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Closing Care Gaps: What 500,000 Patient Calls Taught Us

At DocGo, we’re driven by a simple but powerful mission–to deliver high quality, highly accessible care for all.

One of the ways we’re fulfilling this mission is partnering our affiliate medical practices with insurance payers to bring care that closes care gaps for their hardest-to-reach populations. DocGo’s affiliate clinical practice group is currently working with six different payers on care gap closure programs designed to reach over 500,000 patients. These programs aim to connect patients with preventive and routine care they might otherwise miss, addressing unmet health needs before they escalate into more serious and costly conditions.

For insurers, these efforts carry significant weight. Higher quality scores directly influence reimbursement rates and patient enrollment in Medicare Advantage and Medicaid plans. By fostering healthier patient populations, insurers can reduce the total cost of care—which is a critical factor in capitated payment models.   

It’s more than just a numbers game. Care Gap Closure programs improve patient outcomes, advance health equity, and reduce long-term healthcare costs. A white paper from the National Committee for Quality Assurance and Penn Center for Community Health Workers titled “Critical Inputs for Successful Community Health Worker Programs” found that care gap closure programs led to a 29% reduction in avoidable hospital visits, a 15% decrease in overall healthcare costs, and up to a 35% increase in preventive care utilization in underserved populations.

DocGo facilitates gap closure through a wide range of at-home services, including colon cancer screenings, portable osteoporosis scans, depression and fall risk assessments, and chronic condition management using tools like retinal imaging and mobile HbA1c testing, among many others.

Through these efforts, we’ve learned a great deal about who needs our services most, which outreach strategies work best, and how we can adapt to serve our patients better.

Why Analyze Demographics?

Our patients aren’t all the same. By analyzing demographic data, we can:

• Get more accurate predictions of future success for care gap closure programs.
• Strategically double down on the best-performing patient groups.
• Test and implement strategies and messaging that truly connect with specific communities.

Ultimately, our findings revealed that DocGo performs best with patient populations who face more complex health needs and have been historically underserved. The following insights have helped us identify ways to make an even greater impact.

1. The Elderly Are Among the Most Engaged and in Need

What we learned: Patients over 65 are 150% more likely to complete a visit compared to patients under 30.

The story: Older adults often prioritize healthcare because they face more complex health challenges and know the risks of delaying care. DocGo’s proactive approach removes barriers like transportation and mobility issues, making it easier for them to access the care they need and help improve outcomes.

2. Geography and Demographics Matter

What we learned: Our success metrics are highest in regions with larger non-white and Spanish-speaking populations, like California and New York. Meanwhile, areas with predominantly white populations, such as parts of Connecticut and Michigan, showed lower engagement with our patient outreach.

The story: Underserved communities often have a deeper need for healthcare interventions due to systemic inequities like provider shortages and mistrust of traditional systems. Our ability to connect with these populations highlights the importance of tailored outreach strategies that help address disparities.

3. Language is a Key to Access

What we learned: Spanish-speaking patients booked and completed visits at twice the rate of English-speaking patients. This reflects a higher unmet need in Spanish-speaking communities, which have historically faced barriers to healthcare access.

The story: For decades, systemic barriers such as language access, immigration status, and economic inequity have long hindered Spanish-speaking populations from accessing quality care. Analysis of 2021 federal survey data revealed that healthcare utilization, measured by spending, was up to 42% lower among Spanish speakers compared to English speakers. Nearly 1 in 5 U.S. residents are Latina/Latino, but only 6% of physicians share this identity, leaving most patients without a care provider that reflects their community. Our findings highlight the importance of shared culture and language in delivering effective care.

4. Income Disparities Drive Healthcare Disparities

What we learned: Patients from lower-income zip codes booked and completed visits at significantly higher rates than those from higher-income areas.

The story: In lower-income communities, healthcare often feels out of reach until it’s urgently needed. Limited provider access, lack of transportation, and higher rates of chronic conditions drive a greater willingness to engage when care is accessible. Higher-income areas—despite having better access to health care—engage less with care gap closure outreach due to less perceived urgency or competing priorities.

Meeting Patients Where They Are

We leveraged these insights to continue improving our outreach and optimize our patient engagement: 

• Expanded our multilingual capabilities to ensure communication isn’t a barrier.
• Refined our outreach with culturally resonant images and messaging.
• Optimized our call times to connect with patients when they’re most available.
• Partnered with health plans to focus on patient populations where we make the biggest impact.

A Partner for Health Equity

Care Gap Closure programs are designed to bridge the divide between preventive care and patients who might otherwise fall through cracks in the system. DocGo’s affiliate clinical practice group works alongside health plans to advance this mission, leveraging data-driven insights and compassionate care to address disparities and close care gaps. Together, we’re ensuring underserved patients receive the timely, effective care they need—helping health plans meet their goals and building a healthier, more equitable future.