Why is the HEDIS Technical Update Important?

HEDIS is a set of standardized performance measures that enable consumers, purchasers and policymakers to compare the performance of healthcare organizations. NCQA publishes HEDIS Volume 2 in August of the year prior to each measurement year. The Technical Update helps ensure that:

• Organizations have access to the most up-to-date technical guidance needed to implement HEDIS measures accurately and consistently.
• Coding resources, such as value sets and medication lists, are up to date.
• Any necessary changes are made in response to the evolving healthcare and policy environment.

The Technical Update was sent to all purchasers of the HEDIS MY 2026 Volume 2: Technical Specifications, and a release letter was posted to the HEDIS website on March 31.

What Is Included in the Technical Update?

The Technical Update includes:

• A re-released full-text HEDIS MY 2026 Volume 2 publication with edits in red text.
• Updated HEDIS MY 2026 Medication List Directory.
• Updated HEDIS MY 2026 Value Set Directory.
• HEDIS MY 2026 Risk Adjustment Tables.
• HEDIS MY 2026 Audit Timeline.

NCQA released four new measure-specific risk adjustment tables for MY 2026 and updated the shared risk-adjusted table. Read our blog, HEDIS Risk-Adjusted Utilization Tables: New Measures, Shared Table Updates and FAQs, for more information regarding these changes.

Changes in the Technical Update

Below are some highlights included in the Technical Update; this is not an exhaustive list.

Social Need Screening and Intervention (SNS-E)

• Removed ICD-10 diagnosis codes from the intervention denominators.

Rationale: ICD‑10 diagnosis codes can no longer be reliably linked to documented social determinants of health (SDOH) assessments. The measure will continue to rely on LOINC codes to capture standardized screenings and positive screening results.

• Removed SDOH assessment G codes from the screening numerators.

Rationale: HCPCS G0136 no longer aligns with SDOH screening activities included in the measure following the change in the CY 2026 Medicare Physician Fee Schedule.

• Added a Food Insecurity Screening Item Response Exception for the PRAPARE^® tool.

Rationale: Clarified that because of the structure of screening item LOINC 93031-3, a null result is considered a valid response to this question.

Read our blog, Social Need Screening and Intervention: What’s Changing in the MY 2026 Technical Update, for more details about these changes.

Tobacco Use Screening and Cessation Intervention (TSC-E)

• Updated the age criteria to identify the person’s age as of 180 days prior to the measurement period.

Rationale: Updated the measure to align with current age criteria for FDA-approved tobacco cessation medications.

Race and Ethnicity Stratification

• Updated references from “Some Other Race” to “Other Race” in the Race and Ethnicity Stratification general guideline and in each applicable measure specification.

Rationale: Updated to align with the U.S. Core Version 6.1.0 Model Definitions.

Learn More

If you have not  already purchased the HEDIS MY 2026 Volume 2: Technical Specifications, you can order the publication in the NCQA Store and you will automatically receive the Technical Update with your purchase.

Join the HEDIS Users Group to get timely guidance, expert clarifications and practical support directly from NCQA. You will gain access to exclusive webinars, resources and a collaborative community designed to help you confidently navigate HEDIS updates and reporting throughout the year. Visit our website to learn more.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

PREPARE^® is a registered trademark of the National Association of Community Health Centers (NACHC).

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“People with behavioral health conditions tend to have more medical health issues,” says Vivek Garg, MD, MBA, President and CEO of NCQA. “If you have medical health issues and you have poorly supported mental health issues, the medical issues get worse. We’ve gained clarity as a country that this issue affects all of us.”

A New Partnership to Drive Industry Alignment

To address these challenges, NCQA and West Health recently announced a strategic partnership to advance the integration of behavioral health into primary care. The collaboration combines NCQA’s leadership in quality measurement and accountability with West Health’s expertise in care delivery innovation to identify and test a core set of behavioral health quality measures in real‑world settings.

The initiative also includes the formation of a policy solutions coalition as well as payer workgroups to align with state and federal policy initiatives and ongoing advocacy for behavioral health integration.

Improving outcomes will require more than isolated initiatives or one‑off interventions. Sustainable progress depends on alignment across policy, payment, technology and clinical practice, supported by measurement approaches that reflect real‑world care delivery and enable continuous improvement.

“Heroics aren’t going to change the health of our population,” says Dr. Garg. “That is not systematic, and that is not scalable.”

Measurement Gaps Undermine Behavioral Health Integration

Although there is broad agreement that integrating behavioral health into primary care improves outcomes, the field still lacks consensus on how to define and measure high-quality integration. Measurement gaps have made it harder for payers, policymakers and providers to align around shared expectations, creating barriers to scaling models that are proven to work.

Existing measures are often fragmented, overly complex or disconnected from clinical workflows—particularly in primary care settings already strained by workforce shortages, evolving digital requirements and uneven EHR capabilities. Without a clear, usable measurement framework, efforts to improve behavioral health outcomes remain difficult to sustain.

Convening National Leaders: The Advancing Behavioral Health Executive Forum

On April 21, NCQA and West Health convened national leaders from payer organizations, policymaking bodies and health systems in Encinitas, CA, for an Advancing Behavioral Health Executive Forum.

Discussions examined the disconnect between clinician‑driven, measurement‑based care and the process‑heavy metrics often tied to payment and accountability, underscoring the need for stronger alignment across policy, payment technology and clinical practice to support earlier identification and more consistent follow‑up in primary care.

The Forum featured a fireside chat between Dr. Garg and Zia Agha, MD, Chief Medical Officer at West Health Institute, who explored the real‑world barriers to integrating behavioral health into primary care and the system‑level changes needed to move from measurement to system-wide impact.

Moving From Measurement to Better Outcomes

Forum participants emphasized that reducing complexity is essential to driving improvement. The goal is not more measurement—but better measurement that supports clinical decision-making, reduces burden and enables learning over time.

“If you just measure and don’t provide the resources to fill those gaps, we often see resistance,” says Dr. Agha. “The beauty of the integrated care model is that it does make those resource changes in primary care.”

NCQA and West Health will continue working with stakeholders to advance scalable, measurement‑informed approaches that strengthen behavioral health integration in primary care.

Visit our website to learn more and stay updated on this work.

The post Advancing Behavioral Health Integration in Primary Care: Turning Shared Priorities Into Action appeared first on NCQA.

NCQA has been exploring ways to drive improvement in data quality while reducing the burden of manual data verification. We have shared insights about this topic in our blog, Improving HEDIS Data Quality in a Digital World, and on the Quality Matters podcast, What the Quest for Data Quality is Really About.

“As we modernize our data quality solutions, we’re exploring how automation can help organizations assess the reliability and trustworthiness of clinical data sources,” says Ben Hanley, NCQA’s Director of Product Management.

A Framework for Evaluating Clinical Data Quality

NCQA is committed to developing automated, scalable methods of data validation. Our approach addresses four key areas:

• Ensuring data are complete and properly structured for HEDIS calculations.
• Showing that data are reasonable and likely to depict reality.
• Monitoring changes in data content and delivery for consistency over time.
• Understanding where data originated and how the data have been exchanged and transformed.

Data quality assessment is not a one-size-fits-all approach. “Organizations will need a combination of tools to validate different aspects of the data,” says Hanley. “The assessments will also vary based on the use case. Not all data sources need validation across all four areas.”

Announcing NCQA’s Data Quality Solutions

We are excited to announce our first product offering related to automated data quality assessment—and we are looking for early adopters to implement this new tool and provide feedback.

NCQA developed the HEDIS^® Data Quality Specifications to enable standardized assessments of the quality of electronic clinical data. It includes over 100 specifications for data quality metrics that cover a range of clinical domains such as encounters, medications, laboratory results, conditions, immunizations and demographics.

Each specification includes a metric denominator and a metric numerator. This enables organizations to calculate how often an electronic clinical data source meets the requirements identified in the specifications. Combining relevant data quality metrics for an electronic clinical data source can provide a snapshot of overall fitness for use in HEDIS.

Organizations can use the HEDIS^® Data Quality Specifications in the following ways:

• To evaluate the level of data quality between different electronic clinical data sources.
• To identify targeted areas for electronic clinical data quality improvements.
• To establish standards for how electronic clinical data should be received from or exchanged with external partners.
• To evaluate data sources being considered for use in HEDIS reporting.

The HEDIS^® Data Quality Specifications were released in March for beta testing. NCQA plans to release an updated version of the specifications later this year.

How to Get Involved

NCQA is looking for a limited number of partners to participate in beta testing of the new data quality specifications. To participate, organizations should be:

• Creating, sharing or aggregating data for HEDIS reporting.
• Exchanging and using clinical data files in a FHIR^® format.

Participation in the beta testing offers an opportunity to influence how automated data quality assessment evolves and to ensure the specifications meet real‑world implementation needs. To learn more, please fill out an interest form on our website.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

HL7® and FHIR® are the registered trademarks of Health Level Seven International and their use does not constitute endorsement by HL7.

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“NCQA has been partnering with HRSA to improve quality and efficiency in health centers since 2010,” says William Tulloch, NCQA’s Director of Quality Services. “More than 3,200 health centers have earned NCQA PCMH Recognition to date. NCQA is ready to support the next generation of health centers as they pursue this valuable credential.”

This year, NCQA will expand our support for health centers by offering our Behavioral Health Integration Distinction—an important step toward helping patients achieve whole-person health.

Benefits of PCMH Recognition

The PCMH model of care can help build better relationships between patients and their clinical care teams, while meeting regulatory requirements. Here are some of the benefits of pursuing PCMH Recognition:

• Improve quality and efficiency. Health centers develop streamlined workflows and adopt a team-based approach leading to improved quality of care, increased efficiency, higher satisfaction among patients and staff, and reduced costs.
• Reduce health disparities. Health centers learn to identify, assess and address social drivers of health as a fundamental component of the PCMH transformation process.
• Comply with regulatory requirements. PCMH requirements are aligned with HRSA’s Uniform Data Systems Resources and state Medicaid requirements related to access and clinical quality outcomes.

Visit our website to learn how the PCMH model of care can improve health center operations and view testimonials from health centers that have successfully completed the program.

Benefits of Distinction in Behavioral Health Integration

Behavioral health conditions like mental illness or substance use disorder can often be identified and treated in a primary care setting, which can offer patients a seamless experience and lead to better health outcomes.

NCQA’s Distinction in Behavioral Health Integration helps health centers and LALs integrate behavioral healthcare into their practices. Here are some of the benefits of this distinction:

• Showcase your expertise. Demonstrate to patients, payers and partners that your organization has the right resources, evidence-based protocols and standardized tools to support the needs of patients.
• Deliver whole-person care. Expand your capacity to provide comprehensive care that acknowledges patients’ physical and behavioral health needs.
• Improve outcomes. Integrating behavioral health and primary care leads to improvements in access, clinical outcomes and patient experience.

Health centers and LALs that have already achieved PCMH Recognition or are actively working toward it can apply for the Distinction in Behavioral Health Integration.

How NCQA Supports Health Centers and LALs

In addition to covering survey expenses, NCQA will provide office hours, regional and national training sessions for health center staff, individualized technical assistance from NCQA PCMH Certified Content Experts and educational content.

“Health centers are already doing the work, so applying for PCMH Recognition is the natural next step in the process,” says Tulloch. “NCQA provides the tools and resources to help health centers succeed.”

Visit our training and technical assistance webpage to access recordings of past training sessions and office hours.

How to Apply

Federally Qualified Health Centers (FQHC) must submit a Notice of Intent (NOI) to indicate their interest in the program. Use this link to access step-by-step instructions for submitting an NOI.

LALs should follow these instructions:

1. Go to the BPHC contact form.

2. Scroll down to the Look-Alike Designation section and click on the Accreditation and Patient Centered Medical Home Recognition (APCMH)—LAL A new contact form will open.

3. Select the Notice of Intent option from the drop-down menu.

4. Enter the details about your request in the space provided.

Please submit your NOI as soon as possible to reserve your spot. If you have questions, please contact HRSA via the BPHC contact form.

The post NCQA Is Recruiting Federal Health Centers to Participate in HRSA-Funded Program appeared first on NCQA.

Dr. Ndumele shared his perspective on the challenges and opportunities in CKM Syndrome care and why we need to break down silos and work together to address what he refers to as “one of the largest public health issues of our time.”

What inspired you to become a physician?

Growing up, I liked math and science. When I was in high school, my mom took me to a community health program that was occurring in our area. They were doing health screenings and trying to connect people with resources to support them in their health journey. I was amazed by how providing screenings and enhancing people’s awareness of different risk parameters could have such a positive impact. People were coming back to us and telling us how they had made all these positive changes in their lives—just because we had provided that information to them! It was hard for me to believe we were making a difference to that extent in people’s lives, but it was the case, and I was hooked. I ended up going to Johns Hopkins University and then Harvard Medical School. I really loved studying the workings of the cardiovascular system and also appreciated that it was connected to multiple modifiable risk factors, which made it a natural fit with my interest in prevention.

What is the focus of your clinical practice?

I focus a lot of my efforts on cardiovascular disease prevention, but I also see patients with existing cardiovascular disease who are trying to improve their quality of life and reduce the risk of recurrent cardiovascular disease events. What I’ve noticed in my practice over the last 20 years is that people are coming in with higher risk, more complexity and a greater burden of interrelated clinical conditions. We’re seeing more people who have obesity, many of whom also have uncontrolled diabetes, chronic kidney disease, or both additional comorbidities. Usually, patients with diabetes and chronic kidney disease also have hypertension and some dyslipidemia (an abnormal level of fats in the blood), and it’s this interrelated cluster of risk factors that we’re seeing over and over again.

The clusters of risk factors I saw in my clinical practice overlapped with my research on the growing impact of obesity on multiple downstream systemic challenges, including the development of diabetes and chronic kidney disease, with resultant increased risk for cardiovascular disease—and that is what we’re talking about with CKM syndrome.

How did the name CKM Syndrome come about?

The main reason behind the naming of CKM Syndrome is the interrelatedness, or connectivity, among cardiovascular, metabolic and kidney conditions. Many patients feel like they’re just having bad luck, wondering “Why are all these things happening to me at the same time?” without recognizing that their health conditions are interrelated.

The other reason for the name is that there’s a reliable and predictable trajectory that leads to the development of this kind of complex presentation. It typically starts with excess and dysfunctional adipose tissue (body fat), progressing to the emergence of chronic kidney disease and metabolic conditions like diabetes, hypertension and dyslipidemia, leading to the development of subclinical cardiovascular changes and eventual clinical cardiovascular disease. The consequence of progression along this spectrum is a greater risk for premature mortality, most often due to cardiovascular disease.

As a cardiologist, I often see people at a point when these interrelated factors have not been addressed for many years and now they have cardiovascular disease that is difficult to manage because of its severity and the multiple coexisting comorbidities. But I also recognize the opportunity to identify and address the risk much earlier in the process and, hopefully, avoid getting to these really severe and complex stages.

What challenges do people with CKM Syndrome experience when trying to access healthcare?

First, there’s quite a bit of under-recognition. Many of the risk factors aren’t recognized by patients or clinicians, and even if they are recognized, they may not be addressed due to other things that seem more pressing. If a patient has multiple interrelated conditions and is trying to see multiple clinicians from different specialties, it can be hard to navigate. If there is conflicting advice, they are trying to figure out who to listen to. It doesn’t help that clinicians tend to operate in our own silos. The kidney doctor will be focused on protecting the kidneys, the heart doctor will be focusing on what’s good for the heart and the endocrine doctor will focus on what is best for the endocrine system. CKM Syndrome doesn’t respect our subspecialty silos. We need to move beyond that and understand that these conditions are interrelated and make sure that risks are addressed holistically and in a timely fashion.

How can we empower patients to prevent or manage CKM Syndrome?

We need to help people understand that there’s a predictable trajectory that occurs with these interrelated conditions and that these issues are readily addressable, particularly in the earlier stages. The CKM staging concept is really important. It helps patients to identify where they are along the spectrum and learn what they can do to preserve health for as long as possible. There’s no doubt that a healthy lifestyle is at the core of preventing and managing CKM Syndrome. But a healthy lifestyle is not just about behavioral choices—it is about the multi-level social drivers of health that impact a person’s lifestyle. We need to recognize the barriers patients may encounter and do what we can to make it easier for them to make the healthy approach their default approach.

What was your experience participating in NCQA’s CKM Syndrome convenings?

It was a really thoughtful group of individuals that represented a lot of different perspectives, including some people who were coming into this with fresh eyes. I appreciated the shared sense of urgency. There is widespread agreement that this is a shared challenge across disciplines, driving risk for patients and driving worsening mortality trajectories in the population. It’s something we all need to work together to help solve. The framework outlined in the white paper is a great step forward.

What were some of your key takeaways from the expert panel?

One of the really important things we talked about was using measurement as a platform for enhancing CKM Syndrome care. We need to think about cross-cutting measures that incorporate multiple disciplines and focus on recognizing risk in earlier stages, as well as some patient-facing measures that can guide us toward more integrated care. I also enjoyed the discussions about innovations in our approach to activating and supporting clinicians and patients through EMR-based strategies, other health technologies and the use of artificial intelligence.

What would be the most impactful change we could make to have a positive impact on CKM Syndrome care and outcomes?

It’s hard to pick just one. If people had more of an awareness of what CKM syndrome is, then it would be a great starting point for conversations with their clinicians. If clinicians focused more on holistically recognizing and addressing CKM risk—and if that CKM risk profile could be shared across all specialties—then we would all be looking at the same snapshot and we could talk to our patients in the same language. For example, the American Heart Association recently developed a new online risk calculator for cardiovascular diseases, which integrates and quantifies the clinical impact of CKM risk factors, that has been very impactful.

I also believe care coordination is very important for CKM syndrome. If we had a CKM care coordinator working with patients to address lifestyle changes and social determinants of health and coordinating care across all of the specialties, that would be a tremendous help. In the NCQA convening, we also talked about emerging EMR-based and AI-enabled approaches that could support care coordination when we don’t have enough people to play that role.

Basically, we need to make this complexity a little bit more accessible for both patients and clinicians and help us all speak the same language in a way that makes our care more patient-centered and less siloed. Also, identifying and addressing CKM risk earlier will lead to the best clinical outcomes for patients.

Learn More

• Download our white paper, Cardiovascular-Kidney Metabolic Syndrome: Improving Quality of Care and Accountability.
• Get more CKM Syndrome resources from the American Heart Association.
• Learn more about the American Heart Association PREVENT™ risk calculator.

The post Dr. Chiadi Ndumele: “CKM Syndrome Doesn’t Respect Our Subspecialty Silos” appeared first on NCQA.

Why Risk Adjustment Matters

Individual health outcomes are shaped by underlying risk factors, which can distort comparisons between health plans if we do not properly account for them. Risk adjustment ensures that performance comparisons reflect differences in care delivery, not differences in the distribution of members’ health status (i.e., case mix). Risk adjustment allows for “apples to apples” comparison between health plans.

Essentially, risk adjustment asks: How would performance compare if all organizations had the same patient population?

There are multiple risk adjustment methods. NCQA uses statistical models for our HEDIS measures to predict outcomes by considering factors such as:

• Age and gender.
• Comorbidities.
• Procedure subtypes.
• Discharge conditions.

These models are the source of the risk weights found in NCQA’s RAU tables. Health plans use the tables to calculate an expected event rate, which is then compared to the observed event rate using an observed-to-expected ratio. The observed-to-expected ratio reflects risk-adjusted performance and shows whether a plan performed better or worse than expected based on its unique case mix.

When interpreting measure results, calibrate the ratio by dividing the individual organization ratio or national percentiles by the national average ratio. A calibrated ratio of <1.0 indicates better than expected performance, while a calibrated ratio of >1.0 indicates worse than expected performance.

For example, for the Plan All-Cause Readmission measure, a plan with a calibrated ratio of 0.8 may be successful at achieving fewer readmissions than expected, given its patient population.

New for MY 2026: Four Risk‑Adjusted Utilization Measures

NCQA has added four new RAU measures for HEDIS MY 2026:

• Acute Hospitalizations Following Outpatient Orthopedic Surgery (HFO).
• Acute Hospitalizations Following Outpatient General Surgery (HFG).
• Acute Hospitalizations Following Outpatient Colonoscopy (HFC).
• Acute Hospitalizations Following Outpatient Urologic Surgery (HFU).

These measures evaluate the risk-adjusted ratio of observed-to-expected unplanned acute hospitalizations (inpatient and observation stays) for any diagnosis within 15 days of an outpatient surgical procedure, for persons 65 years of age and older. Each measure focuses on a targeted outpatient surgical procedure.

Risk-Adjusted Tables Overview

NCQA publishes two types of RAU tables:

• Shared Tables: Provides the logic for mapping diagnosis codes into clinical categories and applies across risk-adjusted measures.
• Measure-Specific Tables: Provides measure-specific risk weights used to calculate expected values. There are 10 measure-specific tables—one for each risk-adjusted measure. Some measures report multiple product lines and each product line has its own set of weights.

Note: Measures in the Medicare product line have different sets of risk weights for enrollees ages 65+ and enrollees under 65.

Updates to the Risk-Adjusted Utilization Tables

The HEDIS MY 2026 RAU Shared Tables introduce a new table.

New: Table Proc-Mapping

A new tab titled “Table Proc-Mapping” was added to the Shared Table to support identification of procedure subtypes used in risk adjustment weights for three of the four new RAU measures (HFG, HFO and HFU). This table maps CPT codes to Clinical Classifications Software (CCS) procedure subtypes.

The risk adjustment model identifies all CPT codes associated with each outpatient surgery episode date. Each CPT code is assigned to a procedure subtype using Table Proc-Mapping. Only CPT codes in the denominator value set are included when assigning CPT codes to procedure subtypes. For example, in the HFU measure, only map the CPT codes in the Urologic Surgery Value Set. All associated CCS codes are captured for each episode. CPT codes that cannot be mapped to a CCS category are excluded.

Example

An outpatient surgery episode includes CPT codes 10160, 11762 and 15934:

• CPT 10160 maps to CCS 170 (Excision of skin lesion).
• CPT 11762 maps to CCS 175 (Other OR therapeutic procedures on skin/breast).
• CPT 15934 maps to CCS 170 (Excision of skin lesion).

Final procedure subtypes: CCS 170 and CCS 175 (with CCS 170 counted once). These CCS codes are used as risk weight variables in the risk adjustment calculation.

Note: The HFC measure currently does not assign CCS categories because colonoscopies only fall under one CCS category.

Conclusion

The MY 2026 Risk Adjusted Utilization Tables introduce new measures, enhanced mapping tools and substantive model updates designed to improve fairness and accuracy in health plan comparisons. By refining how underlying patient risk is captured, NCQA strengthens the reliability of HEDIS reporting—ensuring results reflect clinical performance, not population differences.

If you have any questions regarding the measures or ordering the RAU tables, submit a question to NCQA staff through My NCQA.

Frequently Asked Questions (FAQs)

Why did the risk weights change in MY 2024?

Risk weights are refreshed every 3–4 years to keep pace with changes in healthcare data patterns. The risk adjustment models are generated from past cross-sections of utilization data and are used to predict outcomes in future measurement years. As utilization patterns, coding practices, care management trends and population characteristics change, older models become less predictive.

NCQA also periodically re-estimates the models based on more contemporary data, allowing the variables included in the models and their associated weights to reflect changes to underlying relationships between the risk adjustment variables (e.g., age, gender, comorbidities as recorded in claims) and the outcomes (e.g., hospital readmissions). Re-estimating the models supports both measure reliability and validity.

NCQA derives many of the clinical conditions used in risk models from the CMS Hierarchical Condition Category (HCC) risk adjustment methodology. These risk models are also updated regularly. The Shared Tables include a tab summarizing changes for that year.

When the weights and models are re-estimated, new data is incorporated, which can reveal changes in the relationships among different variables.

Why might a condition that appears to be more severe be assigned a lower HCC risk weight than a related condition?

Several statistical and population-based factors can cause this:

• Multicollinearity (or sometimes just collinearity): There is a correlation among HCCs; people with a “severe” level condition might be more likely than people with a “moderate” level of the same condition to have other HCCs that absorb some of the excess risk associated with the condition.
• Outlier exclusion: People with a severe level of a condition may be considerably more likely to have enough hospitalizations to reach the outlier threshold and thus be excluded from the denominator entirely.
• Compositional effect: Those who remain could be unusually unlikely to experience an event, which can be thought of as a compositional effect.

Any of these dynamics could result in the “moderate” or “mild” level of a condition having a higher risk weight than the “severe” level of the condition.

What models are used for the RAU measures?

NCQA employs statistical prediction models to estimate expected event rates for each measure outcome. To obtain the risk weights, statistical relationships between the potential risk adjustors and the outcomes are assessed using generalized linear models:

• Logistic regression is used to estimate model coefficients and values are summed across a plan population for measures with outcomes based on proportions (i.e., each denominator unit can only have one instance of the outcome).
• Logistic + Poisson regressions are used to estimate model coefficients for measures with outcomes based on rates (i.e., each denominator unit can have many instances of the outcome).

The expected rates derived from the models are compared to observed performance to generate risk-adjusted performance assessments (observed-to-expected ratios). NCQA fits these separately for each utilization measure to produce risk weights.

Can you give more details about the statistical models you use?

For the Plan All-Cause Readmissions (PCR) measure and the Hospitalization Following Discharge From a Skilled Nursing Facility (HFS) measure, NCQA uses penalized logistic regression to predict whether an index hospitalization will result in a readmission.

For the other risk-adjusted measures, NCQA uses penalized logistic regression to predict whether the denominator member would have any numerator event (versus none) and then penalized Poisson regression to predict the number of numerator events, among those who have at least one.

Each measure accounts for a combination of risk weight variables:

• Age and gender.
• Comorbidities (HCCs).
• Procedure type.
• Discharge conditions.
• Surgeries.
• Observation stay discharge.
• COVID discharge.
• Medication.

Note: Not every measure or product line has every type of variable.

In addition, the risk-adjustment models consider interactions using the “combination” HCCs, which are specified in the Shared Tables, as some combinations present a greater amount of risk when observed together.

The models address effect modification by estimating separate sets of risk weights for different populations (e.g., Medicaid, Medicare age 18–64, Medicare age 65+).

Example

Considering the PCR measure, the model specifies that the log odds of a hospital readmission within 30 days of an index hospital discharge are a linear combination of a set of indicators:

• Age and gender combinations (of which each denominator unit belongs to exactly one; all combinations are shown in the risk weight tables).
• Comorbidities observed via diagnosis codes in claims in the year prior to the index hospital discharge (shown in the Shared Tables with the HCC labels).
• Conditions primarily associated with the index hospital stay itself (these have the “discharge CC” label in the Shared Tables and/or risk weight tables).
• Whether the index hospital stay was associated with a surgery.
• Whether the index hospital stay was an observation stay.
• Whether the index hospital stay had a principal discharge diagnosis of COVID-19 (for Medicare 65+ only).

Not all possible predictors are in each population’s set of risk weights, which means that for some populations, some of the risk weights are zero.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

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Practice Spotlight: Community Health Centers of Burlington, Inc.

Since achieving PCMH Recognition in 2012, Community Health Centers of Burlington, Inc. in Vermont has built a strong and consistent foundation for delivering high-quality, patient-centered care. They currently have eight PCMH-Recognized practices—Champlain Islands, Essex, Good Health, Pearl Street, Riverside, Safe Harbor, South End and Winooski—serving more than 28,000 unique patients each year. With PCMH Recognition in place, care teams use data to monitor performance, identify gaps and drive meaningful improvements tailored to their community’s needs.

“As a large multi-practice Federally Qualified Health Center, having all of our sites recognized as patient-centered medical homes has provided a solid foundation for data-driven decision making,” says Kerry Goulette, PA-C, MHP, Medical Director of Quality, Risk and Compliance at Community Health Centers of Burlington. “Using data, we are able to implement, monitor and improve care delivery to meet the unique needs of our patients at every site. We have a better understanding of health disparities and barriers that allow us to focus our efforts to achieve improved outcomes.”

PCMH Recognition helps organizations build reliable processes, use data effectively and deliver high-quality, patient-centered care. Ready to strengthen your care model? Learn more about NCQA’s PCMH Recognition.

Announcing the Return and Expansion of PCMH Office Hours

NCQA has expanded PCMH Office Hours, a series of complimentary, hour-long Q&A sessions designed to support NCQA customers. Facilitated by NCQA staff, each session includes a brief program overview and time to answer product-specific questions from the audience. Upcoming topics include:

• Behavioral Health Integration.
• Certified Community Behavioral Health Clinics.
• Diabetes Recognition Program.
• Patient-Centered Specialty Practices.
• Virtual Care Delivery.

Stay tuned for more details about product-specific office hours, including upcoming dates, times and joining instructions.

Important Update: Late Fees for Annual Reporting Submissions Effective January 1

Effective January 1, NCQA began charging late fees for annual reporting submissions received after the reporting deadline. This change will help to ensure timely and consistent reporting across all programs.

To avoid late fees, please submit all required documentation by your organization’s designated reporting deadline. If you anticipate submission delays, please notify your assigned Recognition Programs Representative in advance. Visit NCQA’s PCMH webpage to learn more.

PCMH Public Comment: Open Through April 17

NCQA is seeking feedback on proposed revisions to the PCMH Care Management concept for 2027. The public comment period ends at 11:59 p.m. ET on April 17. Visit the NCQA website for details.

The post What’s New with PCMH: Practice Spotlight, Expanded Office Hours and Annual Reporting Changes appeared first on NCQA.

PCO measures work in tandem with clinical care to help people living with complex health needs make progress toward a health goal that matters to them. PCO measures have three components:

• Identify a goal and document it in a structured way, using goal attainment scaling or a patient-reported outcome measure.
• Follow up on the goal.
• Assess achievement of the goal.

Clinicians across the care continuum and in community-based services can use this approach to identify what’s important to a person and support age-friendly care. Defining a person’s goals—and ensuring that their care is consistent with those goals—can reduce unwanted treatment, improve patient activation and lead to meaningful improvement.

Why It Matters

NCQA is currently moving the PCO measures for C-SNPs and D-SNPs through the HEDIS^® approval process, with the goal of incorporating the measures in Measurement Year (MY) 2027.  We are beginning with special needs plans because they have an existing practice to build on—they already include goal documentation as part of their care models. Plus, the Centers for Medicare & Medicaid Services (CMS) issued a new rule in August 2025 that requires goals to be person-centered and for care teams to follow up on the goals, which aligns with PCO measures.

“In the past ten years, NCQA has tested the PCO measures with over 30,000 patients and over 750 clinicians in a variety of care settings across 17 states,” says Daniela Lawton, NCQA’s Assistant Vice President of Quality Sciences Integration. “We’ve shown that clinicians are able to implement this approach and organizations are able to document and report the necessary data elements for the measures. We are excited to work toward incorporating the PCO measures into HEDIS.”

In Their Own Words: Partner Perspectives on PCO Measures

Our partners explain why they chose to participate in the D-SNP testing.

“Person-centered outcome measures are crucial for our membership as they empower members to take control of their health. This approach fosters better engagement and collaboration, ultimately leading to improved health outcomes. We volunteered for this testing process because our mission is to make a lasting difference in our members’ lives. Supporting our membership in developing their specific, member-driven goals and needs aligns perfectly with this mission. Through this testing, we have recognized that while members may fall within the same category, their individual needs can vary significantly. Generalized goals do not adequately address these unique needs. By focusing on member-driven and specific objectives, we can truly understand our members and provide the support they need to achieve their goals.”

Meghan Crane, MSW, LISW-S, CCM, Manager, Case Management, Integrated Care, CareSource

“Person-centered outcome measures represent a strategic evolution in how we define value and accountability in healthcare. For the D-SNP populations we serve, quality must extend beyond clinical indicators to reflect the goals, preferences and lived experiences that shape each member’s health journey. Our participation in NCQA’s testing initiative reflects our broader commitment to advancing a more integrated, person-centered model of care. By contributing insights from the communities we serve, we are helping shape the future of quality measurement while strengthening how person-centered principles are embedded across our long-term strategy, partnerships and performance framework.”

Dr. Christy Valentine Theard, President, Anthem Blue Cross and Blue Shield Medicaid, New York

“Person-centered outcome measures are especially important for the vulnerable populations we serve because they center care around what matters most to our members—their personal goals and lived experiences. Person-centered outcome goals help ensure we are supporting quality of life, independence and dignity.”

Esther Elefant RN, BSN, CRC, Director II of Health Care Management Services, Anthem Blue Cross and Blue Shield, New York

Lessons Learned from D-SNP Testing

NCQA evaluated PCO measures with two D-SNPs to assess whether goal conversations and documentation are feasible and can be integrated into existing SNP workflows. We provided technical assistance and reviewed data submissions to identify areas for improvement.

“Our testing confirms that the PCO measures are feasible, adaptable to diverse systems and capable of driving person-centered care,” says Lawton. “Goal identification had the highest compliance among D-SNPs. Performance rates for goal follow-up and goal achievement were lower, which is consistent with our past testing efforts.”

Here are some of the lessons learned that can help clinicians as they prepare to implement PCO measures:

1. Focus on what matters to the person. A patient managing diabetes may be more motivated to feel well so they can attend a family event, rather than focusing solely on lab numbers. Ask probing questions to understand why the goal matters to them.
2. Identify a specific task or activity. Singular goals give people a clear focus. Rather than “get more active,” a person with diabetes might choose walking as the specific activity they want to increase.
3. Set a realistic time frame. All goals should be timebound. For example, walking 10–14 minutes daily for the next two months is more actionable than an open-ended commitment to move more.
4. Don’t expect perfection. Build wiggle room into the patient’s goal, so a missed day doesn’t mean failure. Adding “on average” can also help it feel less daunting. For example, setting a goal to walk 10 minutes daily, on average, over two months leaves wiggle room for a 5-minute or a 15-minute daily walk—giving the patient options without derailing progress.
5. Document all follow up discussions. Goal progress should be documented at every visit—even when the patient hasn’t advanced. During testing, we discovered that some clinicians were not documenting the follow-up conversation if the patient did not make enough progress toward their goal. If progress is stalling, check in: Is the goal still realistic? Use that conversation, not just the outcome, as the clinical record.

What’s Next

NCQA recently completed a public comment period for HEDIS MY 2027, which included a recommendation to add PCO measures for D-SNPs and C-SNPs. Institutional SNPs are not included. Next, the recommendation will move through NCQA’s committee process for consideration and approval.

We also see movement toward digitalization of goal-directed care through Health Level Seven (HL7^®), which presents opportunities to standardize the documentation required for the PCO measures. NCQA is participating in the HL7 Patient Care Work Group and co-developed the Person-Centered Outcome Implementation Guide (IG). The IG defines the standards for transmission of data in an interoperable format, such as Fast Interoperability Healthcare Resources (FHIR^®). It includes the steps to document goal-directed care, such as recording a goal, using goal attainment scaling or patient-reported outcome measures to track goals over time and goal follow-up. The IG should be released in the spring.

Learn More

The graphic below provides a high-level overview of PCO measures and how they work. Visit our resource page to learn more about PCO measures and how to implement them in your organization.

Acknowledgements

NCQA developed person-centered outcome measures with support from The John A. Hartford Foundation, The SCAN Foundation and the Gordon and Betty Moore Foundation.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

HL7^® and FHIR^® are the registered trademarks of Health Level Seven International and their use does not constitute endorsement by HL7.

The post NCQA Tests Person-Centered Outcome Measures With D-SNP Plans appeared first on NCQA.

Join us for a webinar on March 18 at 2:00 p.m. (ET) to learn more about the proposed changes.

About NCQA’s Public Comment

NCQA releases program updates for public comment to generate thoughtful feedback and suggestions from interested parties. Many comments result in updates to our standards and policies, helping to strengthen them for all stakeholders. NCQA asks respondents to evaluate whether the proposed requirements are feasible as written and clearly articulated, and to identify areas that may need clarification.

Summary of Proposed Changes

Below is a summary of the proposed changes to NCQA’s programs and standards. You can review the full details on NCQA’s website.

New Accreditation Program for Wellness and Condition Management

NCQA is launching a new Accreditation program— Wellness and Condition Management— using our Wellness and Health Promotion Accreditation program as the foundation. The new program will assess vendors’ ability to empower members to manage their own health across the risk continuum, accounting for risk factors and condition-specific needs. It will create a common quality framework for purchasers and vendors.

The program’s content was informed by robust customer and market engagement—which continues through our new learning collaborative—and reflects the increasing use of digital vendors by health plans, health systems and employers. It shifts from prescriptive requirements toward more flexible and transparent expectations, while still holding organizations accountable for quality, equity and measurable impact.

The new program will include core standards and two modules: Health Assessment and Digitally Enabled Engagement. Organizations may participate in one or both modules. The updated standards will be released in July 2026, with an effective survey date on or after January 2027.

Patient-Centered Medical Home (PCMH) Recognition Updates

Proposed updates to the PCMH Recognition program aim to align standards with the changing market landscape, stakeholder needs and regulatory requirements, and to assist organizations in their pursuit of high-quality care.

For surveys beginning January 1, 2027, NCQA proposes updates to three core criteria within the Care Management concept:

• CM 01: Identifying Patients for Care Management
• CM 02: Monitoring Patients for Care Management
• CM 04: Person-Centered Care Plans

We also propose the retirement of one elective criterion, which will be incorporated into CM 04:

• CM 07: Patient Barriers to Goals

Proposed updates address challenges some practices experience when applying current criteria across diverse clinical contexts (e.g., health conditions, populations, case mix). They are designed to better clarify the purpose and expected outcomes of the Care Management concept’s activities and to support individualized, meaningful care plans that reflect the varied needs of patient populations.

How to Participate in Public Comment

Visit My NCQA to submit comments through our new and improved public comment process. We’ve completely redesigned the experience by reducing clicks and organizing topics more logically. These updates enable NCQA to ask more meaningful questions and make it simpler for you to share feedback.

The public comment period ends at 11:59 p.m. (ET) on Friday, April 17. For details on proposed changes, visit the NCQA website.

Join our webinar, Updates to PCMH Recognition and the New Wellness and Condition Management Program, on March 18 at 2:00 p.m. (ET) to learn more.

The post NCQA Seeks Public Comment on a New Accreditation for Wellness and Condition Management and Updates to PCMH Recognition appeared first on NCQA.

Colorectal cancer represents approximately 8% of all new cancer cases; it is the third most commonly diagnosed cancer in the United States and the leading cause of cancer deaths in men under 50.¹ Routine screening—through colonoscopy, stool-based testing or other methods—can detect precancerous polyps that can be removed before they develop into a later-stage cancer.

“Many individuals with a positive screening through a stool-based test do not receive the necessary follow-up care, such as a colonoscopy,” says Brenna Lin, NCQA’s Applied Research Scientist. “Ensuring that abnormal screening results are followed by timely diagnostic care is essential to achieving the full benefit of screening. The proposed HEDIS measure is designed to address this quality gap.”

Progress Over the Past Year

NCQA continues its partnership with the Council of Medical Specialty Societies and the American Gastroenterological Association to develop a new HEDIS measure to improve follow-up care for patients who receive positive colorectal cancer stool-based test screening results. The project is funded by the Centers for Disease Control and Prevention.

We advanced the measure through several major development steps:

• Completed a comprehensive review of clinical guidelines and evidence to ensure alignment with current standards.
• Presented the draft measure to three NCQA advisory panels. Their guidance informed refinements to the measure’s intent, specifications and feasibility.
• Conducted field-testing with three partner organizations to assess feasibility, evaluate performance using real-world data and guide updates to measure specifications.

Now Open for Public Comment

The proposed HEDIS measure, Follow-Up After Positive Colorectal Cancer Non-Invasive Screening Test, is posted for public comment through March 13. NCQA welcomes feedback from all individuals and organizations who wish to share their perspectives. Public comment is a vital part of the measure development process and helps ensure that new measures are scientifically sound, meaningful and feasible to implement.

Visit our public comment webpage to learn more or to submit your comments.

Acknowledgements

The NCQA Healthcare Effectiveness Data and Information Set (HEDIS) Measures for Colorectal Cancer Screening project is supported by the Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award to the Council of Medical Specialty Societies (CMSS) totaling $1,563,853 with 100 percent funded by CDC/HHS. The contents are those of the authors and do not necessarily represent the official views of, nor endorsement by, CDC/HHS or the U.S. Government.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

¹National Cancer Institute, 2023.

The post NCQA Advances Development of a New HEDIS® Measure for Colorectal Cancer Screening Follow-Up appeared first on NCQA.