Gaps in care in healthcare are costing health plans and providers more than missed metrics.
They’re draining revenue, lowering star ratings, and increasing compliance risk.
According to the Centers for Medicare & Medicaid Services (CMS), gaps in care contribute significantly to lower Star Ratings and increased healthcare costs, with preventive care non-compliance being a leading driver
With AI, healthcare leaders can finally focus on the care gaps that actually move the needle.
At Bulwark Health, RAQ+ zeroes in on high-impact gaps tied directly to HEDIS, Stars, and risk adjustment.
The result? An approach that’s proactive, strategic, and built for decision-makers who care about both outcomes and margins.
Let’s dive deeper.
Understanding Gaps in Healthcare
Gaps in care is the difference between the care a patient should receive (based on clinical guidelines) and the care they actually get.
For example, if a diabetic patient misses their annual retinal exam. Then the gaps include missed screenings, delayed diagnoses, and lack of follow-up due to cost, transportation, or provider shortages.
Care gaps in healthcare can occur at any stage – prevention, diagnosis, treatment, or follow-up.
RAQ+ prioritizes those that impact performance scores, risk adjustment accuracy, and value-based care incentives.
Why Many Care Gap Strategies Fail
Too many care gap programs fall into the same traps: acting too late, targeting everything instead of what matters, and keeping teams in silos.
- Reactive execution: Identifying gaps months after the patient encounter.
- Broad targeting: Spending equal time on low-value and high-value gaps.
- Siloed operations: Risk, quality, and coding teams working without alignment.
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How Do We Identify the Right Gaps in Care?
Traditionally, organizations have depended on manual claims reviews and retrospective chart audits – processes that are slow, labor-intensive, and often flag gaps long after opportunities to act have passed.
As a result, urgent needs may be overlooked, low-value cases may consume resources, and closure efforts often get crammed into the end of the reporting cycle, all of which put compliance, patient outcomes, and revenue at risk.
In contrast, modern best practices emphasize timely data integration, predictive analytics, continuous monitoring of quality metrics like HEDIS and stars, and risk-based prioritization to ensure teams focus on the most impactful gaps first.
5 High-Impact Strategies (and How RAQ+ Executes Them Better)
Focus on Value-Linked Gaps
- Best practice: Prioritize gaps tied to HEDIS and RAF scores.
- RAQ+ advantage: Integrates HCC and HEDIS capture, so critical gaps are never missed.
Act Before the End-of-Year Rush
- Best practice: Spread closure efforts year-round to avoid performance bottlenecks.
- RAQ+ advantage: Real-time alerts flag new gaps within days, enabling steady closure cadence.
Give Providers Actionable, Timely Data
- Best practice: Provide clear, prioritized patient lists.
- RAQ+ advantage: Provider scorecards show open gaps, recommended actions, and deadlines, all inside their workflow.
Align Risk and Quality Teams
- Best practice: Connect coding, quality, and care coordination.
- RAQ+ advantage: A single, AI-powered workflow aligns all stakeholders for faster resolution.
Close Gaps in the Patient Encounter
- Best practice: Resolve gaps while the patient is in the room.
- RAQ+ advantage: In-encounter prompts guide providers to address gaps immediately.
Recommended Read: Smart risk adjustment tool with AI-powered precision that lowers costs for value-based care
The Role of AI in Gaps in Care Healthcare
AI is reshaping how gaps in care are addressed across the industry.
Current trends include the use of:
- Predictive analytics: to identify patients at risk before issues arise
- Natural language processing (NLP): to extract actionable insights from unstructured clinical notes
- Machine learning models: to suggest personalized interventions based on historical patterns and social determinants of health.
Many organizations are also deploying AI-driven clinical decision support tools.
These operate within EHRs to prompt timely care actions, as well as automation tools that streamline reporting for HEDIS and other quality measures.
Together, these advances are shifting the field from reactive gap closure to proactive, precision-targeted prevention.
RAQ+: The AI Solution for Closing Care Gaps Faster
Bulwark’s RAQ+ is purpose-built for leaders who want more than generic care gap reports.
It closes care gaps with a precise, always-on approach:
- Intelligent prioritization: Flags high-impact gaps linked to HEDIS, stars, and risk adjustment, not just any open item.
- Seamless team alignment: Brings quality, risk, and coding teams into one shared workflow.
- Real-time data delivery: Pushes actionable insights directly into dashboards and scorecards.
- In-encounter resolution: Prompts providers to close gaps while the patient is still in the room.
- Embedded workflows: Keeps gap closure a steady process, avoiding last-minute scrambles.
The result? A consistent, proactive strategy that improves quality scores, boosts risk accuracy, and strengthens value-based care performance.
Book a demo today to see how RAQ+ can fit into your needs.
FAQs
How do we identify gaps in care?
By comparing patient records to evidence-based guidelines using EHR data, claims, and predictive analytics.
What causes lack of access to healthcare?
Cost, transportation, provider shortages, and social determinants of health (WHO).
What are current issues in healthcare?
Workforce shortages, rising costs, care disparities, and the shift to value-based models.
Conclusion
Most care gap programs miss the mark because they spread resources too thin.
A stronger approach blends proven industry best practices (like cross-team collaboration, real-time data sharing) with the right technology to make those practices scalable and consistent.
RAQ+ focusing on the right gaps, at the right time, in the right way.
Ready to boost your Star Ratings and close the right care gaps? Book a demo with Bulwark today.
