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.

NCQA’s Advanced Primary Care Pilot Program is defining the next generation of primary care. Building on what we’ve learned from our Patient-Centered Medical Home (PCMH) Recognition program, the pilot will accelerate innovation, test scalable models and help healthcare organizations meet the needs of diverse communities.

“Primary care is the foundation of a high-quality health system and one of the strongest levers to improve population health and affordability. The organizations participating in this pilot are doing more than testing approaches—they’re helping the entire industry learn and shaping the future of primary care,” said Vivek Garg, MD, MBA, President and Chief Executive Officer at NCQA. “We’re grateful to our primary care partners for leaning in as pilot participants and helping advance this work for primary care and patients alike.”

Which Organizations Are Participating in the Pilot Program?

NCQA selected four organizations through a competitive process based on their readiness and ability to lead change in primary care and their dedication to innovation and excellence. We’re pleased to announce our primary care partners:

Aledade

Bluegrass Community Health Center

Jefferson Health

NYC Health + Hospitals

Hear directly from some of the participating organizations about why they chose to join the pilot program and how it will improve care for patients.

“True systemic change in healthcare starts and ends with primary care. Every day, we see how primary care practices transform lives when they are empowered with the right data and a true value-based model. Through this effort we are proud to bring our decade of experience to help shape a quality standard that emphasizes what actually matters for primary care: preventing illness, serving communities, and delivering better care at a lower cost for everyone.”

Farzad Mostashari, MD, Co-Founder and CEO, Aledade

“Bluegrass Community Health Center appreciates the opportunity to collaborate with NCQA on the Advanced Primary Care pilot. As an FQHC, we are committed to models that recognize the depth of our work while remaining practical and sustainable. This pilot is an exciting opportunity to help shape a meaningful, usable program that supports primary care without adding unnecessary burden.”

Brandy Coyle, MBA, BS, RN, Chief Compliance Officer, Bluegrass Community Health Center

“As a large academic health system, Jefferson Health deeply values primary care as foundational to individual, family, community and public health across the many communities we serve. Quality measures shape the daily efforts of our clinical teams, and they articulate the value of primary care’s complex work to stakeholders within and beyond healthcare. We appreciate NCQA’s leadership in bringing on-the-ground voices from diverse organizations to help redefine the nation’s approach to primary care quality metrics.”

Anna Flattau, MD, MS, System Chief for Primary Care and Chair of Family and Community Medicine, Jefferson Health

What’s Involved in the Advanced Primary Care Pilot Program?

The PCMH model demonstrated that primary care practices can mature and deliver better outcomes at lower costs, but they must consistently invest in care delivery, data infrastructure and workforce to keep pace with evolving payment and performance expectations. The Advanced Primary Care Pilot Program will build the next step of primary care’s evolution.

“Today, there is no common definition of what ‘advanced’ primary care truly means, and expectations vary across the industry,” says Jeff Sitko, AVP, Product Management at NCQA. “As primary care takes on growing clinical and financial accountability, clearer shared expectations between plans and practices are essential. Through this pilot, we’re testing these concepts in real-world settings and defining a shared roadmap for how primary care capabilities mature, supporting more integrated, data-driven models that strengthen collaboration, advance behavioral health integration and deliver measurable improvements in outcomes.”

NCQA has developed a preliminary set of standards for primary care organizations. Pilot participants will implement and test these standards within their organizations and help identify what is both valuable and realistic. They will also report on a standardized set of electronic clinical quality measures appropriate for their populations and assess the feasibility of reporting digital quality measures.

At the end of the pilot, the four organizations will be rated on their overall results through a “mock survey” process, and they’ll make recommendations about how NCQA should adjust and evolve the standards and measures in the future.

“We’re excited to bring these organizations into the test kitchen with us to determine what actually matters to them,” says Sitko. “Let’s get rid of the ‘fluff’ so we’re not asking delivery systems to check boxes and perform activities procedurally that don’t actually bring value at the end of the day. And let’s make sure we’re anchored in those areas that positively impact clinical outcomes for patients.”

The ultimate goal is to create a clearer path to integrated, data-driven team-based care that enables primary care to thrive in advanced payment models and strengthens the relationship between payers and primary care.

What’s Next

We’ll share the results of the pilot program later this year, along with details about how NCQA plans to enable the next generation of primary care.

In the meantime, listen to our Quality Matters podcast, What’s New and What’s Next for Primary Care, featuring Jeff Sitko and Karen Johnson, Vice President, Practice Advancement for the American Academy of Family Physicians.

The post NCQA Launches Advanced Primary Care Pilot Program—Meet Our Primary Care Partners! appeared first on NCQA.

You can use this report to:

• Learn more about each quality measure, how it is defined and why it matters.
• Access national averages and historical trends for over 90 measures of clinical quality and patient satisfaction.
• Compare performance across different products, like Commercial, Medicare and Medicaid.

We will add data for MY 2025 in February 2027, or you can get it sooner through NCQA’s Quality Compass^®.

How to Access the State of Health Care Quality Report

The report is available through this link. You can also find a link to the report on the HEDIS Measures and Technical Resources web page.

• We recommend that you bookmark the page for easy access.
• You’ll need to enter your contact information on a measure page to access national averages for all measures. (You only need to do this once, but if you clear your browsing data, you might need to enter your information again.)
• The information in the report is for internal use only and may not be redistributed or used for commercial purposes.

Watch this video to learn how to access the report.

Better Benchmarking With Quality Compass

NCQA’s Quality Compass provides access to health plan performance, including HEDIS^® and CAHPS^® benchmarks to identify areas for improvement. It features benchmarks at the national, state and regional levels as well as plan-specific results for competitor analysis.

Release dates for Quality Compass 2026 (MY 2025 Data) vary by product line: Commercial on July 31; Medicaid on August 28; Medicare on October 30; Exchange on November 20.

Learn More

• Read our blog Improving HEDIS Performance Through Benchmarking.
• Visit the State of Health Care Quality web page.
• Use NCQA’s Health Plan Ratings to review and compare health plan performance.

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

CAHPS^® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

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

The post New Data Added to the State of Health Care Quality Report appeared first on NCQA.

NCQA seeks public feedback on proposed new HEDIS^® measures and changes to existing ones. Reviewers are asked to submit comments to NCQA in writing via the Public Comment website by 5:00 p.m. (ET), Friday, March 13. NCQA acknowledges that the healthcare policy environment is rapidly evolving, and we will consider all comments received, as well as any policy changes, as we prepare the final versions of these measures.

NCQA seeks comments on the following:

• Seven new HEDIS measures.
• Revisions to three existing HEDIS measures.

About HEDIS and Public Comment

HEDIS measures are based on scientific evidence. When new evidence emerges, NCQA reviews the measures to determine if changes may be needed. NCQA convenes multi-stakeholder advisory panels—including independent scientists, clinicians, health plans, purchasers, government and consumer groups—to ensure that measures meet and balance the high standards of relevance, scientific soundness and feasibility.

An important part of developing and updating HEDIS is gathering input from the public. NCQA reviews all comments received during the public comment period, and discusses results with stakeholder advisors.

HEDIS measures do not constitute clinical practice guidelines and should not be used to determine insurance or coverage.

Proposed New HEDIS Measures

Follow-Up After Positive Colorectal Cancer Non-Invasive Screening Test: Assesses the percentage of persons 45-85 years of age who received a colonoscopy for a positive colorectal cancer non-invasive screening test.

Importance: Colorectal cancer represents approximately 8% of all new cancer cases and is the third most commonly diagnosed cancer in the United States.¹ Screening and early detection have a significant role in reducing the impact of this preventable and treatable disease.

Continuous Glucose Monitoring (CGM) Utilization for Patients With Diabetes: Assesses the percentage of persons 18-75 years of age with diabetes who had evidence of CGM utilization during the measurement period.

Importance: Continuous glucose monitoring supports diabetes management and helps prevent hypoglycemic and hyperglycemic events and other life-threatening complications.² Continuous Glucose Monitoring Utilization for Patients With Diabetes is a utilization measure that provides visibility into CGM use patterns.

Intimate Partner Violence (IPV) Screening and Follow-Up: Assesses the percentage of persons 12-64 years of age who were screened for intimate partner violence using a standardized instrument, and who received follow-up care within 7 days of a positive intimate partner violence screening.

Importance: Intimate partner violence is a prevalent public health issue that harms individuals across every demographic group, with approximately 1 in 4 women and 1 in 7 men experiencing IPV in their lifetime in the U.S.³ Screening and follow-up for IPV provide a standardized manner for healthcare teams to collect information about potential safety concerns and identify when additional assessment, support or referrals may be needed.

Person-Centered Outcome Measures (3 Measures):

• Person-Centered Outcome–Goal Identification: Assesses the percentage of persons 18 years of age and older with a complex care need who set a person-centered outcome goal.
• Person-Centered Outcome–Goal Follow-Up: Assesses the percentage of persons 18 years of age and older with a complex care need who set a person-centered outcome goal and followed up on the goal.
• Person-Centered Outcome–Goal Achievement: The percentage of persons 18 years of age and older with a complex care need who set a person-centered outcome goal and achieved the goal.

Importance: There is broad agreement that an individual’s goals and priorities should guide care and the quality measures used to evaluate care.^4-6 For older adults with multiple chronic conditions and functional limitations, clinical guidelines have indicated the importance of providing goal-based care.^7,8 For this complex population, goal setting has been shown to reduce patient-reported treatment burden and unwanted care, and it correlates with greater physical and social well-being and higher care satisfaction.^9,10

Prenatal Syphilis Screening and Follow-Up: Assesses the percentage of deliveries that had a syphilis screening with a documented result during the first trimester, within 14 days of the first pregnancy diagnosis or prenatal visit, or within 30 days of enrollment in the organization, and the percentage of deliveries with a positive syphilis screen that received appropriate follow-up care.

Importance: The prevalence of congenital syphilis is increasing exponentially in the U.S., with a maternal-infant transmission rate of almost 90%. In 2024, 3,941 infants were born with congenital syphilis–a nearly 700% increase from 2015, when only 495 cases were reported.¹¹ Syphilis screening and timely follow-up during pregnancy have a significant role in reducing the impact of transmission and adverse health outcomes for both the pregnant person and baby.

Proposed Changes to Existing HEDIS Measures

Adult Immunization Status: Assesses the percentage of adults 19 and older who are up-to-date on recommended routine vaccines. The measure includes separate rates for influenza; tetanus and diphtheria (Td) or tetanus, diphtheria, and acellular pertussis (Tdap); zoster; pneumococcal; hepatitis B; and coronavirus disease (COVID-19).

NCQA proposes two updates to the pneumococcal indicator:

• Expanding the denominator age range from 65 and older to 50 and older.
• Adding an age stratification for 50-64 in addition to the existing 65 and older stratification.

Emergency Department Utilization: Assesses the risk-adjusted ratio of observed to expected emergency department visits during the measurement period. NCQA proposes to expand this measure into the Medicaid product line for persons 18-64 years of age.

Pharmacotherapy Management of COPD Exacerbation: Assesses whether appropriate medications were dispensed following a chronic obstructive pulmonary disease (COPD) exacerbation for people 40 years of age and older within Medicare, Medicaid and Commercial product lines. The measure includes two separate rates: one that assesses whether a systemic corticosteroid is dispensed within 14 days of a COPD exacerbation event, and one that assesses whether a bronchodilator is dispensed within 30 days of a COPD exacerbation event.

NCQA proposes the following modifications to the measure:

• Adding an exclusion for individuals with asthma.
• Updating the denominator to count people instead of events and including additional qualifying COPD exacerbation events.
• Updating the numerator to include only one rate and revising medication lists.

How to Participate in Public Comment

The public comment period ends at 5:00 p.m. (ET) on Friday, March 13. Visit My NCQA to submit comments. We’ve made some improvements to our site to make it easier for you to submit your comments.

For details on proposed changes, visit the NCQA website.

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

References

­¹American Cancer Society. (2023). Colorectal Cancer Facts & Figures 2023-2025. https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/colorectal-cancer-facts-and-figures/colorectal-cancer-facts-and-figures-2023.pdf.

²American Diabetes Association. (2026). Continuous Glucose Monitors. https://diabetes.org/advocacy/cgm-continuous-glucose-monitors.

³Stylianou, M.A. (2018). Economic Abuse Within Intimate Partner Violence: A Review of the Literature. Violence and Victims, 33(1), 3. https://connect.springerpub.com/content/sgrvv/33/1/3.full.pdf.

⁴McGlynn, E. A., Schneider, E. C., & Kerr, E. A. (2014). Reimagining Quality Measurement. New England Journal of Medicine, 371(23), 2150–2153. https://doi.org/10.1056/NEJMp1407883.

⁵Reuben, D. B., & Tinetti, M. E. (2012). Goal-oriented patient care—An alternative health outcomes paradigm. The New England Journal of Medicine, 366(9), 777–779. https://doi.org/10.1056/NEJMp1113631.

⁶Tinetti, M. E., Naik, A. D., & Dodson, J. A. (2016). Moving From Disease-Centered to Patient Goals–Directed Care for Patients With Multiple Chronic Conditions: Patient Value-Based Care. JAMA Cardiology, 1(1), 9. https://doi.org/10.1001/jamacardio.2015.0248.

⁷American Geriatrics Society Expert Panel on the Care of Older Adults With Multimorbidity. (2012). Patient-centered care for older adults with multiple chronic conditions: A stepwise approach from the American Geriatrics Society: American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity. Journal of the American Geriatrics Society, 60(10), 1957–1968. https://doi.org/10.1111/j.1532-5415.2012.04187.x.

⁸The American Geriatrics Society Expert Panel on Person-Centered Care. (2016). Person-centered care: A definition and essential elements. Journal of the American Geriatrics Society, 64(1), 15–18. https://doi.org/10.1111/jgs.13866.

⁹Tinetti, M. E., Naik, A. D., Dindo, L., Costello, D. M., Esterson, J., Geda, M., Rosen, J., Hernandez-Bigos, K., Smith, C. D., Ouellet, G. M., Kang, G., Lee, Y., & Blaum, C. (2019). Association of Patient Priorities–Aligned Decision-Making With Patient Outcomes and Ambulatory Health Care Burden Among Older Adults With Multiple Chronic Conditions: A Nonrandomized Clinical Trial. JAMA Internal Medicine, 179(12), 1688–1697. https://doi.org/10.1001/jamainternmed.2019.4235.

¹⁰Kuipers, S. J., Cramm, J. M., & Nieboer, A. P. (2019). The importance of patient-centered care and co-creation of care for satisfaction with care and physical and social well-being of patients with multi-morbidity in the primary care setting. BMC Health Services Research, 19(1), 13. https://doi.org/10.1186/s12913-018-3818-y.

¹¹Centers for Disease Control and Prevention. (2025). Sexually transmitted infections surveillance, 2024 (provisional).

The post HEDIS® Public Comment Period Is Now Open appeared first on NCQA.

“The growing prevalence of CKM syndrome and its widespread impact on population health signals the need for a unified framework that integrates prevention, treatment and quality measurement,” says Adrianna Nava, PhD, RN, NCQA’s Applied Research Scientist. “NCQA sees an opportunity to transform CKM care from fragmented, disease-specific management to holistic, patient-centered approaches.”

Our Approach to Evaluating CKM Care

In 2025, NCQA convened three meetings to address the challenges associated with CKM syndrome. The first meeting focused on ways to improve the quality of care for people with chronic kidney disease. The Advancing Care for Chronic Kidney Disease: Using Care Gaps to Inform a Quality Framework white paper captures the dynamic discussions and insights from this convening.

The second and third meetings reconvened the roundtable participants to discuss ways to improve the quality of care for CKM syndrome. The new white paper, Cardiovascular-Kidney-Metabolic Syndrome: Improving Quality of Care and Accountability, captures insights from these convenings.

The white paper outlines a comprehensive approach to improving the quality of CKM care and accountability. It explores five key domains essential for transforming CKM care.

1. Defining ideal care, identifying feasible CKM measures and breaking down silos.
2. Clinical integration, risk stratification and life course perspectives.
3. Patient and community engagement.
4. Technology as a driver of CKM syndrome.
5. Payment reform, health plan and health system coordination.

NCQA gathered input from experts representing a wide variety of disciplines: primary care, pediatrics, nephrology, cardiology, endocrinology, internal medicine, epidemiology, pharmacy, geriatrics, nutrition, gastroenterology, lifestyle medicine, nursing, hepatology, diabetes education, informatics and health policy. The convenings also included three patient advocates who provided valuable input based on their personal experiences with severe kidney disease and diabetes.

Key Findings and Recommendations

This report proposes a framework for improving CKM care quality through measurement and accountability. Recommendations include:

• Measure Integration and Alignment. Reduce the emphasis on process-oriented metrics and develop and promote intermediate outcomes like BP, HbA1c and uACR that are aligned with CKM risk stages and can be tracked over time.
• Risk-Based Framework. Use evidence-based tools and risk calculators to guide early detection, prevention and precision management.
• Cross-Specialty Accountability. Embed CKM coordinators, shared care plans and multidisciplinary documentation to align specialties around shared outcomes.
• Patient-Reported Outcome Measure (PROM) Integration. Incorporate PROMs assessing self-efficacy, health outcome goals, treatment burden and quality of life into performance frameworks.
• Technology Modernization. Invest in interoperability, predictive analytics, remote monitoring and automation to support proactive care.
• Social Determinants of Health Focus. Integrate social needs screening, referral tracking and community partnerships to close disparities.
• Value-Based Payment. Link reimbursement to intermediate outcomes and progression metrics that reward health plans and systems for prevention and coordination.

By aligning professional guidelines, technology and payment systems within an integrated CKM syndrome measurement framework, CKM syndrome care can become a coordinated, holistic and equitable continuum. This approach will not only improve patient outcomes; it will also strengthen accountability, reduce healthcare costs and create a foundation that supports active collaboration among providers, health plans and other stakeholders.

“CKM syndrome is one of the most pressing and complex challenges that clinicians, health systems and health plans face today,” says Nava. “The white paper provides an actionable roadmap for developing a CKM measurement framework that supports whole-person care, equity and sustainability.”

The insights and recommendations gathered from these convenings will guide NCQA in shaping a comprehensive quality improvement framework for CKM syndrome. As this work progresses, NCQA is eager to partner with national stakeholders to drive alignment, strengthen community collaborations and build consensus around a CKM-focused primary care framework for the next phase of this initiative.

To get involved in the next phase of this work, please contact Erin Oganesian, AVP, Corporate & Foundation Relations at eoganesian@ncqa.org.

Learn More

• Download the white papers: Advancing Care for Chronic Kidney Disease: Using Care Gaps to Inform a Quality Framework and Cardiovascular-Kidney-Metabolic Syndrome: Improving Quality of Care and Accountability.

Acknowledgments

Thank you to our panel of experts for sharing their knowledge and insights. This research is made possible with support from Boehringer Ingelheim and Novo Nordisk.

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