KED: A Partial Result Is Not a Closed Gap

By Michelle Canfield Senior Manager, Clinical Quality, ComplexCare Solutions

For health plan quality teams - key points:

• The HEDIS KED measure requires both eGFR (blood draw) and uACR (urine sample); a result for one component alone does not close the gap
• The uACR is the component that fails most consistently. It requires a separate order outside the standard lab workflow, with distinct specimen collection requirements
• Standard referral pathways create two failure points before the full measure is closed; in-home assessment eliminates both in a single encounter
• KED is a required performance measure in NCQA Health Plan Ratings across Commercial, Medicare, and Medicaid lines of business
• In CMS Stars, KED carries a 1x process measure weight; its quality value is the clinical intervention window it creates for heavier-weighted downstream outcomes

Approximately one in three adults with diabetes has chronic kidney disease - and most of them don't know it. That's not a rare complication of poor disease management. It's a routine clinical reality in nearly every diabetic member population, progressing silently until it reaches a stage where intervention is far more costly and far less effective.

Health plans understand this. Most have outreach programs designed to close the Kidney Health Evaluation (KED) gap - provider notifications, member reminders, lab order coordination. And every measurement year, those investments produce results for some members. But for many, the gap stays open. Not because the member refused testing or the plan failed to reach them. Because KED requires two distinct specimens, and the standard referral pathway was never built to collect both.

That's a coordination failure.

Outreach volume doesn't fix a coordination failure.

The Gap Behind the Gap

The Kidney Health Evaluation for Patients with Diabetes (KED) is not a single test. It requires two distinct specimen types: an estimated glomerular filtration rate (eGFR), derived from a blood draw, and a urine albumin-to-creatinine ratio (uACR), derived from a urine sample. Together, they establish whether a member's kidneys are functioning within healthy parameters and whether early-stage nephropathy is present. Each component captures a different dimension of kidney function. Neither is sufficient on its own to close the measure.

This creates a failure mode that doesn't exist for most single-specimen HEDIS measures.

The first failure point is upstream of the member entirely. The standard lab workflow captures eGFR through routine bloodwork - it flows from the metabolic panels that providers already order for members with diabetes in active management. The uACR is different. It requires a separate order that sits outside that standard workflow, one that must be specifically requested rather than generated automatically. In busy clinical environments, that separate order doesn't always get placed. A study of over 500,000 patients with type 2 diabetes across 24 U.S. health systems found eGFR testing rates near 90% - while uACR rates sat at just 53%, a gap the authors tied directly to eGFR's integration into routine metabolic panels and uACR's dependence on a separate urine sample.

When both components are ordered, a second failure point emerges at the collection level. The uACR requires a urine sample - a specimen type with timing and hydration requirements that don't apply to a blood draw. Members who complete the blood draw and don't provide the urine sample often haven't ignored a clear instruction. They've navigated an encounter where both requirements weren't communicated as equally necessary, and completed the step that felt like the primary one.

For members navigating transportation barriers, housing instability, or limited time away from work - groups that are disproportionately represented in populations with open KED gaps - a return visit to complete the missing specimen rarely happens.

THE KED gap stays open. The plan has an eGFR result and a missing uACR. For HEDIS purposes, that outcome is identical to no testing at all.

The result is predictable: gap closure rates for KED consistently underperform relative to the size of the eligible population, not because members are non-compliant but because the two-component structure of the measure creates multiple exit points in the standard pathway. Most members find one of them before both specimens are collected.

There are two fundamentally different ways to approach KED closure, and they produce different outcomes.

Most gap closure programs were built around partial closure. They weren't designed around the coordination requirement that makes KED different from every single-specimen measure in the framework.

Both Components. One Visit.

CCS's approach is built on a straightforward premise: both KED components must be completed in a single encounter, and the clinician in the room is what makes that possible.

• In-Home Assessment: For members reachable through a home visit, a CCS Advanced Practice Clinician arrives with everything needed to collect both KED specimens. The blood card for eGFR. The urine collection materials for uACR. Members are informed that testing will be performed in advance of the visit and may be encouraged to stay hydrated to facilitate urine collection.
  The model is clinician-guided and member-performed. The clinician walks the member through each step in sequence, explaining what each specimen captures and what good collection looks like for each. The member provides both specimens with the clinician present to answer questions and confirm the process. Both components leave the visit together. Both results return on the same report.
  
  The coordination problem doesn't get managed around. It doesn't exist.
  
  
• Mail-In Kit: For members who are harder to reach - those in less densely populated markets, those who decline in-home visits, or those who prefer to complete testing on their own terms - CCS's mail-in kit model extends the same reach without the same access requirement. The kit includes both components. The laboratory partner's engagement team follows up to confirm that both the urine and blood components have been collected and submitted. The collection mechanism is different. The structure that closes both components is not.

What is consistent across both models is the recognition that a partial result doesn't serve the member or the plan. The goal is full measure closure - both components, both results, documented.

The Quality Stakes for Health Plans

In the CMS Stars framework for Medicare Advantage, KED carries a 1x process measure weight - the same category as other annual screening requirements, not the 3x weight assigned to intermediate outcome measures like HbA1c control and blood pressure management. The direct Stars credit for closing KED is modest. The case for closing it is not.

KED closure establishes the conditions that allow downstream Stars outcomes to improve. A member whose kidney function is identified and managed early is more likely to achieve the blood pressure control and medication adherence outcomes tied to those 3x-weighted intermediate outcome measures.

The clinical stakes are distinct from the financial ones but compound them. Chronic kidney disease progresses silently. Members with undetected early-stage nephropathy don't adjust their medication adherence, blood pressure management, or dietary habits - not because they're unwilling, but because no one has told them there's a reason to. By the time symptoms appear, the clinical picture has changed significantly, and the intervention options available in earlier stages are no longer on the table.

The downstream cost of unmanaged kidney disease in diabetic populations (dialysis initiation, cardiovascular events, hospitalization) is well documented and substantial. Among commercially insured patients aged 45-64, those with both CKD and type 2 diabetes incurred mean annual costs of $35,649 - more than double the $16,121 observed in patients with diabetes alone, with costs escalating sharply at later CKD stages.

Early KED closure creates the intervention window. Late KED closure, or no closure at all, eliminates it.

For Medicaid populations, the stakes are different but no less significant. KED is among the chronic condition monitoring measures that Medicaid members most consistently defer - a population facing compounding access barriers for whom the two-component lab referral model creates friction at every step. The measure's continuous enrollment requirement adds a structural layer on top of that: members who cycle in and out of coverage may not maintain enrollment long enough to generate a complete KED result within the measurement year, independent of the testing barriers they already face. Across Medicaid Pay-for-Performance programs, which vary by state but uniformly reward measurable quality outcomes, an open KED gap isn't a deferred result - it's a missing one.

For both Medicare and Medicaid populations, the value of KED closure isn't the HEDIS credit in isolation. It's what the documented result makes possible for the member's health, and what the missing result forecloses.

A Different Standard for Closing the KED Testing Gap

Health plans have invested significantly in KED outreach - provider reminders, member letters, lab order support, end-of-year campaigns. Those investments are real and necessary. But when the referral pathway doesn't account for the two-component structure of the measure, outreach volume doesn't translate into full closure rate.

A member who completes a blood draw and nothing else hasn't had their KED gap closed. A member who receives urine collection materials without real-time guidance on how to use them hasn't had their KED gap closed. A member who completes both specimens in a single encounter - with a clinician present to walk them through each step - has.

CCS's standard for KED closure is the full measure: both components collected, both results documented, the gap closed in one visit rather than deferred across two appointments that may never happen. That's the standard your quality program should hold

Frequently Asked Questions

What is the HEDIS Kidney Health Evaluation (KED) measure?

The Kidney Health Evaluation for Patients with Diabetes (KED) tracks whether health plan members with diabetes received both components of a kidney function assessment during the measurement year: an estimated glomerular filtration rate (eGFR), derived from a blood draw, and a urine albumin-to-creatinine ratio (uACR), derived from a urine sample. Both components are required to close the measure. A result for one component alone does not satisfy the HEDIS requirement.

Does the KED gap have to be closed in the same encounter?

No. Both components, eGFR and uACR, must be collected, processed, and documented within the same measurement year, but they do not need to be completed in the same visit. That said, completing both in a single encounter is the most reliable way to ensure the measure closes. Members who complete one component and are asked to return for the second frequently don't - creating a partial result that, for HEDIS purposes, is equivalent to no result at all.

Is eGFR alone sufficient to close the HEDIS KED measure?

No. The Kidney Health Evaluation for Patients with Diabetes (KED) requires both components - eGFR from a blood draw and uACR from a urine sample - documented within the same measurement year. An eGFR result on file without a corresponding uACR does not close the measure. Because eGFR is frequently captured through routine bloodwork while uACR requires a separate order, health plans may have eGFR data for a large share of their diabetic population and still carry open KED gaps for those same members.

Why do KED gap closure programs frequently close only part of the measure?

The KED gap has two distinct failure points in the standard pathway. First, the standard lab workflow captures eGFR through routine bloodwork automatically, but uACR requires a separate order that doesn't always get generated alongside it, leaving some members without a complete testing pathway before they're ever involved. Second, even when both are ordered, uACR adds a urine collection requirement with timing and hydration considerations that a blood draw does not; members who complete the blood draw and stop there often haven't ignored a clear instruction - both requirements weren't communicated as equally necessary. For HEDIS purposes, a partial result is equivalent to no result - both components must be collected and documented within the same measurement year for the gap to close.

How does CCS close the KED measure during an in-home assessment

A CCS Advanced Practice Clinician arrives with all materials needed for both KED components, the blood card for eGFR and the urine collection kit for uACR. Members are informed that testing will be performed in advance of the visit and may be encouraged to stay hydrated to facilitate urine collection.

Does the KED HEDIS measure apply to Medicaid and commercial health plans, not just Medicare Advantage?

Yes. KED is a required performance measure in NCQA Health Plan Ratings across all three lines of business - Commercial, Medicare, and Medicaid. In the CMS Stars framework for Medicare Advantage, it carries a 1x process measure weight. For Medicaid populations, KED performance contributes to state Pay-for-Performance programs that vary by state. For commercial plans, it is tracked through the Quality Rating System (QRS). The ordering and collection barriers that prevent full KED closure are present across all three populations.

ComplexCare Solutions delivers clinician-guided kidney health evaluation through in-home assessment and mail-in self-collection models. To discuss how CCS can support KED gap closure for your population, speak with our team.