Closing Gaps in Care

How Data Exchange Can Help Payers Boost Quality Measures and Improve Member Outcomes

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Many people don’t receive recommended preventive care. For example, people often miss routine screenings (e.g., mammogram), don’t tell their primary care physician about a diagnosis or fail to take medications. These are gaps in care - the discrepancy between recommended best practices and the care a patient receives.

During COVID-19, 41% of adults postponed or delayed medical care due to the fear of being exposed to the virus, adding to the volume of gaps in care. Some members with diabetes didn’t get regular foot assessments, A1C tests, or eye exams. COVID-19 further exacerbated the challenge of high-risk and rising-risk populations for health plans.

As risk grows, the importance of closing gaps in care also grows. Many benefits come with closing gaps in care, such as member care quality and better health outcomes. Missed yearly exams or screenings may cause missed or delayed diagnoses which are more costly and potentially cause more invasive treatment down the line. Health plans can benefit from closing gaps by improving quality scores, such as HEDIS and potentially reducing healthcare costs.

Patient engagement programs have been successful in helping to close gaps in care, but first organizations must identify members that need care, and automate outreach and tracking. Large volumes of clinical and claims data are required to determine which patients still require screenings or services that need completion. The 21st Century Cures Act mandate for Patient Access APIs will make getting complete data possible. Though health plans are still in the process of completing Patient Access APIs, soon data will flow making identifying members with needs easier. Members will have full access to their healthcare information. After providing consent, they will be able to ensure that their healthcare information is transferred to their health plan.

Gaps in Care Tile

To make that vision possible, health plans are working through many challenges, one of which is adopting the new FHIR standards. After health plans work through implementing the FHIR standards, they can take advantage of resources (such as reports and implementation guides) that The DaVinci Project has developed to help with care gap identification. These types of resources will help health plans leverage more benefits of standardization.

Data exchange is going to help healthcare organizations get a 360° view of patients, enabling them to offer the right care when it’s needed. Read this white paper to gain insights about how data exchange can help close gaps in care. 

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