Understanding a new member's treated disease burden—before the first claim arrives

The first 90 days after a member joins a health plan quietly set the trajectory for everything that follows, including their cost, utilization and health outcomes. It's also the window where value-based care and complex-care management programs have the most leverage to intervene. Unfortunately, for most plans this timeframe is a blind spot.

It all comes down to timing. To gain a clearer and more complete picture of a new member's health, plans have traditionally relied on clinical and claims data. But that information isn't available for someone who just joined a health plan and claims typically don't arrive until 30 to 90 days after the date of service. The result? By the time emerging risk becomes visible in the claims stream, the window to meaningfully intervene has already started to close.

The problem is that claims reflect what already happened, not what's happening now or what was happening before the member joined the plan. For care management teams that are trying to identify rising-risk members early, that information lag presents a major challenge.

Medication data closes the gap

Dispensed medication and pharmacy benefit data reflect care that's actively happening—giving health plans visibility into the conditions a new member is already being treated for well before the first claim is available.

To see how much medication data can reveal, Surescripts analyzed a random sample of 20,000 U.S. adults ages 35–65 whose clinicians requested medication history through Surescripts between December 1 and 10, 2025. Every person in the sample had filled at least one prescription in the prior 12 months—reflecting a treatment-active and care-seeking population.

Medication data provided a clear picture of substantial and layered treated disease burden among the sample population, including:

• 67.7% were being treated for at least one of four common chronic conditions: hypertension, hyperlipidemia, diabetes or asthma/COPD.
• 79.6% were being treated for at least one of the additional conditions examined, such as depression/anxiety, osteoarthritis/pain, dermatologic conditions or GERD.
• 56% had a chronic condition and an additional condition under active treatment at the same time—multi-condition complexity that would otherwise likely take months of claims to surface.
• 38.3% were on medications for two or more chronic conditions, and 48.9% for two or more additional conditions.

One chronic condition is rarely the whole story;

The conditions that surfaced most often spanned cardiovascular, metabolic, respiratory and behavioral health needs—led by hypertension (47.4%), depression/anxiety (45.6%), osteoarthritis/pain (39.9%) and hyperlipidemia (32.7%), followed by dermatologic conditions (29.0%), GERD (28.1%), asthma/COPD (27.4%) and diabetes (20.6%). Behavioral health conditions like depression and anxiety are notable here as they often fly under the radar of early risk models, even though they add real cost and care-coordination burden.

From signal to action: turning medication data into earlier care

For value-based care and population health teams, the first 90 days are where an earlier read can change the trajectory on cost, utilization and outcomes. And because a member can join a plan at any time, medication data provides a signal that works year-round, not just during January’s rush of new enrollees.

Early visibility matters because plans already have medication adherence and care management outreach programs in place. The hard part is knowing which new members need that support, and knowing it as soon as possible, not a quarter into the plan year.

Surescripts Medication History for Populations draws medication dispensing and pharmacy benefit manager (PBM) data from a broad network of pharmacies and PBMs. That gives health plans, and the technology vendors that serve them, a view of a new member's treated disease burden within one or two days of the request. With it, care management teams can build risk stratification tiers, prioritize chronic care management outreach and engage members before the traditional claims-based window even opens.

A caveat worth noting is that medications can be prescribed for more than one condition. While this data is a strong, directional signal of potential disease burden, it’s not a clinical diagnosis. Read as an early indicator of complexity, it gives care management and care coordination teams a timelier and more reliable signal to act on.

Make the most of your 90-day window

The first 90 days will set a new member's trajectory either way. What health plans get to decide is whether they spend that window waiting for claims to catch up or acting on the information medication data already shows.