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Medicare Advantage plans are under increasing pressure to improve member health and outcomes— and that pressure is only accelerating. With the 2027 Final Rule, CMS is aiming to further increase the health and well-being of enrollees by simplifying and refocusing its set of Star measures toward outcomes and experience.
And there’s no time like the present to make this shift. More than 90% of Medicare Advantage enrollees have at least one health condition, with many juggling multiple, overlapping health challenges.
When it comes to addressing members’ health needs, step one is identifying who’s at risk. Since healthcare generates around 30% of the world’s total data volume (and growing faster than any industry), visibility into health challenges and nonadherence isn’t a problem. It’s step two—helping people actually follow through and stay on therapy over time—that’s become the real challenge.
Medication adherence is a human behavior shaped by beliefs, emotions, life circumstances and real-world barriers to access. It’s best addressed through understanding, trust and meaningful engagement that leads to action.
And that is where human connection from Care Navigators makes the difference.
Why does transactional outreach fall short?
Care Navigators are outreach staff that include nurses, pharmacists, pharmacy technicians and trained clinicians. They provide a key ingredient that many current engagement strategies do not: uncovering and resolving barriers to care through behavioral science.
Transactional outreach strategies—automated reminders, robocalls and scripts, one-size-fits-all messaging and high-frequency, generic outreach— don’t address why someone isn’t taking their medication in the first place.
Take the experience of Mrs. Taylor, an AdhereHealth member. Mrs. Taylor has high cholesterol, hypertension and diabetes, and had missed several medication refills. When a Care Navigator contacted her, she explained she was having trouble affording utilities and groceries. When faced with these challenges, getting her medicine was out of the question. She also explained that the recent passing of her husband had been a struggle.
Most transactional outreach techniques fail to uncover situations like these. Common limitations can also include a lack of understanding of side effects, access issues such as cost, low perceived need for a medicine, or cognitive overload due to too much information.
From a behavioral science perspective, a simple transactional approach assumes that awareness alone drives action. In reality, adherence is shaped by capability, motivation and opportunity—not just more reminders.
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The human advantage: Care Navigators as a bridge between challenges and resolution
When it comes to taking action to drive outcomes, Care Navigators play a critical role in translating insight into action. They serve as a critical connection point between:
- Data (what is happening)
- Clinical context (what it means)
- Human experience (why it is happening)
Care Navigators build trust with plan members through real conversations about nonadherence. They ask questions that help to uncover barriers and they adjust their communication in real time based on what information a member shares. Plus, they are able to translate clinical details into understandable, actionable guidance. They support members in reaching decisions about the next step in their healthcare journey.
This critical interaction is operationally powerful and often the difference between outreach and actual outcomes. It’s one of the most effective tools for closing the adherence gaps that can improve health, and ultimately performance on outcomes-based measures.
Behavioral science in action: what to include in an effective care conversation
Effective care navigation is intentional and grounded in evidence-based behavioral science but applied in a way that works in real conversations.
Care Navigators and outreach staff should be trained in the following techniques:
- Motivational Interviewing (MI). Instead of telling members what to do, care navigators:
- Ask open-ended questions
- Use reflective listening
- Help members articulate their own reasons for change
In the case of the AdhereHealth member Mrs. Taylor, the Care Navigator talked to her about her medicines. Rather than saying “You need to take them daily,” they asked, “What would make it easier for you to take your medications every day?”
- Simplifying decisions (reducing cognitive load). Medication regimens can feel overwhelming. Care Navigators can help by:
- Breaking instructions into small, clear steps
- Prioritizing what matters most first
- Clarifying “what to do next” in plain language
Mrs. Taylor was facing a few social challenges that were making it difficult to obtain her medications. The Care Navigator connected her with information about a local food pantry and details about financial resources. They also provided details for grief support and burial assistance to help her through the recent passing of her husband.
- Framing and nudging. Small changes in how information is presented can improve follow-through, such as:
- Positioning adherence as the simplest next step
- Reinforcing default actions (“most people find it easiest to…”)
- Highlighting immediate, meaningful benefits
The Care Navigator discovered that transportation was difficult for Mrs. Taylor, and helped her set up 90-day supplies so she’d have fewer trips to the pharmacy for refills. This step helped simplify the next step to filling her prescription.
- Addressing beliefs and perceptions. Many barriers are not logistical, but perceptual, such as:
- “I feel fine, so I don’t need it”
- “I’m worried about side effects”
Care Navigators help reframe these beliefs in a non-judgmental way, building understanding rather than resistance.
- Building self-efficacy. Behavior change requires confidence. Care Navigators help reinforce:
- Small wins
- Progress over perfection
- Practical next steps members can realistically achieve
These are not casual conversations. They are structured, evidence-based interventions designed to change behavior.
Ultimately, Mrs. Taylor was successful in her healthcare journey. She ended the plan year adherent with her medications, and with well-controlled A1C.
A Stars strategy focused on improving medication adherence amplifies your performace. Find out how in our white paper! Medication Adherence: The “Hidden Multiplier” Behind Sustainable Star Ratings
Key components of a solid adherence strategy
Medication adherence improves when engagement reflects how people actually make decisions and follow through..
As CMS continues to emphasize outcomes and member experience, health plans need to move beyond transactional outreach and adopt strategies that are human, personalized, behaviorally informed and clinically grounded. Care Navigators play a critical role in this shift by connecting data to real-world action—identifying barriers, building trust and helping members, like Mrs. Taylor, follow through over time. The focus is no longer on how many members were reached, but on how many were actually supported to stay on therapy.
For health plans evaluating adherence solutions, the most effective approaches bring together four key elements:
- The right timing through predictive analytics to identify risk early
- The right intervention through coordinated omnichannel outreach
- The right approach through combined clinical and behavioral expertise
- The right support through alignment with providers, pharmacies and plan resources.
When these components work together, adherence becomes not just achievable, but sustainable.
AdhereHealth combines our proprietary technology, omnichannel outreach and behavioral science-powered Care Navigator support to help our clients achieve and maintain medication adherence for Star Ratings success. If you’re evaluating how to improve adherence outcomes, we’d welcome the conversation.
Authored by: Tram Thai, VP Clinical Operations, AdhereHealth
