By Jay Chowdappa, MD, co-founder and CEO, Zynix AI · Updated October 1, 2026
Key takeaways
ACOs close year-end care gaps faster by prioritizing the gaps that can still close before December 31, reaching patients by phone and text rather than mailers, booking the visit or screening during the same conversation, and recovering no-shows quickly. Agents carry the outreach volume, while clinicians handle assessments, documentation and any clinical question.
- Open gaps in screenings, chronic disease control and medication adherence can decide whether an ACO earns shared savings or owes money back.
- Prioritize by deadline, closure feasibility and patient engagement history rather than working the easiest gaps first.
- Mass mailers tend to draw a minimal response, so two-way outreach that books the appointment is a better use of the final weeks.
- For MSSP ACOs, the 2026 APP Plus measure set ties cancer screening, depression screening, blood pressure and diabetes control to the quality score.
- Agents handle outreach, booking and reminders, and clinicians assess patients and document conditions at the visit.
The Year-End Pressure
As the calendar year draws to a close, ACOs face mounting pressure to close quality gaps that directly impact their MSSP and ACO REACH performance scores. Open care gaps in preventive screenings, chronic disease management, and medication adherence can mean the difference between earning shared savings and owing money back to CMS.
The Scale of the Challenge
An ACO managing 20,000 attributed lives may have thousands of open care gaps across HEDIS and STARS measures. Manually identifying, prioritizing, and outreaching to each patient is simply impossible with limited care management resources. Many organizations resort to mass mailer campaigns that generate minimal response rates.
AI-Driven Gap Identification and Prioritization
Zynix AI's preventive and quality activation agent continuously monitors the entire attributed population, identifying open gaps as new data arrives and prioritizing outreach based on gap severity, patient engagement history, and closure feasibility. This ensures that limited resources are focused on the gaps most likely to close and most impactful to quality scores.
Automated Multi-Channel Outreach
Once gaps are identified and prioritized, the system automatically initiates outreach through the patient's preferred communication channel — SMS or phone call. The outreach is personalized, actionable, and designed to minimize friction in scheduling the necessary appointments or completing required screenings.
Measuring Year-End Success
ACOs using AI-powered gap closure aim to outperform their peers on quality measures. The combination of comprehensive gap identification, intelligent prioritization, and automated outreach creates a systematic approach to quality improvement that can still move results before the measurement year ends.
What to prioritize in the last quarter
In the final months of the year, work the gaps that can still close before December 31 and that count toward your contracts. That means sorting by deadline and feasibility, not by volume.
- Gaps that one visit or one test can close, such as a cancer screening, a depression screening or an annual wellness visit.
- Control measures that need a recent reading, such as blood pressure or diabetes glycemic status, where a visit before year-end records the current value.
- Patients who have not been seen this year, since they often carry several open gaps at once and are the hardest to reach late.
- Chronic conditions that need to be assessed and documented by the treating clinician at a face-to-face visit during the year.
For Medicare Shared Savings Program ACOs, the 2026 APP Plus quality measure set includes breast cancer screening, colorectal cancer screening, depression screening and follow-up, controlling high blood pressure and diabetes glycemic status, alongside the CAHPS survey and two claims-based measures. Preventive and chronic care gaps therefore feed directly into the quality score that determines the sharing rate.
Where agents help and where clinicians decide
Agents add the most at year-end by working the long tail of outreach that staff cannot reach in time. Clinical decisions stay with the care team.
Agents can call and text patients with open gaps, explain why the screening or visit matters, book the appointment, send reminders and reschedule no-shows. They route clinical questions and barriers such as transportation to staff by rule, and they never order tests or recommend treatment. HCC gap closure for ACOs follows the same split: agents invite patients who have no visit booked, clinicians see the open conditions before scheduled visits, and the treating clinician assesses and documents each condition.
Frequently asked questions
How can an ACO close care gaps before the end of the year?
Start with one current list of open gaps by patient and practice, then rank it by what can still close before December 31. Reach patients by phone and text, book the visit or screening during the conversation, send reminders and recover no-shows within days. Give each gap an owner, and check weekly that closures show up in the data your quality reporting uses.
Which quality measures matter most for MSSP ACOs in 2026?
For performance year 2026, MSSP ACOs report the APP Plus measure set: the CAHPS for MIPS survey, hospital-wide readmissions, admissions for patients with multiple chronic conditions, diabetes glycemic status, depression screening and follow-up, controlling high blood pressure, and breast and colorectal cancer screening. Meeting CMS's quality performance standard earns the maximum sharing rate for the ACO's track.
What is the difference between care gap closure and HCC gap closure?
Care gap closure means getting patients the screenings, tests, visits and medication follow-up that quality measures count, such as cancer screening or blood pressure control. HCC gap closure means making sure chronic conditions are assessed and documented at a face-to-face visit each year so risk scores reflect how sick patients are. Both depend on getting the patient in for a visit, so many ACOs run them from one outreach list.
Can AI agents close care gaps on their own?
No. Agents handle the outreach volume: calling and texting patients, explaining the visit, booking appointments, sending reminders and following up on no-shows. A gap closes only when the screening, test or visit happens and the care team documents it. Clinical questions, results and treatment decisions stay with clinicians. ACO programs for TCM, wellness visits and HCC and quality gaps follow that split.
Related reading
- Why ACOs Still Miss HEDIS Measures -- And How AI Agents Close the Gap Before Year-End
- How To Improve AWV Completion Rates With AI-Powered Outreach
- Transforming HCC Risk Adjustment: From Q4 Scramble to Year-Round Success
Source notes
CMS: Calendar Year (CY) 2026 Medicare Physician Fee Schedule Final Rule (CMS-1832-F), Medicare Shared Savings Program Changes (fact sheet). https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2026-medicare-physician-fee-schedule-final-rule-cms-1832-f-medicare-shared-savings
CMS: Medicare Shared Savings Program, Shared Savings and Losses, Assignment and Quality Performance Standard Methodology Specifications, Version 14 (April 2026). https://www.cms.gov/files/document/medicare-shared-savings-program-shared-savings-losses-assignment-methodology-specifications-version.pdf-0
About the author
Jay Chowdappa, MD is co-founder and CEO of Zynix AI. He is a physician, and ACOs led by him generated $300M+ in shared savings before he started Zynix AI to help care teams follow through on what their data already shows.