Part 1: Closing Care Gaps to Achieve Quality Goals

Article 2:

How to Identify and Prioritize Care Gaps

In part 1 of our Delivering Value series we introduce Care Gaps and help you understand how to identify and close them. Our first article in the series defined three principal types of gaps in care: process measure gaps, outcome measure gaps, and paper gaps. We also described the effect that care gaps, real or perceived, have on quality of care and costs.

Successful groups are achieving quality goals by identifying, prioritizing and closing or eliminating all three types of gaps. In article 2 of the series, we explain how to identify care gaps in your own group or practice and how to prioritize closing them to deliver the greatest healthcare value.

Get the Data

As discussed in the last article, care gaps have to be identified by certified HEDIS software that integrates data available to a health plan and determines which members are non-compliant on which measures.  And, care gaps can be real or illusory. Providers often have inconsistent records about services performed for individual patients than health plans have for their same members. This inconsistency results in paper gaps: care gaps that exist in health plan records but not in reality.  However, the circumstances in which neither the plan nor the provider has information to suggest that a patient is compliant for a particular measure need to be identified, and these are the focus of this article.

The key to efficiently separating true care gaps from the false ones and acting to close them is having a robust operating strategy.  Care gaps can evolve over the course of the year as patients are seen by a network of providers and can really only be addressed at the point of care.  Therefore, this strategy must be cyclical, information dependent, and integrated into the care delivery model.  Successful providers simply develop a routine of regularly comparing each of the sources of information about their patients and actively scheduling appointments with those patients whose validated gaps can be closed in the visit setting.  It sounds simple, but execution can be tricky.

Getting into a routine is the vital first step.  But what should the frequency be? On one hand, when gap list information is not reviewed often enough, it’s easy to get behind and miss opportunities.  When care gap data is reviewed only once or twice per year, for example, providers can find themselves in a hustle and recover mode at year-end and not have enough appointment slots to handle acute visits and gaps closure without adding office hours or staff.  On the other hand, if the information is shared too often, administrative teams can be trapped in a constant reconciliation process and waste precious time.  On balance, monthly gap review is probably sufficient for most.  A monthly frequency gives time for data analysis and key member appointment setting.  And monthly is most likely to be the maximum frequency at which a health plan can assimilate available data to update official gap status determinations.

While the source of opportunity, monthly gap sharing and analysis is what makes the process of managing care gaps information-dependent and adds another degree of difficulty.  First, since it is the health plans that collect information and submit it to NCQA, it is they who must share the results with physician groups.  In the eyes of a health plan, however, monthly information processing can be expensive and data distribution can be difficult without a secure distribution system.   Regardless, health plans that share this information with aligned providers realize that doing so is in their enlightened best interest.

Further, physician groups must integrate the information they receive with their own records and take appropriate action at the point of care.  At a minimum, lists of care gaps for each member should be compared against upcoming member appointments, and medical charts should be pulled to check for consistency with the reported gaps.  Secondarily, members with large numbers of gaps should be scheduled for visits if they haven’t been seen in over six months.  Having the staffing resources to complete these exercises can be expensive, but aligned providers can often see the rewards in the growth of their value-based incentive compensation or possibly gap-specific quality bonus targets.

The more frequently this cycle is completed, and the comparative results are incorporated into the visit setting, the more successful providers will be at identifying gaps in care, therefore, achieving quality goals over the course of a measurement year.

Know the Panel

If monthly data is not available, or if providers wish to supplement recurring data feeds with some of their own experience, it is important to mention that many gaps can also be found and prioritized by simply knowing the patient population. 

Experienced provider teams will use past activity to predict where the gaps for an upcoming year will likely accumulate and begin outreach early – or already have it scheduled as the patient exited the last appointment of the prior year.  Although some requirements change over time, the bulk of quality requirements are consistent from year to year.  This cyclical nature means that if a patient needed a specific list of actions last year, it is very likely that he or she will need it again.  If known patients are managed in this way, then the analytical focus can be on new enrollees, reducing the administrative burden.

And providers need not guess entirely.  Providers can also obtain and use the same NCQA rules the health plan uses and attempt to apply those rules to their population at the outset, and avoid the need to play catch up later.  This is the basis that some providers leverage to predict with fair accuracy on which members to focus to assure that goals are achieved from year to year.  The main caveat, of course, is that certain plan-side data elements like continuous enrollment and lab values or pharmacy fill data may not be available to the provider group.  A head start never hurts, however.

Finally, regardless of whether the information is available monthly or inferred from the prior year’s goals, patients need to be seen in the office.  Foremost, any provider who is accountable for the value and quality of a patient’s health care delivery will want to take steps to ensure patients are seen regularly.  Of course, visits provide time to reconcile data sources with the patient and provide services that are missing or incomplete.  More importantly, visits also provide the opportunity for providers to develop strong patient relationships.  These relationships are the foundation providers need to help patients influence resource consumption, encourage medication adherence, and get consent to appointment requests if the end of the year needs some hustle unexpectedly.

Prioritizing Care Gaps

To complement an operating strategy that involves cyclical review, it’s important to recognize that some gaps can have a greater impact on the overall quality compliance score of a practice than others, and some can have financial incentives for compliance as well.  Cycling past these opportunities would be a mistake. When balancing how resources are spent, in fact, it becomes important to put an appropriate amount of emphasis on closing gaps that have a higher value as well as those that impact the overall compliance.

Measures can have higher priority because:

  • The health plan emphasizes them with measure-specific incentives; or
  • They are triple weighted measures in CMS’s Stars score matrix; or
  • They are common across multiple health plan contracts.

Health plans decide which measures are most important to them through the detailed analysis of their own internal quality data and estimating the performance of their competitors. Where they feel focused improvement is necessary, plans will often provide financial incentives to physician groups to deliver better compliance. Plans can also develop measure specific incentives where they know they have been historically weak.  Discovering these plan-specific incentives is part of the regular dialog that physician groups and plans should have to coordinate activities.  The Joint Operating Conference (JOC) or a regular dialog with a provider relations representative or a quality coordinator can be the forum to discuss these issues as well as inquire about data sharing opportunities and other mutually beneficial interaction.

Triple weighted measures are those that CMS places significant emphasis on in developing a health plan’s Star scores.  The Star Scores for a plan are derived from a combination of four performance measurement systems: HEDIS, CAHPS, HOS and PDE data.

Components of Star Scores

  • HEDIS: Healthcare Effectiveness Data and Information Set (link)
  • CAHPS: Consumer Assessment of Healthcare Providers and Systems (link)
  • HOS: Health Outcomes Survey (link)
  • PDE: Prescription Drug Event (link)

Where possible, measures related to Stars Scores need to be the focus of both the plan and the provider because failing to perform well in these measures can have a pronounced effect on revenue to provide care for the population in future payment years.  In the 2018 measurement year, the HEDIS measure All Cause Readmission, and the PDE measures of Medication Adherence for Diabetes, Hypertension, and Cholesterol are all triple weighted.  Star ratings, as this short list indicates are compiled from multiple sources, again a subject for discussion among plan and physician group teams.  Providers have an opportunity to improve the performance of these measures through the patient encounter.  Reminding patients on hypertensive medicine, for example, to have their prescriptions filled is a simple action.

Finally, since most physician groups have contracts with multiple carriers, a third focus area is those measures that are common priorities for more than one carrier that they serve.  Identifying these overlapping goals requires internal review and discussion of the emphasis placed on incentives across multiple plan-provider conferences.

While all plans are required to meet the same guidelines, a general approach is possible, but some plans may have different competitive positions or operational strengths driving their historical quality performance.  Don’t miss an opportunity to identify a best practice across an entire patient panel.  If you don’t have that clarity, a few items, for example, that all plans will focus on are:

  • time sensitive screenings and preventative care; and
  • gaps in care that have only a short time left to be addressed.


Identification and prioritization of care gaps require a joint effort by health plans and providers.  Regular and recurring discussion of priorities, as well as regular data sharing, are key foundations of the joint effort.  In addition, provider groups should develop an operating strategy that makes a cyclic review of care gap data and review in patient encounters part of the routine of care delivery.  In these cycles, provider teams should not overlook opportunities to focus on significant plan-specific and plan overlapping priorities.

In our next article, we will present research on methods for closing the gaps identified.