Some of the members dragging down your care gap closure rate left months ago

Some of the members dragging down your care gap closure rate left months ago.

Here is how it happens. A member switches plans, or moves out of the area, in June. The change takes a while to reach every file. Until it does, she is still on the roster, still counted, and still on the open list for a mammogram she will never get from your network.

Nobody did anything wrong. The quality team built the list from the roster it was given. The roster was simply describing someone who was no longer there. But the result is a gap list that looks worse than the care being delivered, and a team spending real hours on people it no longer serves.

How do departed members end up on the gap list?

Patients change plans and doctors throughout the year. They move, they change jobs, they pick a different plan during enrollment season. Each of those changes is true the day it happens. It becomes visible to a care team only when it arrives in a file, and payors send those files on their own schedules, in their own formats, often weeks after the period they describe.

In the meantime, the gap list keeps doing its job. It looks at everyone on the roster, checks each person against the measures, and flags whoever hasn't had the screening or the exam yet. A member who left in early summer hasn't had the screening with you, so she shows up as open. And she will keep showing up as open until the roster catches up, because the care she gets now is happening somewhere your data will never see.

So the gap list ends up measuring two things at once: the care your network delivered, and how far behind your roster is. On the screen, those look exactly the same.

What does it cost the outreach team?

Picture Tasha, an outreach coordinator at a health plan. She is a composite, but her morning will be familiar. Her list for the day is long, sorted by measure, and every row looks equally urgent.

The first number doesn't work. The second reaches a voicemail that belongs to someone else. The third reaches a member who says, kindly, that she isn't with the plan anymore. Tasha notes each call, marks the row, and moves on. None of those calls was long. Each still took time to prepare, place, and document.

Now spread that across a long list and a full outreach team, week after week. The quality team ends up spending weeks of effort on members it doesn't serve, and that time comes out of the calls to members who are still yours and still need the screening. The member who would have said yes to a mammogram appointment waits a little longer, because the list put someone who left ahead of her.

Every call to someone who left is a call not made to someone who is still yours.

There is a quieter cost, too. Once coordinators learn that a share of the list is people who are gone, they start checking before they dial, or skipping rows they suspect are dead ends. The list stops being a plan and becomes a suggestion. We have written about that loss of trust in why so few teams fully trust their care gap list, where the noise comes from gaps that already closed. Departed members are the other half of the same noise.

Why does a distorted care gap closure rate lead to the wrong decisions?

The rate on the internal report is what leaders steer by. When it looks low, the natural response is to push harder on quality: more outreach, more reminders, more conversations with practices about why their numbers are behind.

If part of that low rate is members who left, none of those responses help. More outreach means more calls to disconnected numbers. Pressure on a practice is aimed at patients who are no longer part of the population it is accountable for. A care manager is asked why a gap won't close, and the honest answer is that it was never going to close here.

Meanwhile, the real gaps, the members who are still yours and still need care, are blended into the same rate. Leaders can't see how much of the shortfall is care and how much is roster. That makes it hard to put effort where it will actually change something for a patient.

Quality problems often start as roster problems. Not always, and not entirely. But often enough that it is worth asking which one you are looking at before deciding how to respond.

What does a more honest gap list look like?

The starting point is not a better gap list. It is a better answer to an earlier question: who do we serve right now?

When that answer is current, a few things follow on their own:

• Members who left come off outreach lists soon after the change arrives, instead of staying on them until someone notices.
• The open gaps that remain belong to members who are still yours, so the calls go to people the team can actually help.
• The care gap closure rate comes closer to reflecting the care being delivered, not the lag in the files.
• Quality and care management work from the same population, so they stop arguing about who counts and start talking about patients.

Clean up the list of who you serve, and the gap list gets more honest on its own.

How ElevateCare 360's Roster Module keeps the starting point accurate

ElevateCare 360's Roster Module is built around that earlier question. Payor files, the medical record, and claims are reconciled as new data arrives into one verified record per member, with conflicting doctor assignments resolved by rule and anything that can't be resolved automatically flagged for review.

1. Changes surface dailyNew, departed, and reassigned members are surfaced daily, with a full history of who was attributed to whom and when.
2. Departed members are flaggedMembers who have left are flagged once the change arrives, so outreach lists can drop them instead of carrying them for months.
3. Every module reads the same rosterUpdated panels feed care management, annual visit scheduling, quality, and risk work, so the quality team and the care management team work from the same population.

For Tasha, the change is mostly subtraction. Fewer rows that end with "I'm not with you anymore." More of the day spent on members who can still get a screening this year, while there is still time in the year to get it. The Quality Module then works from that same current roster when it tracks which measures are open.

If you want to test your own list first, start with the questions to ask before you trust this month's roster.