Payer & Health Plan Solutions

The core issue: most outreach programs measure whether the message was sent, not whether the member did anything about it. A care gap reminder that goes to a member who doesn’t understand what the gap means, can’t get transportation to the appointment, or is managing three other competing priorities produces the same outcome as no outreach at all.

Fifty percent of non-compliance and non-adherence stems from social determinants of health. That means half the time a member fails to close a care gap, the reason has nothing to do with willingness. It has to do with barriers the outreach program never asked about and can’t resolve through a letter or a portal notification.

For plans managing attributed populations, the math is direct. Every unclosed care gap is a missed quality measure. Every inaccurate RAF score is lost revenue. Every avoidable ED visit is excess cost. And every member who leaks out of network is a permanent reduction in the value of the attributed life. These aren’t separate problems. They’re the same problem expressed in different line items: members intend to act but don’t complete the action.