The Bottom Line‍

Heart disease is a major cost driver, but many plans still aren't managing it early enough. The opportunity is to treat heart health less like a long-term prevention goal and more like an operating metric—using medication adherence, blood pressure control, and earlier signals to act before risk turns into cost.

• Readiness gap: 95% of plan leaders say heart health matters, but only 29% plan to prioritize it this year
• Operational lever: Medication adherence and blood pressure control are measurable enough to manage now
• Business value: Earlier action can support quality performance, reduce avoidable utilization, and strengthen cost containment

Why plans feel the pressure but still aren’t ready to act

This year, health plans don’t need another initiative. They need tighter control over their biggest cost drivers, and heart disease is still at the top of that list.

Plans are under enormous pressure. Cost trend is stubborn, quality measures are scrutinized, and budgets are tight. Every new program competes with something louder, more visible, and more urgent.

Yet our 2026 Heart Health Matters Health Plan Report found that while 95% of health plan leaders say addressing heart health is important, only 29% plan to prioritize heart disease programs this year.

That gap is not philosophical. It’s operational.

And it’s expensive.

Most plans feel the pressure. Few feel prepared.

Our research shows decision makers agree heart disease is a top cost driver, but only 32% feel prepared to manage rising cardiovascular claims costs.

In my conversations with plan leaders, “not ready” doesn’t mean they don’t understand the risk. It means:

• Competing priorities, like cancer, MSK, specialty drugs
• Budgets are constrained
• Quality and finance teams are siloed
• There are too many point solutions to vet
• It’s unclear which intervention will deliver measurable impact this year

Unlike cancer or MSK, cardiovascular risk is often treated reactively. But just like mammography or colon screening, CVD prevention relies on catching the risk before it becomes a high-cost event.

What’s different is that the tools already exist—blood pressure monitoring, adherence tracking, titration alerts—and the quality metrics are already tied to performance. Heart disease may be chronic, but it’s also manageable, measurable, and materially preventable.

Additionally, while the costs of oncology and MSK feel immediate and visible, cardiovascular risk builds quietly. High blood pressure and high cholesterol often go unmanaged for years, until one hospitalization changes the entire cost trajectory.

By then, the most cost-effective window to intervene has narrowed—or closed entirely.

The controllable lever is medication adherence

If I had to choose one metric that best connects quality performance and cost containment for health plans, it’s medication adherence.

Specifically, PDC and fill rates.

Plans already track them. They’re measurable, tie directly to quality performance, and aren’t just cardiovascular. They affect diabetes, behavioral health, and more.

Our Heart Health Matters research reinforces this:

• 90% say medication management tools are valuable
• 91% would adopt or renew them if measurable outcomes are demonstrated

From a cost perspective, the impact is well established. Medication nonadherence is associated with avoidable hospitalizations and thousands of dollars in excess annual costs per person.

From a quality perspective, adherence directly influences medication-related quality metrics and blood pressure control.

This is where heart health becomes actionable, with known metrics and playbooks already in use.

CBP looks binary on paper. It’s anything but in practice.

Controlled Blood Pressure (CBP) is a critical measure, especially for Medicare Advantage plans. But it’s ultimately based on a snapshot—often the last documented reading of the year.

Recent research published in JAMA reinforces the same point: even among adults receiving treatment for hypertension, many remain more than 10 mm Hg above recommended targets. Reported control rates may appear high, but they are often based on a 140/90 threshold. Current clinical guidelines recommend treatment below 130/80, which suggests true control is lower than it looks on paper.

Many blood pressure–lowering medications are low-cost generics, which means this gap is less about drug cost and more about care delivery and follow-through. That creates real performance and cost risk.

I hear the same pattern from plan leaders:

• Members have elevated readings throughout the year
• Medication titration is delayed
• Lifestyle conversations are rushed or inconsistent
• Members aren’t monitoring at home
• By Q4, there’s little time left to intervene

Without early intervention, BP control defaults to Q4 recovery mode: reactive, not strategic.

Blood pressure damage is cumulative, and so is cost exposure. Waiting until stage two hypertension or an ED visit means the most controllable opportunity has already narrowed.

Plans need visibility earlier in the year. Not just claims data or year-end documentation, but real-time trend data and actionable signals that allow care management teams to intervene before the Stars window closes.

That’s how prevention becomes operational and measurable.

‍For Medicare Advantage teams, the math on CBP has changed. If you aren’t seeing a clear path to Stars performance by July, the window for Q4 recovery is likely already closed. Learn why most CBP gains are won or lost before Q3.

The financial risk of doing nothing is measurable

The disconnect isn’t about awareness. It’s about execution.

When prevention is deferred, plans absorb the downstream impact in:

• Higher inpatient utilization
• Avoidable ED visits
• Medication-related gaps
• Performance pressure on triple-weighted measures

Heart health is one of the few areas where:

• Quality performance improves
• Avoidable utilization declines
• Financial performance strengthens
• Member experience improves

All at once. Very few conditions offer that level of alignment.

AI readiness is real. Skepticism is practical.

One of the findings I found most encouraging is that 91% of health plan leaders say their organizations are ready to adopt AI-enabled digital health tools.

After the pandemic, telehealth normalized digital engagement. Even older populations adapted. Members want convenience, not more appointments.

That said, AI cannot be positioned as autonomous decision-making. It must be:

• Clinically guided
• Transparent
• Integrated with existing systems
• Measurable
  

The biggest barrier cited is not fear. It’s practical integration and ROI proof.

The real issue is silos

On most calls, we start with a Quality or Stars leader who knows exactly where their HEDIS gaps are. Meanwhile, Finance is focused on inpatient days and high-cost claimants, and Population Health is juggling multiple chronic condition initiatives.

All of them care about heart health, but they are rarely aligned around one operating plan.

Heart health often falls between teams, owned by no one even though it affects everyone. And that’s the opportunity.

Medication adherence and blood pressure control sit at the intersection of:

• Quality metrics
• Utilization management
• Pharmacy strategy
• Member engagement
• Care management

It’s one of the few levers that legitimately connects departments.

Heart disease is not an inevitable cost of doing business

CVD is the most prevalent chronic condition category, a top cost driver, and one of the most measurable areas of prevention.

But only 29% of plans are prioritizing heart disease prevention programs this year. And this is not a sustainable disconnect.

Heart health has become measurable enough to manage like an operating metric. It starts with medication adherence, is measured through sustained blood pressure control, and validated through claims-based impact.

In this environment, the risk is no longer whether heart disease matters. It’s whether waiting will cost more than acting now.

Get your copy of the 2026 Heart Health Matters Report to see how health plans are approaching prevention, measurement, and cost containment in 2026.