Stop calling it ‘savings’: the real economics of closing Medicare care gaps

Medicare organizations have become experts at identifying care gaps. Every accountable care organization (ACO), health plan, health system and, increasingly, every independent practice has some combination of registries, dashboards, outreach lists, annual wellness visit campaigns, pharmacy adherence reports, quality work queues and vendor-supported patient engagement programs.

The message behind these programs is usually straightforward: Close gaps, improve care, reduce avoidable utilization and create savings.

It is a compelling story. However, the published evidence does not support it.

Closing a care gap may improve clinical care. It may improve a quality score, meet a contractual requirement, support a Medicare Advantage Star measure or increase risk-adjustment accuracy. It might generate appropriate payment for services such as an annual wellness visit, transitional care management or chronic care management. Those outcomes may be valuable. They may be essential to a practice's survival.

But none of them proves that closing the gap saved Medicare money. And when researchers have actually looked for that proof at the program level, they have not found it.

What the data actually show

The claim that gap closure drives ACO savings has been tested directly, and it does not hold up well. Efforts to raise quality and efforts to cut spending may operate through largely separate mechanisms. Quality-focused initiatives often fail to produce meaningful savings and can sometimes push utilization higher instead.

No published Medicare Shared Savings Program (MSSP) study offers a cost-per-gap-closed figure. None formally compares the labor, vendor, and clinical cost of testing and outreach against the downstream spending that those gaps are supposed to prevent. That intervention-level accounting simply does not exist in the evidence base — which is itself a finding. If gap closure reliably generated net savings, someone would have measured it by now.

Part of the reason is that the underlying question is genuinely hard to answer. Proving that gap closure saves money requires a counterfactual that is rarely observable: whether the patient who received outreach, testing, medication support or follow-up would have been hospitalized or incurred high costs without it. Programs tend to count completed measures, while omitting the full cost of outreach, clinical labor, vendor fees, transportation, testing, referrals and the additional treatment triggered by uncovering unmet needs. Savings may materialize years later, outside the performance year, or after a patient changes ACO attribution or coverage entirely. And patients selected for intensive intervention are usually sicker to begin with, which makes simple before-and-after comparisons misleading rather than informative. A credible analysis requires full-cost accounting compared against a similar untreated population, not a higher gap-closure rate or a better quality score.

Why this matters for how practices operate

A care gap is not automatically a cost-reduction opportunity. It is a signal that a service may be overdue, a diagnosis may be undocumented, a patient may have an unmet need or a recommended action may not have occurred. Whether that signal merits action is a clinical question. Whether it justifies intensive outreach is an operational question. Whether it produces net savings is a financial question. Primary care practices and ACOs need to stop treating all those as the same question.

The relevant equation is simple to write and hard to apply, honestly:

Net savings = avoidable downstream spending prevented − full cost of the intervention

The intervention cost includes far more than the person who places a call. It includes the analytics platform, vendor fee, registry maintenance, roster reconciliation, staff training, outreach attempts (successful and failed), scheduling, record retrieval, transportation assistance, clinical review, documentation and follow-up. There are downstream clinical costs too: A patient contacted for an overdue preventive service may appropriately receive laboratory testing, imaging, referrals, new medications or specialist visits. That can be good medicine. It also raises short-term spending.

An intervention that increases spending is not automatically wasteful; it may catch a serious condition early or improve function. But it should not be marketed as "savings" unless the full cost of the activity is demonstrably lower than the spending it avoids. The Centers for Medicare & Medicaid Services treats quality and cost as separate tracks: MSSP ACOs must meet quality-performance requirements and reduce growth in Parts A and B expenditures relative to the benchmark. Quality alone does not create shared savings, and lower spending alone does not establish a successful ACO. Physician organizations should apply the same separation internally rather than assuming one automatically produces the other.

The gap is not the opportunity — the patient's trajectory is

Most gap-closure programs start with the wrong unit of analysis. They ask which patients have not completed a screening, filled a medication or had a wellness visit, then build an outreach operation around that list.

The better unit of analysis is the patient's risk trajectory. A high-risk patient recently discharged with heart failure, chronic obstructive pulmonary disease, pneumonia or sepsis may have several open gaps. Still, the decisive question is not how many gaps exist; it is whether the patient is at risk for a preventable return to the hospital.

The same logic applies to patients with repeated emergency room use, worsening frailty, medication-access problems or rapid escalation in outpatient utilization. There, a plausible pathway exists from intervention to avoided high-cost care: A nurse who calls within 48 hours of discharge, reconciles medications and catches worsening symptoms early may prevent a readmission that costs far more than the outreach.

The identical effort applied to a stable patient with a routine screening gap may be valuable for quality reasons. It is far less likely to generate near-term savings. The same gap carries very different economic value depending on who has it, which is precisely why the program-wide data show no consistent savings signal tied to broad gap-closure activity.

Savings, revenue and quality are not the same thing

Part of the confusion in the field stems from lumping distinct financial outcomes under a single term. A practice may be paid for an annual wellness visit, bill for chronic care management, earn a quality incentive or appropriately capture a risk-adjustment condition. Medicare covers chronic care management for beneficiaries with two or more chronic conditions expected to last at least 12 months; it’s a legitimate acknowledgment that coordination work has value. But payment for that work is payment for services rendered. It is not evidence that the work reduced overall Medicare spending.

Physician leaders should ask, for every campaign, “Is this a clinical benefit? Quality performance? Contract revenue? Documentation accuracy? Or true net savings after every cost is counted?” These are all legitimate goals, but they require different interventions, metrics and claims about what was actually achieved.

What a defensible program looks like

Every gap-closure initiative should fall into one of three categories, as follows:

• Clinical value interventions are worth doing because they are evidence-based and patient-centered, whether or not they save.
• Quality- or revenue-value interventions should have their financial return calculated relative to their operating costs.
• Utilization-avoidance value interventions — the only category where "savings" is a defensible claim — should be reserved for patients with a specific, near-term, modifiable risk of expensive utilization, supported by a credible clinical hypothesis, not a generic denominator.

Organizations should report gap-closure results as an activity measure, not a financial one, unless they can show the incremental effect on utilization and total cost compared with a similar untreated population. Absent that comparison, the honest conclusion is that care improved — not that money was saved.

The bottom line

The MSSP literature does not support the assumption that closing care gaps generates net Medicare savings once the cost and time of testing and outreach are counted. The best available program-level evidence found gap-closure and care-management strategies were not the major driver of MSSP savings, and that filling preventive-care gaps may even increase utilization by improving access. Meaningful savings generally are driven by clinicians’ and care teams’ decisions about how, when and where patients receive care, rather than by completion of preventive-care or testing measures alone.

And no study has produced the cost-per-gap-closed accounting that would settle the question either way.

A care gap is a signal. It is not a business case. The business case exists only when the expected benefit — clinical, quality or financial — exceeds the full cost of the work required to achieve it. Until an organization can show that, it should stop calling the result savings.

Robert Resnik, M.D., MBA, is a board-certified internal medicine physician practicing in Cary, North Carolina. He earned his medical degree from Eastern Virginia Medical School and completed his residency at East Carolina University. He also holds an MBA from Duke University.