Care Gap
A care gap is a preventive or chronic disease management service that a patient is eligible to receive based on clinical guidelines but has not yet received — representing both a quality measure miss and often an undelivered reimbursable service.
What is a Care Gap?
A care gap exists when a patient who meets the eligibility criteria for a clinical quality measure (the denominator) has not yet received the specified service or achieved the specified outcome (the numerator). Care gaps represent the difference between evidence-based recommended care and actual care delivered. They are the operational unit of quality improvement in population health management.
Common Care Gaps in Primary Care
- Annual Wellness Visit (AWV): Medicare patient due for G0438/G0439 — highly reimbursable and triggers additional care gap closure opportunities
- Diabetic A1C overdue: Diabetic patient without A1C in past 12 months (or past 3 months if poorly controlled)
- Diabetic eye exam: Diabetic patient without retinal exam in past 12 months — a significant HEDIS measure
- Colorectal cancer screening: Patient 45–75 without appropriate CRC screening (colonoscopy in past 10 years, FIT annually, Cologuard in past 3 years)
- Mammography: Female patient 50–74 without bilateral mammogram in past 24 months
- Blood pressure control: Hypertensive patient with most recent BP > 140/90
- Depression screening: Adult patient without PHQ-2 or PHQ-9 in past 12 months
- Pneumococcal vaccine: Patient ≥65 without PPSV23 and PCV15/20 vaccination
Revenue Per Closed Gap
Care gap closure generates both quality measure performance improvement and direct reimbursable revenue. An AWV gap closure generates ~$147–196 in G0439/G0438 reimbursement plus potential same-day E&M if chronic problems are addressed. A diabetic eye exam referral generates specialist revenue. A colorectal cancer screening generates $150–$800+ in colonoscopy revenue. Practices that systematically identify and close care gaps during scheduled visits generate significantly higher per-patient annual revenue than those that address only presenting complaints.
HEDIS Measure Impact
For health plans, closing care gaps before the HEDIS measurement window closes directly improves reported HEDIS rates, which affects Medicare Advantage Star ratings and commercial quality designations. Each percentage point improvement in a high-weight HEDIS measure can shift a plan's composite Star rating, with implications of hundreds of millions of dollars in Quality Bonus Payments. Provider-level care gap closure drives plan-level HEDIS performance.