What are Gaps in Care, and How Can Benefits Data Help?

When we talk to employee benefits professionals about their goals, they come back to one key theme: helping employees lead healthier lives. In fact, in a recent research study, we found that 36% of benefits teams said that employee health and well-being was their top priority, ranking just below employee productivity and employee satisfaction. 

One key way benefits leaders address employee health is through closing “gaps in care.” But what does that mean and how do they do it? 

What are Gaps in Care? 

Gaps in care refers to the discrepancy between the care provided to patients and the recommended best practices in healthcare. Gaps in care can manifest in a number of ways: 

• A patient in an at-risk age group fails to comply with recommended screenings (i.e. doesn’t get a yearly mammogram or misses a vaccine booster) 
• A patient’s new diagnosis isn’t shared with their PCP or specialist for another related condition 
• A patient doesn’t follow recommended prescription guidelines for a condition 
• A patient isn’t able to find the care they need in their network or area 
  

Here’s an example from the real world. Let’s say a member on your plan is newly diagnosed with diabetes. They are prescribed medication, advised to lose weight, and advised to seek out a retinal screening for potential vision loss as a result of their condition. The patient fills their prescription dutifully for the first few months, but they are often late in refilling and aren’t taking the recommended dose. As a result, they suffer extremes in blood sugar levels and need to be seen in the emergency room. The patient also never seeks a diabetic eye screening, and later suffers vision loss. This is a very real example of a gap in care, where the patient now has added medical issues as a result of missing recommended steps in their treatment. 

Other examples include: 

• A female patient age 50 with a family history of breast cancer who doesn’t get annual mammograms 
• A hypertension patient who doesn’t refill their medication for blood thinners 
• A child who isn’t scheduled for regular well visits or vaccinations 
• A mental health patient who seeks help in the emergency room because they can’t find an in-network psychiatrist 
  

Gaps in care are a quality issue for both patients and payers like self-insured employers. Those who work in employee benefits understand the benefits of high-quality care, regular preventive visits, and access for all their members. Closing these gaps can help support the goal of offering better health and wellness to employees and their families. 

How Does Benefits Data Address Gaps in Care? 

Benefits data is the key to identifying and closing gaps in care. Using medical claims, prescription drug claims, care management program data, and more, employers and advisors can find out where there are opportunities for improvement in their benefits utilization and compliance. Let’s look at an example from the Artemis Platform. 

This grid chart shows screening information for three major types of cancer: breast cancer, cervical cancer, and colon cancer. You can see in our sample population, screenings range from 49% to 20%, so the data has clearly identified a gap in care. While breast cancer and cervical cancer screening trends are going up, fewer members are being screened for colon cancer than in the previous year. 

Diabetes compliance is another avenue for finding gaps in care. With a few key visuals, employers and advisors can see what percentage of diabetic members are taking medication, seeking physical exams, getting foot care, and more indicators of effective disease management. In this sample data, we can see that 77% of diabetic members have also been screened for LDL cholesterol. Because heart disease and obesity are often comorbid with Type II diabetes, this type of screening can help catch other health problems early and encourage members to seek care management. 

This same logic applies to a number of high-cost, chronic conditions for healthcare payers; earlier screening, regular preventive care, and compliance with treatment recommendations make for a healthier, lower-cost population. 

How Benefits Teams Can Address Gaps in Care 

What can benefits teams actually do once they discover a gap in care? There are several interventions that benefits consultants and self-insured employers can consider: 

1. Adding programs: Benefits teams may want to add a care management program if they find a gap in care for some chronic conditions. For example, a diabetes care management program can offer members coaching, regular check-ins, and other help complying with treatment protocols. 
2. Employee education: Employers often help members understand their coverage options through education campaigns and communications like email blasts, mailers, and plan documents. For example, benefits teams could work with their health carriers to send out reminders to members over 50 for certain recommended health screenings. 
3. Network audits: Advisors and employers may want to examine their network and care options if they discover a gap in care. For example, if members in one geographic area are using the ER for mental health care, benefit managers may decide to expand their network of mental health professionals. 
   

These are just a few options for addressing gaps in care. Benefits data is the key to understanding, identifying, and taking action on gaps in care. 

Want to see how Artemis Health can help you access holistic benefits data? Watch our 2-minute demo video for a sneak peak at our benefits data platform.