Across the country, health plans are investing heavily in complex care management programs. The logic is sound: identify high‑risk members, assign a nurse or social worker, and intervene before avoidable utilization occurs. Yet despite decades of refinement, one stubborn truth remains — the members who drive the highest costs are often the least likely to be reached.
This is the engagement gap. And it is widening.
The Hidden Majority of Spend
Every plan can identify its top‑spend members who need complex care management. Multi‑chronic, polypharmacy, homebound adults with behavioral health comorbidities, social instability, or functional limitations with increasingly complicated treatment plans. They account for a disproportionate share of emergency department visits, readmissions, and unplanned utilization.1, 4
But look at who is actually enrolled in complex care management programs:
- Members who answer the phone
- Members who attend appointments
- Members who respond to mailers
- Members who are already connected to the system
The result is a structural mismatch. The highest‑cost members aren’t in your care management program. They’re in the emergency department.
Why Traditional Care Management Misses Them
The issue is not strategy. It is not software. It is not another dashboard. The issue is reach.
Traditional care management models rely on remote engagement — phone calls, letters, portal messages, and clinic‑based follow‑up. These tools work for reachable members.2 They do not work for the individuals who:
- Do not pick up the phone
- Do not attend scheduled visits
- Do not respond to outreach
- Do not have stable housing, transportation, or support
- Do not trust the healthcare system
- Do not speak the plan’s primary language
- Do not have the functional ability to navigate care
These members are not “non‑compliant.” They are unreachable by design within traditional models.
The Cost of Missed Engagement
When the highest‑need members remain outside the care management program, predictable patterns emerge:
- Repeat ED visits
- Avoidable admissions
- Failed transitions of care
- Medication mismanagement
- Unaddressed behavioral health needs
- Worsening chronic conditions
- Rising total cost of care
Plans end up managing crises rather than preventing them.
A Workforce Built for the Gap
The solution is not more phone calls. It is a different workforce.
A community‑based, multilingual, in‑person care team — one rooted in the member’s neighborhood and lived experience — can reach the members traditional care management cannot. This workforce:
- Meets members at home rather than by phone
- Navigates social barriers directly
- Builds trust through presence, not outreach attempts
- Coordinates with clinical teams to close gaps
- Supports behavioral health and medical needs together
- Stabilizes members who would otherwise cycle through the ED
This is not a replacement for complex care management. It is the missing layer that makes it work.
Why Plans Are Moving Now
Value‑based care contracts, rising dual‑eligible enrollment, behavioral health integration, and increasing regulatory expectations all point toward one reality: plans must engage the members who drive spend, not just the members who answer the phone.
The economics reinforce the urgency. Programs using community‑based engagement models have demonstrated:
- Significant reductions in avoidable admissions
- Lower ED utilization
- Improved medication adherence
- Better chronic condition management
- Higher quality performance
- Stabilization of members previously considered unreachable
Healthy at Home’s GLIN results — 66% fewer admissions across 315 members in three months — are one example of what becomes possible when the engagement gap is closed. These results form the foundation of Healthy at Home’s case study, conference collateral, and executive briefings.
The Strategic Moment
Every plan has care management. What they do not have is engagement with the members who drive the spend.
The gap is clear. The solution exists. And the plans that act now will be the ones positioned to lead in a value‑based future where outcomes, not outreach attempts, define performance.
Readiness is no longer optional. It is a strategic advantage.
CARE AT HOME SOLUTION
Close this engagement gap with a better approach to care management. See if your population is a fit.
Endnotes
1. Concentration of Healthcare Expenditures and Selected Characteristics of High Spenders, U.S. Civilian Noninstitutionalized Population, 2018.Statistical Brief #533. January 2021.2. Cruz, B., & Koransky, M. High Cost Members in Medicare Advantage Plans: Strategies for Success. Wakely Consulting.
3. Cruz, B., & Koransky, M. High Cost Members in Medicare Advantage Plans: Strategies for Success. Wakely Consulting.
4. Substance Abuse and Mental Health Services Administration (SAMHSA). The Impact of Mental and Substance Use Disorders on Chronic Disease and Health Care tilization. U.S. Department of Health and Human Services.
5. Jencks, S.F., Williams, M.V., & Coleman, E.A. “Rehospitalizations among Patients in the Medicare Fee-for-Service Program.” New England Journal of Medicine, 2009.