Healthcare has solved identification. Not follow-through.
Health plans have become remarkably good at identifying members who need intervention. The harder, unsolved problem is follow-through: a care gap does not close because it appears on a dashboard. Someone still has to reach the member, answer questions, remove barriers, and see the next step through. The strategic question is shifting from "can we identify the right members?" to "can we help more of them take action?"
Over the last decade, health plans have built remarkable capabilities to identify members who need intervention. Through claims data, pharmacy records, risk stratification, quality programs, and predictive analytics, plans can identify the member with prediabetes who has not enrolled in a prevention program, the patient with uncontrolled hypertension missing medication refills, the recently discharged member at risk of readmission, or the Medicare Advantage enrollee overdue for an annual wellness visit.
A national survey published in the American Journal of Managed Care found that health plans consistently use claims data and care gaps to identify and segment members for intervention. The same study found that plans still struggle to engage those members and their providers. The stratification capability is there. What comes next is where the gap opens.[1]
A care gap does not close because it appears on a dashboard. Someone still has to reach the member, answer questions, overcome barriers, coordinate the next step, and follow through until the action is complete. Traditional payer outreach has depended heavily on call centers, clinical teams making outbound calls, mailed reminders, portals, and fragmented follow-up workflows. These approaches create value, but they require significant human effort and become increasingly difficult to scale across every member, program, and moment of need.
Typical response rates for traditional payer call-center outreach, the wall that human-only follow-through keeps hitting.
A 2025 peer-reviewed study led by Aetna and CVS Health researchers described the constraint plainly. Many existing interventions are high-intensity, costly, and resource-intensive, making them difficult to sustain broadly at scale.[2] The members are identified. The outreach machinery cannot keep up.
A care gap does not close because it appears on a dashboard.
Closing that gap requires more than another reminder. Members may need help understanding why an action matters, navigating scheduling or eligibility, addressing language and access barriers, or simply finding a time that works within the realities of their lives. The next phase of member engagement will be defined by how effectively plans convert the intelligence they already have into completed action.
From a call-center ceiling to over half of members reached.
Conversational AI does not replace care managers or clinical judgment. It extends outreach capacity, supports routine conversations, answers common questions, and escalates the complex cases, so more members complete the next step.
The question is changing
The strategic question for health plans is changing. It is no longer simply, "Can we identify the right members?" Increasingly, it is, "Can we help more of those members take action?"
That is the operational challenge that will define the next generation of member engagement.
Frequently asked
What is the follow-through gap in member engagement?
It is the distance between identifying a member who needs care and getting that member to complete the next action. Health plans can now pinpoint who has an open care gap, but closing it still depends on human outreach that is hard to scale across every member and program.
Why can't traditional outreach close the gap on its own?
Call centers, outbound clinical calls, mailers, and portals create real value, but they are labor-intensive. As the number of identified members grows, the outreach capacity needed to reach all of them grows with it, and staffing does not scale the same way.
How can AI help without replacing care teams?
Conversational AI can extend outreach capacity by handling routine conversations, answering common questions, and helping members complete a next step, while escalating higher-risk or more complex needs to clinical staff. It changes the economics of the work rather than the people doing the judgment.
- Mattke S, Higgins A, Brook R. Results From a National Survey on Chronic Care Management by Health Plans. Am J Manag Care. 2015;21(5):370-376. ajmc.com
- Fernandes D, Kokonas E, Bansal J, et al. An Informatics-Based, Payer-Led, Low-Intensity Multichannel Educational Campaign Designed to Decrease Postdischarge Utilization for Medicare Advantage Members. JMIR Hum Factors. 2025;12:e63841. humanfactors.jmir.org
Field observations reflect Mila Health's work supporting more than 300 healthcare organizations. Based on Mila Health customer contract and deployment records as of July 2026.
