Staying on track: How Health Plans Can Identify Risk Sooner and Act Faster 

In parts one and two of this series, we explored how January’s enrollment surge creates a “blizzard season” for health plans—driving year‑round gaps in medication visibility. In part three, we shift our focus to how health plans can take a more proactive approach to identifying medication adherence risks and acting sooner.

Health plans can now identify emerging risk and close gaps in care faster than is possible using claims data alone.

Value-based care models place responsibility on health plans for outcomes, quality performance and total cost of care—making early risk identification and timely intervention essential. Yet many health plans still rely on claims data and other downstream indicators that can lag by 30 to 90 days.

The result?

Plans miss early risk signals, struggle to intervene while issues are still actionable and lose valuable time to respond to medication-related concerns.

It’s true that claims data can be useful for understanding what was billed and paid. Yet teams focused on proactive risk management need more timely and comprehensive insights.

How Comprehensive Medication Data Helps Health Plans Identify Risks

Health plans can’t proactively manage risk with data that arrives months late. Surescripts Medication History for Populations changes this, with more complete medication history data and actionable insights to support earlier awareness of potential risks.

Medication History for Populations provides a comprehensive and accurate view of medication activity sourced directly from pharmacies and pharmacy benefit managers (PBMs). These insights help close gaps that can occur when medication events show up in one channel but not in others—like when members pay for prescriptions with cash.

Access to comprehensive medication data is increasingly critical as the number of patients aligned with value-based care models is projected to more than double between 2022 to 2027—from about 43 million to roughly 90 million.

To keep pace, health plans need faster and more reliable ways to:

• Identify emerging medication-related risks earlier—including therapy changes and potential gaps in medication use
• Support timely review and follow-ups that allow teams to act on medication activity signals sooner based on existing policies and priorities
• Enable more consistent oversight workflows that support standardized approaches to monitoring medication activity and follow-up

Read part one

It’s Blizzard Season for Health Plans

Read part two

Navigating the Medication Adherence Whiteout

Why Comprehensive Medication Data Beats Claims Data

Traditionally, risk monitoring has been dependent on claims data, PBM-restricted views, disconnected point solutions and admission, discharge or transfer (ADT)-only alerts. This can create blind spots across prescribers, pharmacies and care settings—limiting health plans’ ability to conduct meaningful and effective outreach to their members.

With Medication History for Populations, medication related risk indicators—such as potential nonadherence—can be identified earlier, enabling a more proactive approach, including:

• Risk-based outreach prioritization: Create a more targeted outreach list by prioritizing members based on medication-related risk.
• Stronger visibility and follow-through: Support clearer tracking of medication-related risks and outreach activity—enabling more consistent oversight.
• Improved program performance: Address medication-related issues while they’re still actionable to improve adherence, reduce avoidable utilization and support value-based care programs where quality and total cost are continuously measured.

Aligning to Value-Based Care Models

As value-based care models continue to expand, health plans need a dependable way to identify and mitigate risk early. Many programs also require health plans to maintain effective monitoring, escalation and follow-up processes.

Having complete and accurate medication data supports these value-based care requirements in three main ways, helping plans:

1. Detect potential risk earlier
2. Apply consistent and aligned outreach and intervention workflows
3. Maintain clearer records of identified risks and related actions taken

This can mean the difference between reacting to issues after the fact and proactively managing emerging risk.

Medication History for Populations supports these efforts by enabling more strategic oversight and more responsive workflows under value-based care models.