NCQA updates HEDIS measure for colorectal cancer screening

The National Committee for Quality Assurance has updated its Healthcare Effectiveness Data and Information Set quality measures for colorectal cancer screening in response to the U.S. Preventive Service Task Force guidelines, which supported viable alternatives to colonoscopy in an effort to increase flatlining screening rates.

The USPSTF gave an “A” grade to screening all adults aged 50 to 75 years at average risk for CRC, including newer screening methods like CT colonography (or virtual colonoscopy) and Cologuard (multitarget stool DNA test; Exact Sciences).

This “A” grade requires insurers that participate in insurance exchanges under the Affordable Care Act to cover these alternatives with no co-pay, which could begin as soon as January 2017, according to a press release from the American College of Radiology.

Accordingly, the 2017 HEDIS measures — which are used by over 90% of health plans in the U.S. to measure quality — will now provide health care providers, systems and plans with quality credit when patients are screened with the alternative methods recommended by USPSTF.

The measure continues to provide credit for use of the other tests recommended by the USPSTF, including fecal occult blood test/fecal immunochemical test, flexible sigmoidoscopy and colonoscopy, an NCQA spokesperson told Healio Gastroenterology in an email.

“Providers and health systems can now document CT colonography quality data and CTC’s impact on their overall colorectal cancer screening rates via universally accepted HEDIS criteria,” Judy Yee, MD, chair of the American College of Radiology Colon Cancer Committee, said in a press release. “This may expand the number of facilities offering this care and strengthen patient access to this potentially lifesaving exam.”

Multitarget stool DNA testing is another alternative screening method included in the 2017 HEDIS measures. Its 3-year interval will provide payers, health systems and providers with quality credit for a 3-year lookback period during HEDIS audits, and the 2016 HEDIS audit will give credit for tests beginning in 2014 when the test was approved, according to a press release from Exact Sciences.

“Cologuard’s inclusion in the preeminent quality measures and its standing as an A-graded service in a leading screening guideline are critical steps toward becoming a standard of care for colon cancer screening,” Kevin Conroy, chairman and CEO of Exact Sciences, said in a press release. “Quality measures rate health care providers, systems and payers on metrics, including colon cancer screening compliance and patient satisfaction. These quality scores influence the level of reimbursement providers receive under value-based health care structures. Providers can now receive quality credit when their patients are screened using Cologuard, and Exact Sciences’ comprehensive compliance program encourages completion of screening following a physician’s prescription.”

CMS Star Ratings use HEDIS as the main data source to guide quality measures for Medicare Advantage plans. Based on the HEDIS update, the USPSTF recommendations and the upcoming mandate for private insurance coverage of CT colonography, Medicare should follow suit and cover this alternative screening method, according to the ACR press release.

“Medicare coverage of CT colonography would remove a financial barrier to this screening option that can help overcome cultural stigmas and attract more people to be screened,” Yee said in the press release. “This would prevent many cancers, find more cancers before they progress and save thousands of lives each year from this terrible, but often preventable, disease. It’s time for Medicare [to] cover seniors for these exams.”

The public comment period for the 2018 CMS Star Ratings is expected to be announced in November, and the updated Star Ratings are expected to be published in February of next year, according to the press release from Exact Sciences.

The updated HEDIS measures now also align with colorectal cancer screening guidelines from the American Cancer Society, the National Comprehensive Cancer Network and the ACG.

Colorectal cancer is the second leading cause of cancer death in the U.S. An estimated 134,000 Americans will be diagnosed with colorectal cancer this year, and approximately 49,000 will die of the disease, yet up to 40% of Americans aged older than 50 years are still not being screened.

Disclosures: Conroy is employed by Exact Sciences. Healio Gastroenterology was unable to confirm Yee’s relevant financial disclosures at the time of publication.

Editor's note: This article was updated on October 12 with additional information from the NCQA.