Gaps in care are among the most daunting challenges facing American healthcare. According to one study, less than 10% of people ages 35 and older receive all the preventive care services they need — and nearly 5% receive none.
When patients don’t receive preventive services and screenings, they can get diagnosed later, incur higher costs, and face poorer outcomes. At the same time, health plans can face higher costs, lower quality scores, and increased member churn.
But other gaps don’t get so much attention. Call them gaps in data. When health plans don’t have a complete view of their members’ screening histories, they can’t appropriately risk-adjust their members, close gaps in care, and identify at-risk members who could benefit from care coordination strategies and interventions.
“Most health plans only have access to claims-based lab data, so they can only get a partial view into members’ health,” says Kirk Loveless, health plan executive director of healthcare analytics and solutions at Quest Diagnostics. “It’s like trying to solve a jigsaw puzzle that has key pieces missing; our goal is to provide those missing pieces.”
Quest offers health plans access to comprehensive member-based lab data, a service Quest is uniquely positioned to provide. As the world’s leading provider of diagnostic testing, information, and services, Quest generates 4 billion lab results every year and has access to more than 90% of US insured lives.
With the comprehensive member-based lab data offering, plans can access
- Claims submitted to the plan by Quest
- Claims submitted to other payers by Quest
- Claims submitted to the plan by an IPA
- Claims submitted to the plan by a provider
- Claims submitted to the plan by a hospital
The comprehensive member-based data offering can provide18% to 25% more lab test results as compared with claims-based data alone.
What difference does that make? Access to member-based data can let payers
- Fill in member data gaps, which could potentially improve lab-related quality-performance measures, such as HEDIS®.
- Identify high-risk populations and intervene sooner, decreasing member care costs and improving member health outcomes over time.
- Identify unrecorded health conditions and inform disease diagnosis coding, which could lead to more accurate and higher reimbursements.
- Determine an optimal care plan to deliver better member health and experience.
The benefits of comprehensive member-based lab data show up clearly with diabetes, a condition that affects nearly 12% of the US population. Recently, Quest Diagnostics analyzed the data gap for a payer receiving test results solely through claims data. It was discovered that the payer had access to just 63% of members who had an HbA1c lab test result. They could only see:
- 61% of their members who had an HbA1c test result in the prediabetes range
- 66% of their members who had an HbA1c test result in the diabetes range
“That prediabetes number is especially concerning,” says Loveless. “We know that people who join a structured prevention program can cut their diabetes risk by 58% — by 71% if they’re over age 60.”
Of course, payers also benefit when members get the services they need, potentially enjoying lower costs and higher HEDIS scores and Medicare Star Ratings. (For 2026, HEDIS scores account for 25% of a Medicare Advantage plan’s Star Rating.) Member-based lab data can help close testing gaps related to nine quality measures and three Medicare Star measures.
Quality measures
- Glycemic Status Assessment for Patients With Diabetes (GSD)
- Kidney Health Evaluation for Patients With Diabetes (KED)
- Colorectal Cancer Screening (COL)
- Lead Screening in Children (LSC)
- Chlamydia Screening in Women (CHL)
- Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM)
- Cardiovascular Monitoring for People With Cardiovascular Disease and Schizophrenia (SMC)
- Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD)
- Diabetes Monitoring for People With Diabetes and Schizophrenia (SMD)
Star measures
- Hemoglobin A1c Control for Patients With Diabetes
- Kidney Health Evaluation for Patients With Diabetes
- Colorectal Cancer Screening (COL)
Health plans can access member-based data through the Quest Member Insights Portal. Features include custom reporting tools, HEDIS-reporting templates, and both individual and batched clinical laboratory improvement amendments (CLIA) reports of record. The goal is to offer payers what they need and in the format they can use so they can better serve their members.
“Quality teams don’t need to spend weeks or months chart-chasing,” says Loveless. “Instead, they can conveniently access batched reports of records for attestation.”
To learn more about how member-based data helps payers, visit the Quest Diagnostics Member Insights page.