What Actually Is a Care Gap?
A care gap is the delta between recommended care and actual care delivered. It's a missed mammogram, an overdue A1C test, a prescription that wasn't refilled. In isolation, each gap seems minor. At scale, they represent billions in preventable costs and thousands of avoidable adverse outcomes.
For patients, care gaps aren't abstract metrics. They're the difference between catching cancer at stage 1 versus stage 4, between managing diabetes and losing a limb, between a $20 copay for a screening and a $10,000 hospital bill. Most patients don't even know they have open care gaps. They assume that if something were wrong, their doctor would tell them. Closing these gaps isn't just a financial imperative. It's how we deliver on the promise that the healthcare system is actually looking out for people.
Preventive Screenings
Routine screenings designed to catch diseases early, when they are most treatable and least costly.
Chronic Disease Management
Ongoing monitoring and management of chronic conditions to prevent complications and hospitalizations.
Medication Adherence
Ensuring patients take prescribed medications consistently to manage conditions and prevent acute events.
These three categories (preventive screenings, chronic disease management, and medication adherence) account for the majority of HEDIS quality measures that determine Star Ratings. Each category has distinct intervention strategies, cost profiles, and ROI characteristics.
The Economics of Care Gaps
The math is stark: a $200 screening can prevent a $50,000+ complication. But the calculus only works in your favor if you're accountable for the downstream costs. In fee-for-service, hospitals profit from complications. In value-based care, you pay for them.
Gap Cost Calculator
See the financial impact of care gaps at scale
Cost Comparison
$11.1M
Potential Savings
55x
ROI on Prevention
150
Complications Prevented
Key Insight
For every dollar spent on closing breast cancer screening gaps, you save $56 in avoided complications. At 1,000 patients, that's $11.1M in annual savings.
The Star Ratings Connection
For Medicare Advantage plans and ACOs, care gap closure directly translates to Star Ratings. The difference between a 3.5-star and 4-star rating can mean millions in bonus payments. Use the simulator below to see how closing gaps in specific measures impacts your rating.
Star Ratings Simulator
See how closing gaps impacts your Star Rating and bonus payments
Current
3.0
70% performance
Projected
4.0
80.0% performance
Bonus Payment Impact
Attributed Lives
Annual Revenue Base
$360.0M
Additional Bonus Payment
+$18.0M
5% bonus for achieving 4+ stars
Congratulations! By closing 500 gaps, you would cross the 4-star threshold and qualify for $18.0M in annual bonus payments.
The Scale Problem
Here's where theory meets reality. You have 50,000 attributed lives. How many actually need intervention? The answer requires sophisticated risk stratification, because not every patient with an open gap requires the same level of outreach.
Population Risk Funnel
For a typical 50,000-member value-based care population
Effective gap closure means matching the intensity of your intervention to each tier. Automated reminders for the broad base, dedicated care management for the high-risk few.
The challenge isn't identifying gaps. Your EHR can give you a list. The real challenge is allocating limited resources (care managers, outreach staff, intervention budget) across a population with vastly different needs and different potential ROI.
Resource Allocation Game
Allocate your care managers to maximize impact
Healthy/Low Risk
25,000 patients
Complications Prevented
4
Cost Saved
$20K
Rising Risk
12,000 patients
Complications Prevented
19
Cost Saved
$285K
High Risk
5,000 patients
Complications Prevented
24
Cost Saved
$840K
Critical
1,000 patients
Complications Prevented
8
Cost Saved
$600K
Your Allocation Results
$1.7M
Annual Cost Saved
55
Complications Prevented
1.8x
Return on Investment
Try optimizing! Consider reallocating care managers from low-risk segments (use automation) to high-risk and critical segments where human intervention has the highest impact.
The Care Gap Lifecycle
Closing a care gap isn't a single action. It's a process. From initial identification through intervention to confirmation, each step has associated costs, success rates, and escalation paths. Understanding this flow is essential to optimizing your approach.
Gap Closure Intervention Flow
Click nodes to explore or simulate a patient journey
Gap Identified
Automated Outreach
25% success
$2/patient
Live Phone Call
45% success
$25/patient
Care Manager
65% success
$75/patient
CHW Home Visit
70% success
$150/patient
Gap Closed
Gap Remains
Intervention Steps
0
Total Cost
$0
Outcome
In Progress
How it works: Each intervention has a success rate. If successful, the gap closes. If not, the patient escalates to the next intervention level. The key insight: automated outreach is cheap but catches 25% of gaps. High-cost interventions like CHW visits have 70% success but cost 75x more—reserve them for patients who need them.
What Makes Gaps Close (And What Doesn't)
Not all interventions are created equal. The effectiveness matrix below plots each intervention type by its success rate and cost per intervention. The sweet spot is in the upper-left: high impact at low cost.
Intervention Effectiveness Matrix
Hover over bubbles to see intervention details
Hover over a bubble to see intervention details
Bubble size indicates scalability potential
Sweet Spot
Strategic
Minimal Use
Avoid
Key Insight: The sweet spot is in the upper-left quadrant—high effectiveness at low cost. Automated outreach (SMS/email) offers the best scalability, while provider alerts during visits achieve high effectiveness at near-zero marginal cost. Reserve expensive interventions like CHW visits for patients where lower-cost options have failed.
Key Insights from Research
- Personalization matters: Generic reminders have 15% effectiveness; personalized outreach achieves 45%
- Timing matters: Outreach within 2 weeks of a missed appointment is 3x more effective than waiting longer
- Channel matters: SMS for younger patients, phone calls for elderly. Matching channel to preference boosts success
- Context matters: Transportation barriers require different solutions than awareness gaps
Why This Is Hard (And Why It Matters)
Data Fragmentation
Claims data lags by months. EHRs are siloed. Patient attribution changes. Getting a real-time, accurate view of open gaps is surprisingly hard.
Intervention Scale
You can't manually manage thousands of gaps across dozens of measures. But automation without personalization doesn't work. The balance is delicate.
Measurement Challenges
Proving that your intervention caused the gap closure (vs. the patient doing it anyway) requires rigorous attribution modeling.
Resource Constraints
Care managers are expensive and scarce. Every minute spent on low-yield outreach is a minute not spent on high-impact interventions.
These challenges explain why most organizations struggle with gap closure despite understanding its importance. Bolt-on solutions don't work. This requires purpose-built infrastructure that integrates data, workflows, and analytics.
The Future of Gap Closure
Reactive
Quarterly reports identifying gaps with 3+ month claims lag
Semi-Automated
Real-time identification with manual outreach processes
Proactive
Predictive gap emergence with automated, personalized intervention
Transformative
AI-driven personalized care journeys preventing gaps before they occur
The organizations that move first on this capability curve will define the next decade of value-based care. They'll achieve Star Ratings their competitors can't match, negotiate better contracts, and build moats around their patient populations.
The Stakes Are Clear
Remember Sarah? The 64-year-old diabetic who hasn't had an eye exam in 18 months. In a system with mature gap closure, Sarah gets a personalized text reminder at month 10. At month 12, her care manager calls. By month 14, she's had her retinal exam, and the early-stage retinopathy they caught is treated with a $500 intervention instead of a $50,000 crisis.
Multiply that by millions of patients, and the math is clear. The organizations that master gap closure will define the next decade of healthcare. The infrastructure investment is real, but the returns compound over time. The question isn't whether to invest in gap closure capability. It's whether you can afford not to.