An Untapped Cost Lever in Diabetes Care May be the Most Human—Member Engagement

By Vimbai Mudimu, Indrani Halder and Mike Cantor

Key takeaways:

• Member engagement drives measurable cost control by improving adherence, reducing diabetes-related admissions and enhancing member experience across diverse populations.

• Artificial intelligence (AI) enables precision care coordination by predicting risk, tailoring outreach and connecting members, caregivers and clinicians in one continuous engagement journey.

• Health plans that prioritize engagement align cost management, quality improvement and health equity in one strategy that strengthens both margins and member outcomes.

Health plans were created to help people live healthier, more fulfilling lives. Yet many now find themselves focused on checking boxes and managing transactions instead of improving members’ health. As healthcare costs continue to climb at an unsustainable rate, fewer patients report feeling cared for. Traditional levers—contract negotiations, utilization management and payment integrity—are no longer enough to manage costs. The next frontier of cost control must be behavioral. Operational levers have reached their limits, and member engagement remains the most underused source of impact.

ZS’s Member Engagement First (ME First) model centers on the concept of one member, one plan. Engagement becomes the organizing principle that turns transactions into transformation. It shifts the focus from program compliance to personalized partnership, and no condition reveals this truth more clearly than diabetes.

Diabetes management magnifies the member experience weaknesses in our system

Diabetes exposes where the health system and payers fall short across quality, cost management and coding. These gaps are the core of the quintuple aim: improving population health, enhancing patient experience, reducing costs, supporting providers and advancing health equity.

• Cost management: GLP-1s and insulin dominate pharmacy benefit budgets. Between 2018 and 2023, total spending on GLP-1 in the U.S. increased by 500%. ZS’s internal analysis shows that by 2023, Medicare members averaged $3,800 in diabetes-related drug spend, while chronic condition costs rose 58% since 2018 even as nonchronic spend declined 44%. The result is rising medical expenses and tightening margins despite heavy investments. 

• Quality: Members struggle with adherence and missed screenings, dragging down Healthcare Effectiveness Data and Information Set (HEDIS) measures and Medicare Star Ratings. Each percentage point drop in A1C control translates into lost bonus revenue and lower plan performance scores. 

• Appropriate coding: Missed or inaccurate coding hides the true disease burden, leading to underestimated risk adjustment factors and millions in unrealized reimbursement. Payers face a silent financial drain. 

• Provider satisfaction and burnout: The increasing prevalence of diabetes is placing additional demands on overworked primary care teams and specialists and revealing the lack of effective systems to manage diabetes. Increased prior authorization requirements for diabetes medications increases stress on clinicians.

• Equity: Medicaid populations are hit hardest by food insecurity, transportation and housing gaps. Diabetes also impedes an even more important goal: longevity and what scientists call healthspan, the number of years lived free from chronic disease. Diabetes erodes healthspan more than almost any other condition, reducing life expectancy by roughly six years and doubling or tripling cardiovascular risk.

These breakdowns erode the quintuple aim and threaten payer sustainability. Poor outcomes raise costs, bad member experiences drive churn and clinical burnout worsens access when access to care and quality gaps based on member characteristics are not equitable. Moreover, diabetes reduces healthspan, leading to years of disability. Diabetes is the mirror that shows how far we have drifted from the vision of better health at lower cost. 

Why decades of disease management haven’t closed the engagement gap

Decades of disease and care management programs haven’t solved the engagement problem. Members face a patchwork of disconnected touch points—a digital nudge here, a vendor call there or a case manager inquiry from another department—all removed from the reality of daily life.

The result is predictable. Nearly half of all diabetes prescriptions show adherence gaps. Missed screenings and abandoned prescriptions translate into hospitalizations and complications. These are not isolated lapses but symptoms of a system that talks at members instead of with them. They are failures of engagement.

Disengagement is not a soft problem. It is a hard financial risk factor.

Engagement becomes the scalable lever for cost and care coordination

Based on the evidence of continuously increasing costs despite the myriad interventions implemented, one clear conclusion emerges: the only lever left to effect meaningful change is human behavior, guided by insight.

The ME First framework turns engagement from a set of tasks into a system of understanding. It uses precision microsegmentation to tailor outreach by diagnosis and by motivation, culture and readiness to act. Engagement becomes personal, contextual and continuous.

• Segment members by behavior and culture. Recognize that language and linguistic competency, neighborhood, daily life activities and preferences, and health beliefs shape health behaviors.
  
  

• Orchestrate omnichannel journeys. Connect texts, apps, outreach calls and community touch points into a single coherent experience.
  
  

• Focus on motivation over metrics. Speak to the goals that matter—symptom mitigation, independence and personal and professional commitments, not compliance checklists.
  
  

• Activate caregivers. Families influence diet, medication adherence and care-seeking patterns. Engagement pathways must include these decision influencers.
  
  

• Build equity by design. Embed social drivers of health data into every engagement model. Reminders don’t matter if members lack food or transportation.

Engagement done right changes behavior and changed behavior changes cost. When these actions work together, they create a virtuous loop between insights and outcomes, turning what used to be understood as outreach into sustained improvement.

How precision engagement and AI reduce diabetes costs in real-world care

Consider a health plan that applied precision engagement to 1,000 high-risk diabetes members with A1C above 9%.

• Predictive models flagged the top 200 members at risk for nonadherence

• A unified outreach plan combined text messages, case-manager calls and caregiver coaching

• Community partnerships addressed food insecurity barriers

• Transportation vouchers closed the loop on missed primary care, specialty visits and lab draws

After 1 year:

• A1C above 9% prevalence decreased

• Diabetes-related admissions fell significantly

• Star Ratings and HEDIS measures improved, unlocking bonus revenues

• Program savings offset costs with the potential for higher ROI in future years

The lesson is simple: when members engage, costs bend. For payers, the returns are quantifiable:

• Financial: Reduced medication abandonment, fewer complications and lower inpatient spend

• Quality: Better Star Ratings and HEDIS compliance translates to real revenue

• Clinical: Reduced emergency room utilization and better care coordination

• Equity: Narrowed outcome gaps across race, income and geography

Member engagement is not a wellness tactic. It’s a new business model that aligns cost control, quality and longevity.

Meaningful engagement improves both cost control and quality of life

Somewhere along the way, health plans’ mission to help people improve their lives and how they live them became mired in process. If a plan cannot meaningfully engage members living with diabetes, a condition with clear evidence, measurable ROI and mature interventions, how will it ever address the next wave of chronic disease? The choice is stark. Health plans can keep managing transactions or begin managing trust. With the right partner, they can turn engagement into measurable improvement in cost, quality and healthspan.