Care Gaps Harm Health Plans, Providers, and Members Alike

For health plan members, having access to quality healthcare is a safety net: it’s there when they need it. But what if the safety net is so loosely woven it either fails to catch some who tumble into it, or only partly breaks their fall? For many health plans, employers, and plan members, this is no hypothetical question. Members are falling through healthcare gaps all the time, and the consequences are serious.

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Consider:

  • Too many health plan members are not receiving all the care they need. The Centers for Disease Control estimates one-third of Americans are not making use of routine healthcare visits, and that four out of ten Americans delay or forego access to care when they need it.

  • Too many members with chronic conditions are out of compliance with treatment. Six in ten Americans have at least one chronic medical condition; one in four has two or more. Many of these individuals are falling through treatment gaps. For example, as few as three percent of members with diabetes comply with their treatment plans. For conditions like coronary heart disease, high blood pressure and high cholesterol, the rate of member compliance is from one-fifth to about one-third.

  • Care gaps worsen inequality in healthcare coverage. Physical, cultural, and language hurdles keep some members from making best use of available healthcare. One in five doctors’ offices lack adequate wheelchair access; African-Americans and Hispanics disproportionately defer or forego treatment at urgent care and emergency care facilities; and members who do not speak English as their first language experience longer inpatient stays and higher hospital readmissions rates.

Why It’s Important to Reduce Gaps in Care

The problem with care gaps is more than just bad-looking numbers. Health plans and providers lose money through missed care delivery opportunities. For members, care gap consequences include missed or delayed diagnoses, delayed treatment, reduced healthcare access and lower treatment compliance. These contribute to higher rates of morbidity, worsening medical conditions, lower quality of life, and even loss of life.

But gap closure is about more than avoiding negatives. Incentives exist, too:

  • Closing gaps in care saves money for health plans and employers. Care gaps adversely affect health plan organizations and employers by distorting healthcare spending. On average one in four plan members has a care gap, but the amount of care they require averages about 40 percent of employer member health spending. In today’s value-based health cost environment, reducing the number of gaps can lead to similarly magnified cost savings.

  • Gap closure can increase revenue. The Centers for Medicare and Medicaid Services (CMS) encourages Medicare-Medicaid plans to meet or exceed quality standards by enabling them to claw back withhold amounts if they meet annual gap closure targets. Meeting CMS gap closure improvement targets is key to recovering these amounts.

Reveleer: Accelerating and Refining Care Gap Closure for Today

One source of good news this year is the force of nature that made the problem worse last year – the COVID-19 Public Health Emergency and its effect of forcing many providers to temporarily or permanently close their doors – is receding. As the lockdowns end and more members feel safe resuming their old healthcare behaviors, gaps reflected in delayed care and disruptions to routine healthcare visits should improve on their own.

But passively waiting for a sense of “Back to Normalcy” is not enough, and neither is falling back on old methods to find and close care gaps. Reveleer provides advanced machine learning and automation tools to enable health plans, providers and employers to identify and close more care gaps, faster. It does so in the following ways:

  • Complete data integration. One of the most important proactive steps that health plans, providers and employers can take is to work with a vendor company such as Reveleer to consolidate and integrate their otherwise scattered data. Reveleer does this and shows the results in a member-centric, single chart that is intuitive to use.
  • Identify care gaps as they occur. Reveleer provides real-time tracking and reporting of closed, current and pending care gaps. No more discovering gaps only after they happen.
  • Accelerated record review and analysis, powered by Reveleer’s Natural Language Processing (NLP) technology. No longer is it necessary for providers to manually review charts and spreadsheets to find evidence of care gap closures. Reveleer’s advanced analytics and machine learning automates and accelerates this once labor-intensive and time-consuming work.
  • Automated analysis and follow-up with health plan providers and members. Reveleer provides actionable data to target for educational campaigns, providers and members who need help identifying and solving open care gaps, and to encourage members to make more use of preventive medicine.

Before Reveleer’s deep learning and automated NLP-driven approach, the importance of finding and closing care gaps has been matched only by the burdens this placed on health plans and providers: forcing them to use fragmented data and manual reviews to find existing gaps after the fact. There is no reason today to cling to these old ways, and instead find compelling efficiencies, increased accuracy, and improved economy in adopting an artificial intelligence-based approach that we provide.

To find out more about Reveleer’s gap closure solution, see our gap closure web page; or, if you’d like, make arrangements to talk with one of our gap closure experts.

About The Author

Reveleer is a healthcare software and services company that empowers payers in all lines of business to take control over their risk adjustment and quality improvement programs. The Reveleer platform enables payers to independently execute and manage every aspect of provider outreach, retrieval, coding, abstraction and reporting – all under one single platform. Leveraging its technology, proprietary data sets, and subject matter expertise, Reveleer also assists payers with full record retrieval and review services to support financial performance and improved member outcomes.