April 16, 2021

    Build Best-in-Class Habits to Address Care Gaps in Primary Care

    Summary: Coupling a culture of quality with an evidence-based approach to reduce care gaps can bolster your practice’s bottom line in a world of value-based payments.


    Primary care is the backbone of the US healthcare system, providing access for patients to receive clinically indicated preventive and chronic disease care. Factors such as patient complexity, lack of care continuity, and an increasing administrative burden create competing priorities in the clinic, leading to gaps in care. Moreover, the COVID-19 pandemic has further exacerbated the problem, as delays in care were experienced across the clinical spectrum from wellness exams/preventative screenings to chronic disease management. For example, delays in recommended cancer screenings have resulted in patients presenting with a greater percentage of advanced cancers. This and other delays necessitate incentives for both patients and providers to ensure a rapid return of essential services that meet or exceed pre-pandemic levels.

    “Value-Based Insurance Design enhances access to high value services and deters use of care that does not improve patient-centered outcomes. As the rate of high-value services use increases, clinical outcomes are improved and in many situations (e.g. asthma, heart disease, diabetes)  preventable hospitalizations and ED visits are reduced,” says Mark Fendrick, director of the University of Michigan Center for Value-Based Insurance Design and the father of “Value-Based Insurance Design” (VBID).

    The Opportunity of Addressing Care Gaps

    Health plans and other payers are increasingly adopting alternative payment models that include pay-for-performance programs and other quality incentives.  Addressing care gaps that are included in these quality driven payment schemes can be the difference between an unprofitable practice requiring additional federal grants (like FQHCs) to profits that can be reinvested back into the clinic, the staff, and community. Here is a quick breakdown of the reimbursements that can be achieved:

    • Commercial: up to 4% increase to reimbursements through P4P programs
    • Medicare: up to 6% increase to reimbursements through programs like MSSP
    • Medicaid: up to 40% increase to reimbursements through P4P programs (high variability)

    There are always competing priorities for your clinic, but success requires team alignment, operational best practices, and the right tools.

    Start With Your Team

    Your clinic needs a point-person to be the cultural driver and quality champion at your clinic. In a small practice, this could be the part time responsibilities of a rockstar Medical Assistant or in large clinics it is critical to have a quality leader that has strengths in prioritization and data management to balance frequently changing and competing needs.

    Getting team buy-in and alignment around quality of care is also necessary. This is not merely a monthly meeting to look at the numbers, but ensuring the team is motivated to deliver best practices by focusing on the impact to a patient’s health.

    Proactively screening patients for depression or nutritional/weight counseling -- even during acute visits -- should be the standard route. Once bought in, ensure the entire team is oriented around the mission: Use every opportunity to address care gaps.

    Operational Best Practices

    Operationally, your clinic needs to do these three things very well to be running effectively to manage care gaps.

    1. Scheduling: Are you proactive about reaching patients who are overdue for care?
    2. Preparation and Follow Up: Are your patients getting all necessary clinically indicated care, including referrals (e.g. retinal eye exams for diabetic patients) and post-visit care (e.g. insulin education)?
    3. Documentation: Is your coding capturing all of this?


    Clinician time management and frictionless communication are the key to a successful modern primary care practice. Patient’s expect more convenient engagement -- outreach should include either email or text messages.

    TOOLS: Patient’s expect modern and convenient engagement, and your outreach should start with either email or text messages. Patients are more likely to respond in the evening.

    The quality manager should use care gap performance data to create a list of patients by determining the number of addressable care gaps per patient, prioritized from highest to lowest. More sophisticated methods like taking into account a patient’s general health risk, age, or existing conditions, however, the general rule of thumb is that the more “at risk” a patient is, the more care gaps they have.

    TIP: Block 25% of your schedule for quality-focused patient visits to ensure there is extra time for annual wellness visits and by ensuring that there is space on the schedule that is not exceedingly far into the future, which often result in many no-shows or rescheduling.

    Preparation and Follow Up

    Prior to every visit, the EMR should be prepped with a set of addressable care gaps for the patient to simplify the next day’s operations. This falls squarely into the responsibilities of the quality managers. Leveraging your EMR and/or other population health tools is necessary.

    TIP: There may be a difference between the care gaps that the EMR surfaces and what the patient’s health plan is aware of. Always check the patient’s health plan portal to ensure that the list is up-to-date.

    Addressing care gaps is a team effort starting at the front desk with proper forms -- or, even better send forms, such as health risk assessments and depression screenings, to patients electronically prior to the visit.

    During the visit, the physician needs to discuss the patient's immediate needs and address other care gaps as well. Remember, “use every opportunity to address care gaps”.

    TIP: Send a message to the patient after every visit with a summary of their care plan. Follow up one week later with a quick message to see if they have follow up care scheduled.

    Last, many care gaps such as routine A1C labs and mammograms require post-visit care. It is important to follow up on ordered imagings, labs, and referrals. Simply handing the patient a reminder note does not emphasize the importance to their care.

    TOOL: EMRs do not have good systems in place for tracking and managing care coordination. Consider a 3rd party tool that helps coordinate labs, imaging, and referrals with patients and ensures that not only patients receive the care, but results are returned to your practice.


    Proper billing and coding is necessary to get the credit for doing all of this hard work. In practice, many medical offices close more care gaps than their performance report cards indicate because of missing codes on claims. This is especially true for post-visit care. For example, if a patient gets an A1C blood work done and the results show an A1C of <8, then it is necessary to document those results in a supplemental claim not tied to a specific visit. Periodic audits are incredibly effective at catching the human error of dropped codes. By tracking these gaps with a weekly audit to ensure common care gap codes are entered -- primary practices can often recoup tens of thousands of dollars.

    TIP: Create a simple sheet of all the most common care gaps and their corresponding CPT codes to save your physicians a lot of time.


    By proactively reaching out to patients to manage care gaps, you will not only improve health for your community but bolster the financials of your clinic. By demonstrating high-performance in managing population health quality measures, you will also put yourself on a path for further recognition such as the Patient Centered Medical Home program, which opens up new ways to provide even better care for your patients!


    Pair Team is an end-to-end provider enablement solution for Medicaid, with a focus on independent clinics and Federally Qualified Health Centers. With no upfront costs, our tech-enabled care teams, and EMR support tools, we drive quality of care while reducing workload for your clinicians and staff. Contact us to learn more.