How Can Healthcare Organizations Prioritize and Close Care Gaps?
Identification and prioritization of care gaps require an urgency and accuracy impossible with manual data analysis processes.
A consistent, automated process highlights nonadherence to value-based care (VBC) measures in real time, for outreach that accommodates member and clinician schedules, eliminates surprises at contract reconciliation, and supports better health outcomes. To achieve this healthcare trifecta:
Integrate Relevant, Reliable Data
Claims data available to health plans rarely tells a true story of member compliance with quality measures. Electronic health records, pharmacy receipts, and specialty systems (such as those for admissions, discharges, and transfers), state health information exchanges, and CMS databases may have documentation that payers don’t.
Health plans also typically have access to information that individual provider groups may not. Sharing data sources creates an accurate view of the member population to be analyzed in a transparent, recurring process. A single source of truth of integrated data and routine care gap verification enables timely action throughout the term of the VBC agreement and trustworthy reconciliation at year’s end.
Know the Population
Historical member information, demographics, and social determinants of health data also help organizations anticipate where care gaps are likely to occur and focus resources on high-risk members. Care management programs and proactive outreach and clinic visit scheduling provide opportunities to reconcile records and build relationships that support medication adherence and appropriate utilization.
Prioritize Care Gap Closure Based on Financial Opportunity
Not every care gap has the same effect on quality or financial performance. Measures connected to incentives warrant greater attention. Organizations need a clear understanding of which actions can make the greatest difference in collecting full potential revenue and avoiding penalties.
Embrace Quality Measurement Changes
Medicare Advantage Star Ratings add another consideration. The 2026 Star Ratings include Part C and Part D measures across nine domains. CMS calculates summary and overall ratings using weighted measure scores rather than giving every measure the same influence.
- Outcome and intermediate outcome measures generally receive a weight of 3.
- Patient experience, complaints, and access measures receive a weight of 2.
- Process measures receive a weight of 1.
- Measures generally receive a weight of 1 during their first year in the ratings.
This represents an important change from earlier star ratings methodology. For 2026, CMS reduced the weight assigned to patient experience, complaints, and access measures from 4 to 2.