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Medmo attended the Spring Conference hosted by America's Physician Groups (APG) in San Diego this year, where the association put its member organizations front and center to share what's actually working in value-based care. Of the featured programs from APG's 2025 Case Studies in Excellence, one theme kept coming up across both diabetes care management and health equity: identifying a patient at risk isn't the same as getting them the care they need. The gap between the two is where outcomes are won or lost.
Reaching Patients Before They're Referred
CareAllies built a proactive diabetes care management model using certified diabetes educators across three Texas IPAs, targeting Medicare Advantage patients with a recent diagnosis, an HbA1c above 8.5%, or a diabetes-related hospitalization. The results:
The lesson: physician referrals alone leave most high-risk patients unreached, no matter how strong the underlying diabetes care management program is.
More Than One Way to Close the Gap
Short on endocrinologists, Vancouver Clinic expanded a pharmacist-led program to cover diabetes care management directly. Pharmacists optimized medications, tackled cost barriers with copay cards and assistance programs, and used collaborative drug therapy agreements. Among 119 patients with a repeat A1c, the average reduction was also 2.1%, the same result through a completely different model.
Health Equity Takes a Person, Not a Protocol
Hill Physicians deployed a bilingual outreach worker as part of a broader health equity initiative, reaching Hispanic/Latino Medicare Advantage patients behind on colorectal cancer screening.
The mechanism wasn't new technology. It was a culturally concordant person with time for an unhurried conversation, the kind of human infrastructure health equity work actually depends on.
The Takeaway
The lesson is consistent across both diabetes care management and health equity programs: identify patients proactively, then remove every barrier between identification and action.
Diagnostic imaging is often where that breaks down. Diabetes patients need retinal and cardiovascular studies to close care gaps. Screening programs need accessible, low-cost imaging sites. Every extra step between the referral and the scan is a chance for a patient to fall through the cracks.
Medmo manages the imaging referral end to end, so the patients you work hard to identify don't get lost on the way to their scan.
Medmo partners with ACOs, IPAs, PCPs, and FQHCs to manage diagnostic imaging referrals end to end:
To learn more, visit https://medmo.com/.
