Undermining Health and Driving Costs in the U.S. and Beyond
Gaps in care refer to the discrepancy between evidence-based medical recommendations and the care patients actually receive. In the U.S., these gaps are not rare — they are systemic. They delay diagnoses, worsen chronic conditions, increase avoidable hospital visits, and deepen health inequities.
"A gap in care is more than a missed appointment; it's a missed opportunity to prevent suffering, improve health, and manage resources wisely."
Preventive Care Gaps
Missed screenings (e.g., mammograms), vaccines, and routine wellness visits
Chronic Care Gaps
Poor adherence, missing regular monitoring (e.g., HbA1c), lack of education
Acute/Post-Acute Gaps
Delayed diagnoses, no follow-up after hospitalization
Mental Health Gaps
Missed screenings, access barriers, stigma
Equity Gaps
Inconsistent quality of care across race, income, geography, and more
What Are Gaps in Care?
Gaps occur across the continuum of care and impact prevention, chronic disease management, acute care, mental health, and equity.
Key types of gaps in care are :
Why do these gaps happen - Root Causes?
Fragmentation
No single provider oversees the full care picture
Access Barriers
Uninsured, underinsured, long travel distances, or limited appointment availability
Affordability
High out-of-pocket costs deter patients from pursuing needed care
Low Health Literacy
Patients may not know what care they need or how to navigate the system
Limited Provider Time
Burnout, short visits, and admin demands reduce proactive engagement
Social Determinants of Health (SDOH)
Housing, transport, food, and job instability impact care access
The Impact of Gaps in Care
U.S. vs. Global: How Do We Compare?
The U.S. performs poorly on many key healthcare indicators compared to other high-income countries, especially regarding cost-related access issues.
Within the U.S.: Disparities Persist
Even where national averages seem solid, equity gaps are stark.
Example: Colorectal Cancer Screening Rates
Real-Life Scenarios
Preventive Gap:
"A 55-year-old with a high-deductible plan skips their colonoscopy due to cost."
Chronic Gap:
"A diabetic patient misses regular check-ups and monitoring due to lack of transport."
Coordination Gap:
"Multiple specialists prescribe conflicting medications without coordination."
Mental Health Gap:
"A teen with anxiety waits months for an in-network therapist."
Equity Gap:
"A Black woman’s chest pain is dismissed, leading to delayed heart disease diagnosis."
Closing the Gaps with Care Coordination
Effective, AI-powered care coordination offers a direct path to bridging care gaps:
01
Proactive Identification
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Analyze data (EHRs, claims) to flag patients overdue for screenings, follow-ups, or labs. Use AI for risk stratification.
02
Targeted Outreach
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Coordinators can call, message, or app-notify patients about gaps — and help remove barriers (e.g., appointment help, transport, reminders).
03
Enhanced Communication
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Facilitate info flow across PCPs, specialists, and hospitals. Reduce duplication and conflicting care plans.
04
Chronic Condition Support
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Support adherence through regular check-ins, remote monitoring, and education.
05
Addressing SDOH
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Screen for food, housing, or transport insecurity — and connect to local services.
06
Equity-Focused Coordination
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Devote targeted efforts to underserved groups. Culturally competent outreach can narrow care disparities.