In value-based care, closing care gaps isn’t about checking boxes or rushing to meet year-end targets—it’s about building a system that supports continuous, proactive, and equitable care delivery. The most effective organizations have shifted from reactive fixes to embedded performance oversight, enabling earlier interventions, better patient outcomes, and stronger HEDIS performance.
A care gap occurs when a patient misses a clinically recommended service or treatment—such as not being prescribed a statin despite cardiovascular risk, or discontinuing beta-blocker therapy after a heart attack. These gaps are more than operational misses; they’re signs of systemic breakdowns in patient access, provider workflows, pharmacy coordination, or documentation.
When left unresolved, care gaps lead to worse health outcomes, lower quality scores, and higher costs.
Understanding and Anticipating Care Gaps
According to 2025 quality reporting standards, HEDIS measures evaluate the percentage of patients receiving recommended care within the measurement year. Addressing care gaps not only supports better patient outcomes—it also enhances quality performance and helps manage medical loss ratios (MLR).
But effective gap closure starts not with today’s data—but with yesterday’s performance.
Organizations should first review last year’s results:
- Which measures fell short?
- Were prescriptions filled—but not refilled?
- Were recommended therapies initiated on time?
- Were exclusions like ESRD or hospice care correctly documented?
- Which provider panels had the highest rates of care gaps?
This retrospective analysis builds the foundation for targeted action. Patients who ended the year with unresolved gaps are more likely to repeat that pattern unless engaged proactively.
Next, teams must identify and predict gaps at the patient level. By analyzing pharmacy claims, EHR data, and care coordination reports, health systems can flag:
- Patients currently missing evidence-based treatments
- Those at risk based on prior behavior (e.g., missed refills)
- Patients who meet exclusion criteria but are not yet properly coded
Tools like Patient Care Opportunity Reports (PCOR), Gaps in Care Reports, and Practice Assist support early identification of care needs, enabling timely, personalized outreach. Dashboards tracking quality measures and pharmacy adherence further help providers close gaps efficiently—strengthening both outcomes and performance.
Coordinated Care in Action: Closing High-Risk Cardiovascular Gaps
Two high-impact measures—beta-blocker persistence and blood pressure control—showcase how oversight and coordination can make or break performance.
Beta-Blocker Persistence: A Technical and Clinical Priority
The HEDIS measure for Persistence of Beta-Blocker Treatment After a Heart Attack (PBH) requires patients to stay on therapy for 180 days post-discharge, with at least 80% adherence based on proportion of days covered (PDC) from pharmacy claims. Medical records alone cannot be used to meet this measure.
Organizations must monitor more than the initial prescription—they must ensure consistent refills. Care teams can:
- Track PDC through pharmacy data
- Schedule timely post-discharge follow-ups
- Contact patients after missed fills
- Resend prescriptions to preferred pharmacies
Without this level of real-time monitoring and intervention, performance suffers—and so do patient outcomes.
Managing High Blood Pressure Through Coordinated Care
The Controlling High Blood Pressure (CBP) measure benefits from a similar, team-based approach. When analytics flag a patient with uncontrolled BP and no recent specialist input:
- A virtual cardiology consult is initiated.
- The specialist adjusts medications and provides education.
- A care coordinator follows up, ensures medication pickup, and schedules a PCP visit.
- The PCP remains at the center of the patient’s care.
This connected workflow speeds up intervention, improves medication adherence, and reduces cost—without sidelining primary care.
Statin Therapy: Addressing a Persistent and Costly Gap
Statin therapy remains one of the most prevalent—and preventable—care gaps in value-based care. The HEDIS measures for Statin Therapy for Patients With Cardiovascular Disease (SPC) and Statin Therapy for Patients With Diabetes (SPD) rely entirely on pharmacy claims data—documentation alone is not enough.
National adherence rates for statins often fall 10–15 percentage points below target, creating major risks for both patients and quality ratings.
To close statin gaps, organizations should:
- Identify patients who haven’t filled a statin despite clinical indications
- Monitor for early discontinuation or refill lapses
- Ensure valid exclusions (e.g., ESRD, pregnancy, liver disease) are properly coded in the EHR
These are high-volume, high-impact opportunities. Addressing them early—rather than waiting until the fourth quarter—maximizes gap closure, improves outcomes, and prevents last-minute scrambling.
80% of care gap closures are attempted in the last quarter, when staff are stretched and outcomes often fall short.
From Missed Measures to Meaningful Improvement
Closing care gaps isn’t a one-time initiative—it’s an ongoing strategy that combines data, collaboration, and clinical precision. By embedding real-time performance oversight into everyday operations, organizations can move from reactive clean-up to proactive, measurable improvement.
Whether the focus is on beta-blocker persistence, blood pressure control, or statin adherence, successful care gap closure hinges on five essential elements:
- Actionable analytics to identify patients at risk—before a gap widens
- Targeted provider engagement to address variation in quality and workflow
- Care coordination and pharmacy support to drive follow-through
- Accurate exclusions and documentation to reflect true performance
- Scalable interventions like telehealth and refill monitoring to close gaps efficiently
When these components work together, organizations don’t just meet HEDIS benchmarks—they improve outcomes, reduce unnecessary costs, and build a system where patients get the care they need, when they need it.
This is what high-performance, value-based care looks like: intentional, informed, and built to last.