Uncovering the Healthcare Information Gap: The Role of Claims Data in Closing Care Gaps


We’ve all heard it before: Data is the new currency. It’s true. In fact, value-based care contracts depend on it. If we don’t know what patients to target and why, we can’t possibly move the needle on outcomes and costs.


The challenge: Data blind spots

There are many data sources to consider, most notably medical claims. Claims data in healthcare typically includes healthcare information about the services provided to a patient, the diagnoses given, and the payments made for those services. While claims data can provide valuable insights into healthcare utilization and costs, it may not always effectively communicate the healthcare information needed to close care gaps.


One reason for this is that claims data is lacking the details that paint a picture of a patient’s overall health and specific care needs. For example, claims data doesn’t include resulted lab values. For a diabetic patient, it is one thing to document that an A1C lab was done via a claim record, it is even more important to know whether the A1C measure was within controlled limits or not; the lab value doesn’t appear within claims data communicated to payors. As a result, many payors will default a diagnosed diabetic to “uncontrolled” unless the lab value is communicated that demonstrates otherwise, adversely impacting overall quality performance scores.


Another reason is that claims data is often siloed within individual healthcare organizations and may not be easily shared or integrated with data from other sources. This can make it difficult to get a comprehensive view of a patient’s healthcare history and identify potential care gaps that may exist.


The solution: Data integration and proactive patient care

To effectively close care gaps, healthcare organizations need to use a variety of data sources to better identify care gaps and develop targeted interventions to address them.


By incorporating supplemental data feeds, providers and payors more accurately reveal and communicate valuable insights into healthcare utilization and costs that may not be captured by traditional claims data alone. By incorporating these additional data sources into their analysis, providers, and payors can make more informed decisions and improve patient outcomes while also reducing costs.


      1. Clinical data from electronic medical records. EMR data can provide a detailed view of a patient’s medical history and treatment plans. By integrating EMR data with claims data, providers and payors gain a more complete understanding of a patient’s healthcare journey and identify opportunities for improved care coordination and cost savings.
      2. Information from external sources. The FDA, U.S. Census Bureau, CDC, American Heart Association, American Diabetes Association, and other organizations provide valuable evidence-based guidelines and best practices. Surfacing this information at the point of care equips providers with a more accurate view of risk scores and potential care gaps.
      3. Targeted intervention. Examples include targeted messaging campaigns for cohorts of identified patients, proactively calling patients to schedule Medicare Annual Wellness visits, leveraging community-based care workers, or enrolling patients in chronic care management programs.


    When thinking about value-based care, providers and payors need much more than the data from the medical claim. They need to leverage additional data sources and surface actionable insights at the point of care and, even better, in advance of the point of care.


    Closing the healthcare information loop ensures patients get the right care at the right time, while providers and payors achieve the goals of value-based care, improving quality, reducing costs, and increasing patient satisfaction. By achieving these goals, providers can increase the likelihood of receiving higher reimbursement rates in value-based care models.


    About DignifiHealth

    DignifiHealth partners with health systems on value-based healthcare, chronic disease management, care gap closure, and more to create exceptional patient and health system results. To learn more, visit https://dignifihealth.com/.