From Risk Scores to Real Outcomes: Why Having More Data Isn’t Solving the Medication Adherence Problem

Health care plans have never had more insight into member risk—and yet member engagement, adherence, and long-term health outcomes remain stubbornly difficult to improve. That contradiction should concern every Medicare Advantage, Medicaid, and Dual-Eligible Special Needs Plans (D-SNP) executive.

For years, health care plans have invested heavily in identifying at-risk members. Today, most plans can pinpoint which members are likely to disengage from care, become nonadherent to medications, or experience worsening health. But identifying risk is no longer the hard part. Instead, the hidden operational challenge across managed care has become consistently influencing human behavior at scale.

At the same time, the health care plan environment is increasingly more difficult to manage. The US Centers for Medicare & Medicaid Services continues to shift toward outcomes-based performance models that reward sustained member action, not simple administrative completion. Meanwhile, organizations are navigating workforce shortages, rising specialty drug costs, increasing behavioral health needs, and growing complexity of dual-eligible populations.

Medication adherence is one of the clearest indicators of whether plans can successfully translate insight into action, but it is too often approached in a transactional way: identify a refill gap, send a reminder, and encourage a refill. However, adherence is not fundamentally a reminder problem. It’s a behavior problem.

People do not become adherent simply because they receive a single text message reminder or outreach call. Adherence is shaped by many factors, including trust, medication affordability, health literacy, mental health, competing priorities, and the demands of daily life. A reminder does not fix someone’s fear of medication side effects. A pharmacy refill notice does not overcome food insecurity. And disconnected outreach campaigns rarely create the consistency and reinforcement necessary for long-term behavior change.

This is where many engagement strategies break down. Health care plans may successfully identify who needs help, but they often lack scalable systems capable of building ongoing member trust, sustaining member engagement and addressing members’ ever-changing barriers over time.

The organizations making meaningful progress are increasingly treating adherence as a longitudinal engagement challenge rather than a short-term, one-and-done occurrence. That requires a different operational mindset. Instead of fragmented outreach efforts, leading plans are building more coordinated engagement models around the member experience that: 

• Connect the health care plan with members’ providers, pharmacies, and care management teams;
• Use behavioral science principles to simplify communication, reduce friction, overcome members’ barriers to adherence and care, and initiate and reinforce behavior change over time;
• And recognize that culturally competent and health equity efforts directly influence member experience, health outcomes, and the plan’s overall quality performance.

For care teams already stretched thin, technology and artificial intelligence can certainly help improve efficiency and support outreach prioritization. However, organizations are learning that technology alone will not solve medication adherence challenges. That’s because adherence goes beyond a technology issue. It’s a human engagement issue. 

The plans that will outperform in Medicare Advantage, Medicaid, and D-SNP are not simply those with the most sophisticated data. They will be the organizations capable of using that data to operationalize continuous member engagement and behavior change over time.

Ultimately, improving medication adherence is not about closing a refill gap. It’s about helping people successfully manage their health within the context of their real lives. In the next era of managed care, identifying risk will be expected. But influencing behavior will differentiate performance.

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Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of First Report Managed Care or HMP Global, their employees, and affiliates.