Unlocking the Hidden Potential of Modern Care Management

Brian Drozdowicz

Health plans face mounting pressures as traditional cost controls lose their edge. Care management, despite its proven potential, remains vastly underutilized. Modern care management approaches harness real-time clinical insights at critical care moments, transforming reactive cost control into proactive relationship-building that drives lasting behavior change and measurable positive outcomes.

Looming headwinds and untapped potential

Health plans face numerous potential headwinds: healthcare costs surging at the fastest pace in over a decade, CMS reimbursement cuts through Version 28 risk adjustments, and mounting regulatory pressure as states overhaul prior authorization requirements.

Amid these intense industry pressures lies an untapped opportunity. McKinsey research reveals that health plans dedicate over 10% of administrative budgets to care management while capturing only 10% of its potential value, leaving 90% unrealized due to poor member engagement and outdated approaches. As a result, health plans have an opportunity to unlock significant cost savings, reduce readmissions, and improve quality by empowering care teams with better tools.

3 pillars of the modern care management playbook

To fully realize the potential of care management, health plans must embrace a new, proactive playbook built on three foundational pillars: real-time member awareness, timely clinical context, and actionable insights.

Real-time member awareness: Instead of learning about discharges days after they occur through claims data, care managers are armed with real-time alerts for discharges, ED visits, and inpatient admissions. Real-time awareness is the foundation that enables intervention within the critical 72-hour window when readmission risk is highest and member receptivity peaks.

Timely, rich clinical context: It’s not enough to know that a care event happened; care managers need comprehensive clinical details to build member trust and develop proactive care plans that deliver immediate value. This means access to diagnoses, medication changes, and follow-up requirements delivered directly in their workflows. This clinical context transforms the care manager’s role from investigator and data extractor to trusted advisor, enabling them to proactively add value rather than spending precious time gathering basic information from members. This trust fosters better member engagement and drives improvements in quality metrics, such as HEDIS and CAHPS scores.

Actionable, embedded insights: This is where data enables action. Empowering care managers with AI-driven tools that surface prioritized risks and evaluate clinical information transforms care delivery from reactive to proactive. These embedded insights streamline workflows and focus attention on members with the highest risk, ensuring that resources are allocated effectively. When insights are seamlessly integrated into daily operations, care managers can intervene earlier, coordinate across providers, and support members in making meaningful health decisions — all of which contribute to improved health outcomes and reduced total cost of care.

The path forward

By addressing the long-standing engagement gap and moving beyond reactive workflows, payers have an opportunity to transform care management from a perceived cost center into a powerful strategic asset. Early adopters understand that sustainable change requires solutions that seamlessly integrate into existing workflows, providing care managers with real-time clinical intelligence without adding complexity or burden. The three pillars of modern care management — real-time member awareness, timely clinical context, and actionable insights —form the backbone of this transformation.

The future of healthcare cost management lies not in denying more claims, but in preventing the need for them. By transforming care management from reactive administration to proactive intervention, health plans can build trusted relationships that drive lasting behavior change and cost savings.

Brian Drozdowicz is the chief revenue officer of PointClickCare.