THOUGHT LEADERSHIP
Why shifting enrollment and rising complexity are pushing plans to manage risk earlier
Keith Jacobs, Vice President, Health Plan Strategy, Teladoc Health
Health plans today are facing more uncertainty than ever. Across government programs, commercial plans and employer-sponsored coverage, frequent and less predictable changes in enrollment have created market volatility. This makes it harder for plans to understand risk, manage costs and stay financially stable.
As market volatility reshapes who enrolls and how long they stay, historical claims data alone is no longer enough to predict utilization or costs. Managing risk increasingly depends on identifying and engaging rising-risk members before that risk shows up in claims.
This new environment requires a different approach to managing risk. Here’s what’s driving the shift and how plans can respond.
Movement in and out of plans has been intensified by shifting coverage rules. Changes to ACA subsidies, Medicaid redeterminations, community engagement requirements and shrinking Medicare Advantage benefits are all contributing to enrollment changes that affect 15-20% of Americans every year.
At the same time, rising costs are influencing when people seek care. A recent study shows one in three adults have skipped or delayed care because of the cost. Many members delay care even while underlying health risks are growing.
As enrollment shifts, the mix of members in a plan can change in subtle ways. Healthier members leave sooner, while members with higher needs stay. Over time, this can raise costs even if enrollment doesn’t change.
What’s often underestimated is how much risk remains hidden during this churn. Members who move in and out of coverage, delay care or don’t engage with the healthcare system may appear low-cost in claims, even though they have unmet chronic or behavioral health needs. As a result, plans may miss early signs of risk, not because the risk isn’t there, but because it isn’t visible yet.
Relying mainly on claims data to understand risk has always meant working with a lag, since claims reflect care after a member seeks treatment or receives a diagnosis. When enrollment was more stable and members stayed covered longer, the delay was often manageable.
Today, that same approach often comes too late. More frequent movement in and out of coverage and longer delays in care mean early signs of risk are more likely to go unseen or appear only after costs have already risen.
To better understand this gap, Teladoc Health tested what happens when plans look beyond claims data by analyzing an expanded set of clinical information from a pilot population to create a more complete picture of member health.
Reviewing information such as diagnoses, lab results and medication history showed that 97% of members had signs of chronic health risk when a more complete set of clinical data was included. This broader view supports more timely identification of risk and allowed plans to intervene earlier to better manage health outcomes. As part of the pilot, this data also enabled earlier and more accurate risk-grouping, with higher-risk members showing significantly higher emergency and inpatient utilization.
In a volatile market, this matters. Waiting for claims to confirm risk limits how early plans can act. Seeing risk sooner helps plans reach members, guide care earlier and manage costs before needs become more complex.
Spotting risk earlier starts with removing barriers to preventive care. Many members don’t regularly seek care or have a primary care provider, which makes early signs of risk easy to miss. This is where solutions like VirtualCheckup® are designed to close the gap by making preventive screenings more accessible.
When those barriers are reduced, plans can uncover health needs that weren’t previously visible. An analysis of VirtualCheckup patients from 2020-2025 shows that nearly half of newly identified risk appears among people without a primary care provider. These are members who may otherwise remain invisible in claims.
Virtual care helps plans act on risk, not just find it.
Once risk is identified, engagement is key. VirtualCheckup combines at-home preventive screenings with a follow-up visit with a nurse practitioner.
This approach helps turn early insights into clear next steps for care. As part of the visit, nurse practitioners can enroll patients in Teladoc Health services in real-time, leading to two times higher enrollment compared to clients relying on traditional marketing alone.
They can also guide patients to other appropriate next steps, including in-network providers and employer- or plan-sponsored programs, helping ensure members receive the right care beyond virtual services.
By supporting members beyond an initial screening, virtual care helps prevent small issues from becoming more complex and costly and helps plans manage risk across the member lifecycle.
Market volatility isn’t going away. Enrollment will keep changing, costs will stay high and members will need more care over time.
For health plans, this means looking for more proactive options to spot risk and seamlessly connect them to care.
Virtual care helps make this possible. It removes barriers that give plans earlier insight, helps them engage members more often and support ongoing care. This approach helps plans manage risk across different populations and make more informed decisions as they plan for the year ahead.
