Encore! EP361: The Gap in Closing Care Gaps, With Carly Eckert, MD, PhD(c), MPH
Relentless Health Value™September 28, 202330:3327.96 MB

Encore! EP361: The Gap in Closing Care Gaps, With Carly Eckert, MD, PhD(c), MPH

For a full transcript of this episode, click here.

I decided to encore this episode with Carly Eckert, MD, PhD(c), MPH, because I keep finding myself quoting Dr. Eckert in conversations, even a year later.

First off, if you’re not familiar, a care gap is what happens when there is a bad transition of care. Patient has no idea what their discharge instructions actually mean, so they wind up back in the hospital. Patient didn’t pick up their prescription, so they wind up in the hospital or back in the hospital.

Patient still has uncontrolled hypertension long after being diagnosed with uncontrolled hypertension or uncontrolled diabetes. It’s crazy how many patients keep going to their doctor and being told they have high blood pressure or high blood sugar and their care plans are not adjusted. Or they don’t take their meds due to cost or a lack of trust or whatever other reason.

Or care gaps exist because the patients don’t go to their doctor in the first place. So, they settle right into a care gap that no doctor can fix because down there in the bottom of that care gap, there’s no medical professionals.

So, a year later and the year after that, their blood sugar or their blood pressure is still high. These are patients in care gaps.

I mean, consider that heart failure … I heard it called the “a little too late disease” by William Bestermann, MD, the other day. You don’t just spontaneously develop heart failure, after all. If you have uncontrolled hypertension and/or uncontrolled diabetes for too long, you will get heart failure and you’ll also probably get chronic kidney disease.

Chronic kidney disease, by the way, is often the cause of most heart failure readmissions, so think about the entire impact of heart failure and most kidney disease when you think about the cost of care gaps.

This is what we talk about today. And with that, here’s your encore.

In this healthcare podcast, I’m speaking with Carly Eckert, MD. It’s kinda funny, actually. I originally wanted to get Dr. Eckert on the show to talk about care gaps and how to close them, but this show did not wind up going how I thought it was going to go because Carly Eckert is a physician by training who got really interested in the upstream causes of what she was seeing in clinical practice. Despite my best efforts, she refused to be lured into my closing care gaps conversation. So, instead, this conversation is about the construct of care gaps and thinking about them in context. Closing care gaps is a model of care and maybe not a particularly great one, relatively speaking. In fact, here’s another name for the model of care called closing care gaps: care gap whack-a-mole. Care gap pops up … we whack it. Care gap pops up … we try to close it. Another care gap pops up … we try to close it. Another care gap … you get the idea.

Carly Eckert has worked in epidemiology and public health and also clinical informatics for health systems and payers.

I recorded this show with Dr. Eckert prior to EP359 with Dan O’Neill. In that interview, which you should go back and listen to when you have a sec, Dan O’Neill cleared up a couple of things that I struggled with during this interview.

Here’s the big one that I could not figure out: Why with the whack-a-mole? Why do we still insist as a nation on waiting for someone to show up in clinic to retroactively and reactively address a missed preventative care opportunity?

Why don’t so many more provider organizations create pop health programs that consider the whole person proactively? Why don’t they take the time to operationalize whole-person care in a meaningful way?

Ah, yes … to the surprise of exactly no one, it’s all about the Benjamins.

As Dan O’Neill put it, if all a provider organization is doing is slapping a sheet on a doc’s desk every morning with a list of care gaps for all the patients that he/she will see that day, it’s highly likely that incentives, or penalties to do anything else, are very weak. It’s a sign that, from a paying for value perspective, we’re not paying enough for value that it’s worth it or maybe even feasible for any provider organization to take the time and capital expense to switch up their business model in any meaningful way. So, the provider gets a little bump or a little knock if they don’t meet some quality standard. Okay, great … so then they’ll minimally tweak their workflow and have doctors within their 7- to 15-minute visit suss out and try to close care gaps.

I don’t want to say this is entirely negative. It’s known that when provider organizations do close care gaps, patient outcomes do tend to get better—so, not arguing that. But there’s opportunities that get left on the table with all this reactiveness. Bottom line: You insurers, you purchasers of healthcare, pay for value, for real.

But you provider organizations, if you don’t fix this stuff yourself, you’re gonna get doctors and other clinicians (as we’re seeing) burning out and quitting because there’s only so much you can jam into a 7- or 15-minute visit, number one. But number two, doing population health reactively like this is suboptimal—and everybody knows it. So, what winds up happening is dedicated doctors and nurses desperately want to do the right thing but simply do not have the time. And they watch patient after patient suffer for it. That sucks. So, fix it. At the end of the day, it’s probably cheaper than having to recruit all new doctors and hire traveling nurses when all of the current staff quits due to burnout and/or moral injury.


You can learn more by connecting with Dr. Eckert on LinkedIn and following her on X (Twitter).



Carly Eckert, MD, PhD(c), MPH, is a physician and technologist with dual board certifications in preventive medicine and clinical informatics. With nearly a decade of experience, Dr. Eckert has led multidisciplinary teams encompassing clinical, product development, and data science domains within healthcare start-ups. Her areas of expertise include AI governance, ethical considerations, and bias mitigation, along with a deep understanding of healthcare data and its appropriate use. Dr. Eckert also educates fellow physicians and healthcare professionals on the practical and applied facets of AI solutions, as well as how to foster effective communication with technical teams.

In her current professional role, Dr. Eckert is embarking on collaborations with various partners to assess and accelerate the transformative influence of data and technology on care delivery. The overarching goal of this work is to enhance the healthcare experience for broad and varied populations, with exciting new developments on the horizon.


05:31 What is the true goal in making population health successful?

05:58 How does the clinical pathway need to manifest in population health?

06:29 How do we get a nonfragmented state of care?

06:54 What is the best model of care?

08:37 “Identifying and addressing care gaps is an important element of population health.”

11:30 Closing care gaps vs creating a nonfragmented system of care.

15:38 “I think you have to take small steps with people.”

16:45 “There’s a lot of power in peer support.”

17:18 Why should provider organizations connect with peer groups?

19:05 “The key is that it’s not going to be the same for everybody.”

23:09 Why is diversity of the workforce key to closing care gaps?

23:33 EP322 with Monica Lypson, MD, MHPE.

23:37 EP347 with Ian Tong, MD.

28:36 Where can providers improve transparency to help close care gaps?


You can learn more by connecting with Dr. Eckert on LinkedIn and following her on X (Twitter).


@carlymeckert discusses #caregaps in #healthcare on our #healthcarepodcast. #podcast #digitalhealth #valuebasedcare #vbc


Recent past interviews:

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Dr Robert Pearl, Larry Bauer (Summer Shorts 8), Secretary Dr David Shulkin and Erin Mistry, Keith Passwater and JR Clark (Summer Shorts 7), Lauren Vela (Summer Shorts 6), Dr Jacob Asher (Summer Shorts 5), Eric Gallagher (Summer Shorts 4), Dan Serrano, Larry Bauer, Dr Vivek Garg (Summer Shorts 3)


care gaps,costs,health care,patient outcomes,physicians,value-based care,