HEDIS teams as we move into the Q4 push. If you’re already using an NLP platform, you’ll definitely want to include COL in your measure set because one of the key inclusion criteria (colonoscopy within the last 10 years) is an excellent example of where NLP can be crucial to close gaps. Many health plans still saw lift from hybrid season in MY23, likely due to the long lookback period for the colonoscopy inclusion criteria. But keep in mind that NLP can also provide critical auxiliary information such as which members have received FIT or FOBT kits but still remain gaps. These members are especially important to reach out to and could benefit from reward programs to help them take the last step to close that gap.

Just in time for 2025

Even as you are focused on mitigating the risks from 2024, you’ll want to be rallying around what’s necessary for 2025. For Medicare Advantage programs, that’s the retirement of EED from hybrid season. And this one poses far more challenges because health plans often do not have high coverage access to data from retail optometry chains, including those in the big box stores which provide most optical care in some parts of the US. Accessing this data is clearly now a critical need and we are hopeful that this measurement change will drive new business opportunity that makes better data interoperability a reality for this specialty care area.

In the meantime, Medicaid plans are facing their own mini-crisis as more measures become ECDS and come out of the hybrid season (add these to COL and EED). For at least two of these Medicaid-only measures (IMA and CIS) we see significant differences based on markets, because states vary in the maturity of their vaccination registries. For states where vaccination registry maturity is low, medical record review with NLP will be a critical success factor. And keep in mind that Cervical Cancer Screen (CCS) is another cancer screening measure where many health plans were still seeing lift in their MY23 results.

The main thing to keep in mind is that the removal of the hybrid method is that transition to ECDS is coming for more measures. So, it’s definitely wise to set the foundation for the future now, so that you aren’t left responding in a purely reactive mode.

Get ahead for 2026

As described in the Medicare Advantage 2025 Program Announcement, a number of measures in the display category could be seen in the Stars Program 2026 announcement. These include the following Part C measures:

• Blood Pressure Control for Patients with Hypertension
• Breast Cancer Screening Follow-Up
• Social Connection Screening and Intervention
• Chronic Pain Assessment and Follow-Up
• Tobacco Use Screening and Cessation and Lung Cancer Screening and Follow-Up
• Functional Status Assessment Follow-Up

Astrata either has already developed similar previous measures, or is working on new NLP measures for many of these display measures. We think some of these will be very difficult to succeed at without an NLP platform.

And Don’t Forget…

Keep three more things in mind as you continue your prospective HEDIS planning for 2025 and 2026:

• Access to chart data is one of the most important steps you can take, and we find that this takes time. Use all of your available resources (HIEs, Direct provider connection, EHR interoperability agreements, data aggregators and chart chase vendors) and focus on building out a broader data strategy. You can learn more about this in our recent white paper.
• Changes are coming fast. While the measures described above are must-haves for your NLP platform, it’s best to try to stay ahead of these changes. Even once you have the technology working smoothly, it can take a complete season in order to put the necessary people and processes in place. Now is the time to double down on Prospective season, as you prepare for a HEDIS season that is truly continuous after the sun sets on the hybrid methodology.
• Transition to ECDS is only part a broader transition to digital measures. There are more technology and reporting changes coming as HEDIS transition to digital by 2030.