Introduction
Medical costs continue to rise, and payer margins are under pressure. The tools most organizations rely on to manage those costs aren't keeping pace.
Legacy telephonic outreach and batch-style digital campaigns share the same flaw: they deliver information, but they don't drive action. Education only matters if it changes what happens next. A content piece that arrives three weeks post-discharge doesn't close a care gap. It doesn't prevent a readmission or move a Star Rating.
McKinsey estimates that high-performing payers can capture 2–5% in savings through care management built on a clear clinical strategy.¹ But many organizations still struggle to operationalize that opportunity. The gap between what's possible and what's being delivered comes down to one thing: the models haven't changed.
The good news is that the gap is closable.
This blog walks through why older care management models fall short and three strategies to modernize them.
Why legacy care management is falling behind
Rising medical costs are exposing the limits of older models. When margins were healthier, inefficient outreach was tolerable. It isn't anymore.
Telephonic outreach is resource-intensive and often poorly timed. A registered nurse spends hours dialing members who may never pick up, working from claims data that's weeks old. By the time the call connects, the moment to act has often passed.
Batch digital campaigns solve for scale, not timing. They distribute information to large member lists on fixed schedules, but they don't reliably drive action. A member receives a mailer or an email, reads it or doesn't, and nothing changes on the other end.
The core issue is the same across both approaches: content without activation doesn't change outcomes. Members don't need more information. They need the right prompt, at the right moment, with a clear path to act.
Three strategies address each of these gaps directly — and together, they build the foundation for a care model that actually drives action.
Strategy 1: Replace batch lists with event-driven triggers
Claims-based member lists are already outdated the moment they're built. Claims lag by weeks — sometimes 30 to 60 days — as they move through billing, adjudication, and reporting cycles. By the time a member surfaces on a list, you're looking at a snapshot of their health from last month. The window to intervene has often closed. A readmission risk goes unaddressed. A care gap widens. A prescription lapse goes unchecked. Delayed identification doesn't just slow outreach, it removes the opportunity to influence behavior at the moment it would have mattered most.
Event-driven triggers change the timing — and bridge the gap between having real-time clinical data and acting on it. Plans already have ADT (Admission, Discharge, Transfer) data from clinical encounters. The problem isn't access to that data. It's activation. Instead of blasting a static list, event-driven triggers transform ADT and other real-time signals into targeted micro-nudges the moment something happens — 24 hours after a hospital discharge, immediately after a member completes an HRA, or when a prescription goes unfilled past a threshold date. The message reaches the member when the action still matters. A post-discharge nudge that arrives within 24 hours can prompt a follow-up appointment before readmission risk peaks. An HRA-triggered alert can close a care gap the same day it's identified. Timing the outreach to the clinical moment — rather than the calendar — is what separates activation from noise.
The result: outreach that meets members at the point of decision, not weeks later.
Strategy 2: Anchor prompts in bite-sized, contextual education
A nudge that says "schedule your follow-up" tells a member what to do. It doesn't tell them why it matters. And "why" is what drives action. Members who understand the consequence of the next step — that a post-discharge visit cuts readmission risk, that filling a prescription prevents a preventable complication — are meaningfully more likely to follow through. Relevance is the missing link between a reminder and a decision.
Replace dry administrative prompts with short, clinically vetted education delivered at the moment of decision. A member recovering from a cardiac event doesn't need a 10-page PDF. They need one clear, accessible explanation of why a follow-up visit lowers their readmission risk — right when they're deciding whether to book it. According to the National Institutes of Health, self-management programs that pair targeted education with specific delivery strategies have proven successful at improving outcomes in high-risk populations. Format matters, too. Some members watch videos. Others prefer short articles they can read at their own pace. By combining text, visuals, and interactive content, recall of health information can increase substantially. Bite-sized education, offered in the format a member will actually use, is what turns a prompt into a plan.
Strategy 3: Deploy automated triage to protect clinical bandwidth
Registered nurse (RN) time is your most valuable and most limited resource. The average RN care manager handles dozens of members at once — and when that time gets absorbed by low-acuity check-ins, routine confirmations, and basic medication questions, high-risk members wait longer for the attention they actually need. Spending clinical hours on tasks that don't require clinical judgment isn't just inefficient. It's a risk.
Automated triage protects that bandwidth. Two-way digital communication loops resolve simple responses on their own — confirming an appointment, answering a routine medication question, closing a basic care gap. When a response signals real clinical complexity, the system routes it straight to an RN.
Low-acuity issues resolve automatically. Complex cases reach a nurse faster. Clinical time goes where it delivers the most value.
Final thought: Turning care management into measurable savings
Modernizing care management isn't about sending more messages. It's about making each one count. Event-driven triggers fix the timing, contextual education supplies the "why," and automated triage protects clinical capacity. Together, they close the gap between information and action.
That gap is where the 2-5% savings live. High-performing payers capture it by pairing a clear clinical strategy with activation — turning outreach into outcomes, content into behavior change, and spend into measurable results.
Start with one high-cost, high-volume moment — post-discharge follow-up is a strong candidate. Build an event-driven, education-anchored, triage-supported workflow around it. Then measure, refine, and scale.
SOURCES
How insurer-led care model innovation can transform healthcare, McKinsey & Company, https://www.mckinsey.com/industries/healthcare/our-insights/healthcare-blog/how-insurer-led-care-model-innovation-can-transform-healthcare
