Understanding the precision problem in member outreach
For payer care management teams, care gap closure isn't just a volume problem; it's a precision one. Payers likely already have the data and analytics to flag large numbers of members experiencing potentially harmful gaps in care, so identifying volume isn't the problem. Addressing those uncovered needs instead becomes a precision problem: Reaching the right member, in the right way, at the right moment, rather than just reaching more members overall.
This precision starts with understanding what members still need after they've already seen a provider. It's common for members to have unresolved needs after a healthcare visit. In a Wolters Kluwer survey of patients who'd recently had a healthcare encounter, nearly half said they didn't get all their questions answered, and 80% said they often or sometimes had follow-up questions. This is why outreach precision matters: Members want communication and education that's relevant to their specific care needs, not a generic message that leaves those questions and needs unaddressed.
Beyond unanswered questions, hesitancy or anxiety can also keep members from following through on care plans. Members may delay or avoid preventive visits, screenings, and follow-up appointments out of hesitation, even when they know the care matters. That avoidance can worsen outcomes and increase costs over time. Outreach that anticipates these common points of hesitancy, rather than treating every member the same way, is far more likely to move someone to act.
Members are also navigating more health misinformation and conflicting guidance than before. For instance, 70% of people believe at least one of six common but false health claims, on topics ranging from vaccines to everyday medications. Consumer confidence in making health decisions has dropped sharply, from 61% to 51% in just a year, according to the 2026 Edelman Trust Barometer. As a result, members may feel more cautious about acting on outreach that isn't personalized or relevant to them. When they're already sorting through competing claims like that, a generic outreach message has to work harder to be believed.
Medication complexity adds another hurdle
Adherence barriers, polypharmacy, and affordability concerns can impact whether a member acts on the guidance they receive from their providers or care management outreach. It's not just about whether the message reaches them. For many members managing complex health conditions, the obstacle is the medication itself.
Nonadherence is common and costly. About one in five new prescriptions are never filled, and nearly half of those that are filled are taken incorrectly. This causes an estimated $100 billion to $300 billion in avoidable U.S. health care costs every year, according to the US Centers for Disease Control and Prevention (CDC).
Polypharmacy adds to the difficulty. More than a third of US adults ages 60 to 79 take five or more prescription drugs at once, which makes it harder to track what's working, what's not working, and what's causing side effects. Cost intensifies both problems. Four in 10 adults say they didn't take a medication as prescribed in the past year because of cost, and about one in five have cut pills in half or skipped doses altogether.
Quality standards drive member action
Focusing on outcome-based measures like HEDIS and Star Ratings can help plans engage flagged members around what closes a gap, such as a completed screening or filled prescription. This specificity can turn a long list of care gaps into a set of targeted, meaningful outreach priorities, instead of one broad campaign aimed at everyone.
These completed actions can contribute to real outcomes: One study by the National Committee for Quality Assurance (NCQA) found an 11% drop in emergency department visits and 12% fewer hospitalizations among patients receiving coordinated, gap-closing care, along with lower total costs per member per month. It is this type of measurable impact that matters just as much as the outreach effort behind it.
Care management goes beyond identifying care gaps
Predictive analytics and AI-enabled tools allow health plans to identify more high-risk, rising-risk, and chronic condition members, often before hospitalization occurs. Richer data sources are making this possible, such as admissions and discharge feeds and utilization management data. Better data helps health plans flag members earlier and more precisely than they could by relying on claims data alone, according to McKinsey’s research on payer care management. However, care management team capacity hasn't grown to match the volume of members who have fallen into a care gap.
Closing care gaps means pairing targeted engagement with five key elements:
- Trusted education that members can rely on for care plan adherence.
- Clinical relevance that’s specific to their condition and gap.
- Outreach timing that lines up with when they're ready to act.
- Medication-related support when there are adherence issues.
- Follow-through that confirms the action actually happened.
Without all five elements in place, even well-targeted outreach and suggested guidance can fall short. That's the balance every care management program is working toward: Scaling volume to reach the members who need it without sacrificing the precision required in how each one is engaged to close care gaps.
Discover evidence-based solutions for payer care management teams. To learn more about how care management teams are addressing gaps at scale, read the whitepaper, Balancing volume and precision in payer decision-making.