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Every January, health plans experience what we call "blizzard season"—a surge of new members, reverification of benefits and prior authorizations that can overwhelm even the most prepared care management teams.
But the real storm lasts well beyond the January rush.
A year-round visibility gap prevents health plans from truly understanding how members are using their medications, when they're struggling with adherence and where timely intervention could make all the difference.
The fundamental problem isn't a lack of data on medication intelligence. Rather, it comes down to how timely, complete and actionable it is for health plans. This has profound implications for member outcomes, Star Ratings and the financial viability of value-based care arrangements.
The Hidden Cost of Delayed Medication Intelligence
Consider what happens when a doctor prescribes medication for a newly enrolled member. The default assumption is that the patient will pick it up at the pharmacy and begin their therapy. Yet this assumption breaks down with alarming frequency. More than 1 in 4 new prescriptions written are not filled due to a number of factors. Perhaps the medication is too expensive, or the patient never makes it to the pharmacy due to transportation barriers, or they’re a new member with limited historical data, making it impossible for care managers to anticipate their needs.
The critical issue is timing.
By the time a care manager discovers the member hasn't filled their prescription—often weeks or months later when claims data finally arrives—the opportunity for meaningful intervention has passed.
According to recent analysis in the Journal of Managed Care & Specialty Pharmacy, health plans demonstrating high performance on Star Ratings adherence measures achieved higher ratings: at least 4-star overall summary ratings. Yet many plans still lack the timely, comprehensive intelligence needed to drive those adherence outcomes.
Three Persistent Challenges in Medication Visibility
The medication intelligence problem manifests in three distinct ways:
Timeliness gaps: Plans receive pharmacy claims, but processing timelines vary significantly across retail, mail order and specialty pharmacies. These delays make it harder to spot emerging adherence issues early.
Unnotified medication changes: Members switch or stop medications without informing their care team. While the behavior itself can't be prevented, timely medication intelligence can reduce the impact of outdated information on care coordination.
Therapy delays and discontinuation: Members may postpone starting therapy or discontinue treatment over time. These behavioral challenges often aren't visible until claims arrive—if they arrive at all, given that cash-pay transactions typically don't appear in claims data.
Data fragmentation compounds these challenges. By the time patterns emerge, preventable hospitalizations and accelerating disease progression have already begun driving costs upward while potentially sending Star Ratings downward.
The Solutions Changing the Game
Healthcare has reached a pivotal moment in addressing these longstanding challenges with solutions like Medication History for Populations, which delivers medication history information from pharmacies and PBMs to clinical and care management workflows. With a comprehensive understanding of patients’ prescriptions, care managers can quickly spot adherence gaps.
The growth in medication history utilization tells a compelling story. Medication histories delivered across the Surescripts network grew 14.3% year-over-year to reach 3.79 billion in 2025, up from 3.31 billion in 2024—a trajectory from 2.37 billion in 2021 that reflects increasing recognition that comprehensive, timely medication data is foundational to effective care management.
This high utilization is comforting as I know that care managers are receiving cleaner, more complete data without manual reconciliation work. Care teams can instantly pull all dispensed medications from a single source of truth, with no need to wait for claims or member self-reporting. Imagine how powerful a panoramic view of your members' medication use could be.
From Reactive to Proactive: The Paradigm Shift
The most significant opportunity lies in fundamentally redesigning how health plans approach medication management. Instead of discovering adherence gaps months after they begin, imagine care managers receiving real-time alerts when a new member fills their first prescription, a member on multiple medications suddenly stops filling a critical prescription or the member makes a switch to a new prescriber or pharmacy.
This shift requires comprehensive, population-level medication intelligence for entire member populations. The economic impact is substantial. Analysis shows that with just 5% of members enrolled in proactive medication management programs, health plans could save $648.3 million from reduced medical costs and higher Star Ratings. At 25% enrollment, that figure climbs to $1.25 billion. Improving adherence and avoiding unnecessary costs?
That’s a win-win.
Building the Infrastructure for Sustainable Success
The path forward requires health plans to invest in three critical areas:
Comprehensive data infrastructure that moves beyond claims-based medication tracking to include dispensed medication data from pharmacies and PBMs directly
Real-time monitoring capabilities that deliver proactive prescription notifications
Intelligent workflow integration that ensures medication intelligence flows seamlessly into existing care management platforms.
For health plans operating in value-based arrangements, the stakes couldn't be higher. Medication adherence directly impacts risk adjustment, revenue streams and member satisfaction. Yet it remains one of the most challenging aspects of care management to influence at scale. The difference between success and failure increasingly comes down to the quality and timeliness of medication intelligence available to care teams.
Blizzard season will return every January. The medication adherence whiteout will continue to obscure visibility throughout the year. But health plans that invest now in comprehensive medication intelligence infrastructure will find themselves navigating these storms with unprecedented clarity—spotting risks earlier, intervening more effectively and ultimately delivering better outcomes for the members who depend on them.
The data is clear. The technology is proven. The opportunity to close gaps in care with a sharper view of patients’ medication history is now.