How Closing Gaps in Care Is Revenue Generating for Primary Care Under Fee for Service (FFS) Reimbursement

Key takeaways:

• Closing gaps in care is a healthcare imperative
• Closing gaps in care for the patients who present in the clinic is not enough
• Closing gaps in care increases revenue for primary care practices and prepares them to succeed in future value-based contracts

Why are gaps in care important?

A gap in care is a discrepancy between medical best practice and the care the patient receives. Gaps in care include things like annual physicals, well-child visits and immunization, colorectal cancer screening, blood pressure monitoring, diabetes screening, and more.  

45% of US deaths have been attributed to modifiable risk factors. Routine health screening is key to reducing healthcare burdens. Despite this, only 8% of people obtain all recommended screenings, per the National Institutes of Health. Looking at it another way, in 2021:

We are missing a huge opportunity to improve the population’s health.

What are primary care practices doing today?

Physicians follow these best practices to keep patients healthy. They work with patients in the office to ensure that these patients are following best practice guidelines. Many EMRs support alerts that highlight gaps in care for patients in the office.

It is not easy for physicians to see the full extent of their patient’s needs.  I worked on a gaps in care initiative a number of years ago.  I clearly recall presenting physician performance data that shocked them. They challenged the results as they were so different from their perceived performance.  Meeting with them later and delving into their patient specific data, I often saw a lightbulb-like reaction when they realized that:  

• they were doing well to close gaps in care for patients seen in the clinic,
• that their challenge was related to their patients who were not making appointments

Support for proactive outreach is growing.  EMRs and analytic systems can create lists of patients who are due for various preventive testing for staff to call. Today, closing gaps in care is largely a labor-intensive telephonic and mail-based effort. Given current staffing challenges, staff are only able to contact a small subset of patients who are due for testing.  Mailing reminders is expensive.

Compounding these challenges, a recent survey revealed that 75% of people do not answer an unknown phone call. With more patients put on hold due to staffing shortages, this further adds a barrier to gap closure. 60% of patients will hang up after waiting one minute.  

Why shifting responsibility to the patient is not the solution

Patients don’t schedule recommended screenings for many reasons, including:

• A lack of awareness  
• Limited understanding of the risks and benefits of preventive health
• Cost concerns
• A lack of time
• Health equity concerns

Most patients do not have the health literacy to track and manage their health needs.  

Per the US Department of Human Services Report, America’s Health Literacy: Why We Need Accessible Health Information “Only 12 percent of U.S. adults had proficient health literacy…Over a third of U.S. adults…would have difficulty with common health tasks, such as…adhering to a childhood immunization schedule using a standard chart. There is an urgent need to address the gap between the health information currently available and the skills people have to understand and use this information to make life-altering decisions”

Yet, talk to many healthcare providers and they will say that they don’t have the time or the resources to proactively manage gaps in care. There is truth in this argument looking only at the way care gaps are managed today.  

There is another option that is more effective in closing gaps in care, increasing revenue, and reducing the need for time-consuming phone calls. Proactive digital outreach enables organizations to use their EMR or analytic patient lists to:

1. Automate outreach to all patients with a care gap  

2. Provide targeted education, 5th-grade level to maximize understanding  

3. Screen & address barriers to care

4. Make it easy to schedule needed care

5. Send reminders and visit preparation materials to increase patient follow-through  

Why FFS primary care should invest in digital outreach?

Clinics participating in value-based arrangements focus on closing gaps in care to increase incentive revenue.  There are also compelling reasons clinics reimbursed primarily by FFS should embrace digital outreach:

How does this work?

Let’s look at an example of a 50-provider Primary Care practice or Community Health Center.  

The model does not include increases in incentive revenue.  The savings are calculated based on national prevalence of each population and current levels of outreach.  

This is more than a theory.  The assumptions on response rates, reduction in no-shows and streamlining patient intake come from our own clients’ experiences in three different initiatives. All I have done is combine these three successes into one package that aligns with primary care and CHC needs and model the financial benefit of the clients’ successes.

Implementing chatbots to proactively reach out to engage and then activate this large population of patients provides low-cost, effective outreach. If you would like to discuss how this would look at your organization, please reach out to me at Bobbi.Weber@QliqSOFT.com.  We can apply the model to your practice and together develop a plan for success.