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The Members You Can’t Reach Are Costing You the Most

An Interview with Yong Kim, Vice President, Health Plan Partnerships at DocGo

At DocGo, Yong is responsible for expanding and strengthening health plan partnerships, shaping growth strategy for new collaborations, and scaling value-based care programs that improve outcomes for underserved populations. Prior to joining DocGo, Yong served as Head of BizOps and Strategy, Population Health and Care Management Solutions at CVS Health, where he led business operations and defined business strategy for CVS Health’s payer-agnostic population health and care management businesses. He also has a decade plus in healthcare management consulting and strategic advisory, supporting provider and payer organizations including HCA Healthcare and Elevance Health.

What is a care gap?

A care gap (also known as gap in care) is when a patient misses or delays a recommended clinical service – or unable to achieve a clinically acceptable threshold for targeted measures – that are supported by evidence-based clinical guidelines or quality measures.  In other words, care gaps reflect care that a patient should have received but has not.  

This could be a child needing to be caught up on their vaccination schedule, an age-eligible adult not receiving a colorectal cancer screening, or a diabetic patient that does not regularly monitor their A1C.  It can be related to a patient who has ASCVD not being on statins, or a patient who has been discharged from a hospital not receiving post-discharge follow-up.  Care gaps are comprehensive – they can be preventive, medication-related, chronic disease-related, focused on follow-up and monitoring after certain clinical episodes or results management, ensuring care coordination across providers, or even capturing social determinants of health.  

Care gap closure are services that health plans are expected to deliver at scale, and many are publicly measured on performance against a select number of care gaps.

Why do care gaps matter so much? 

Care gaps matter for patients because there is evidence indicating that it is a clinical service they should receive.  When care gaps aren’t addressed and closed, patients are expected to have worse health outcomes, and worse health outcomes forebode higher medical costs.  

For example, a patient with hypertension with persistently elevated blood pressure and no treatment adjustment is much more likely to develop acute cardiovascular disease that will in turn trigger higher medical costs incurred by more cardiologist/specialist visits, more hospitalizations, and more expensive specialized medications.  If that patient’s blood pressure is controlled effectively by adjusting treatment, the care gap for uncontrolled blood pressure can be closed and reduce expensive avoidable care.

Health plans, at their core, take on financial risk for the population they insure. They receive fixed pre-paid amount per member for defined services – through employer/ individual premiums for commercial insurers or through government-funded capitated payments to Medicare Advantage “MA” and managed Medicaid plans.  

Although there are meaningful nuances and exceptions, health plans financially benefit when they are able to close care gaps in their population, resulting in better health outcomes and lower medical costs given the “fixed” nature of the pre-paid funding pool that pays for healthcare services.  On the other hand, a health plan can financially suffer if their members have worse health outcomes and higher medical costs due to care gaps a health plan is unable to close, eating into the health plan’s profit portion of the funding pool.

Why are quality measures and quality ratings so critical to health plans?

Above and beyond the structural need to improve health outcomes to reduce medical costs, care gaps have an outsized impact on a health plan’s financial performance and the perceived quality of the insurance plan. Quality measures for health plans measure performance of “good care” provided to members. Quality measures and care gaps can be considered two sides of the same coin – quality measures define the standard for the health plan, while care gaps represent the standard at the patient level.  

Those measure results roll up into quality ratings, which are summary scores that translate multiple quality measures into an overall performance rating – the most widely recognized being the Centers for Medicare & Medicaid Services “CMS” Star Ratings Program for MA plans, which gives them 1 to 5 Stars annually.  Quality ratings for MA and managed Medicaid have direct and indirect material impacts to a health plan’s financial performance and the viability of their business.  

For MA plans, high performing plans (typically 4 stars or above) are eligible for bonus payments that are above and beyond the initial funding pool determined during the bidding process for MA regions.  Moreover, when plans bid, they bid against a CMS benchmark, and if a bid is below the benchmark then the plan is eligible to receive a rebate – with the rebate percentage being determined by quality ratings where higher quality plans receive a higher rebate.  Bonus payments and rebates often represent the lion’s share, if not almost the entire profit margin of a health plan for the year.  These funds can be used for extra benefits, reduced cost sharing, and possibly even lower premiums – further driving performance of a health plan.  Medicaid plans also see direct impacts to financial performance from quality ratings – although each state determines how to incentivize high quality ratings, many states use quality withholds where a portion of the capitated funds are held back and only earned back if quality targets are met.  Poor performance can also result in enrollment sanctions and contract termination, accentuating the existential importance of Quality ratings for MA and managed Medicaid plans.  Lastly, there are many indirect effects as well – one of which is the enrollment growth expected from members choosing between different health plans by looking at quality ratings, among other factors. 

When a health plan moves up or down in quality performance, the change can also impact projected revenue, enrollment expectations, and investor confidence. Just to underscore how dramatic this can be, if you track publicly traded health insurers after a small star rating change, you can see significant valuation swings tied to star results. There have been cases where a single lost star resulted in a public company losing a third of its market capitalization. Closing care gaps reduces medical costs by improving health outcomes for specific populations, which impacts Quality ratings, which directly and indirectly affects the financial performance of both MA and managed Medicaid plans. 

How does DocGo help health plans to close care gaps at a practical, operational level?

Plans invest heavily in closing member care gaps that impact quality measures that in turn make up a quality rating performance.  The most common investment is to incentivize members and providers to close care gaps, as well as investing in care management teams that can close gaps telephonically.  However, health plans persistently struggle with populations that are under-engaged with, or have trouble accessing the health plan’s provider network.  

That’s where DocGo and its affiliated medical practices (collectively, “We”) come in.

1. We engage hard-to-reach populations using proprietary engagement capabilities and tactics designed to reach those patients who typically don’t respond to traditional outreach, informed by the millions of outreach attempts that we make annually.
2. We deliver care directly to members’ homes, making it easier for them to say yes, even if they avoid traditional brick-and-mortar locations or don’t trust the system, and especially if they struggle with accessing care in a convenient and timely fashion. 

For many, a visit from a mobile clinician is the first time they’ve experienced truly accessible, high-touch care. These visits can help build trust and boost long-term engagement.

Operationally, plans provide us with a list of members and specific care gaps and target volumes (e.g. “200 diabetic eye exams, 50 bone density scans”) that they believe their existing capabilities will struggle with, and we deliver.  As we engage with members and close those gaps, we share results with our health plan partners on a daily basis through our portal, as well as in meetings multiple times a month where we review our engagement and gap closure performance. This transparency enables precise, tactical deployment of our services to help our health plan partners hit their quality targets and improve financial performance.  

What differentiates DocGo’s model from other care gap vendors?

We believe other vendors lack the breadth or depth of our offering.

Our engagement approach is grounded in data and is statistically sound. We learn what drives engagement in specific populations and return those insights to health plans. We analyze patterns by geography, language, appointment timing, and we A/B test continuously to understand covariates that influence a patient’s propensity to say yes to a care gap closure visit. This year alone, we ran over 150 tests across variables like messaging, cadence, and script design.  Even visual choices, like using postcards that feature patients wearing bright clothing, have moved the needle in a statistically significant way. When we talk about 200 percent year-over-year improvement in engagement from 2024 to 2025, it is these small refinements that compound, ultimately improving how we connect with the patients who are traditionally hardest to reach.

We also support a wider range of care gaps. With up to 50 distinct services, plans can direct us toward whatever mix they need: whether that’s high-denominator (lots of care gaps to be closed) and low-denominator care gaps that have outsized impacts on quality scores based on their quality targets.  Our affiliate medical practices facilitate high-volume gaps like annual wellness visits or low-volume ones like bone density scans where even modest improvements can meaningfully affect quality scores.

We embed social determinants of health (SDOH) assessments into every in-home visit. These cover barriers like housing, food access, mobility, and access to medication. While not presently required, many health plans expect SDOH to evolve into a directly reportable quality measure; so we capture it in a proactive, structured way using the PRAPARE screening tool, while also reporting our results to our partners however they prefer – whether g-codes, LOINC codes, or SNOMED CT codes. Moreover, when we identify a barrier, we don’t stop at documentation. Our care navigation teams then help connect members to plan benefits, local programs, or community networks that solve for those barriers. For example, if a member needs transportation support or access to healthy food, we educate them on what their plan already offers and connect them to the right resources in their wider community.  We typically do not charge for these additional services.

We bring a primary care provider mindset to every visit. Most vendors focus on closing out the care gap that was requested.  DocGo strives to do so much more when we have an opportunity to serve a historically underserved and under-engaged member.  Dr. Jim Powell, CEO of the DocGo Clinical Practice Group, has built a licensed clinical model that can provide services on the spot, including bridge prescriptions or providing referrals if a member can’t re-engage with their attributed primary care physician (PCP) in a timely fashion.  We have had rare instances where our clinicians will spend hours with a patient who finds us the only real opportunity to address their healthcare needs. 

DocGo reaches populations others can’t and delivers care others don’t. We succeed when our health plan partners succeed. Our work supports quality performance, strengthens plan-member relationships, and reduces downstream costs. Behind every care gap closure is a real person: someone who got a screening they’d been putting off, or finally connected to a benefit they didn’t know existed. That’s what makes this work meaningful, and it’s why health plans keep coming back.