The Crisis Hiding in Your Claims Data: The Cost Lever You’re Missing in 2026

Key takeaways for benefits leaders:

• Medication adherence is not only a behavior problem, it’s a budget problem
• Removing friction works better than asking people to try harder
• If you want to control costs, watch inpatient days and prescription refills

The Problem Doesn’t Start in the ER

Medication non-adherence is one of the most overlooked drivers of avoidable inpatient spend. And as healthcare costs rise in 2026, that blind spot is getting more expensive.

It doesn’t show up as a line item in your pharmacy budget. It shows up later—as ER visits, inpatient days, and “sudden” high-cost claims that feel hard to explain after the fact.

As a cardiologist, I’ve seen exactly how this gap forms, long before it ever appears in claims data.

The Claim Before the Claim

A patient—let’s call her JB—would come in for a routine visit. Her blood pressure was elevated, but she felt fine. I prescribed the medication she needed, but taking medication made her feel old. It didn’t fit how she saw herself: active, capable, still in control.

She also didn’t feel the benefits of the medication, so she missed doses and eventually stopped taking it.

Six months later, JB had a hypertensive crisis and was rushed to the ER—an event that required urgent, expensive care.

That outcome wasn’t driven by a lack of intelligence or education. JB understood what the medication was for.

It was a failure of the system to account for beliefs and the friction of daily life. And unfortunately, it’s an all-too-common occurrence—especially with conditions like high blood pressure that patients can’t see or feel. 

As we head into 2026, costs are still rising. Benefits leaders are under intense pressure to show impact, and one of the most frequent drivers of preventable utilization is hiding in plain sight.

Medication Adherence Isn’t a Motivation Problem. It’s a Budget Leak.

Non-adherence is often framed as a “member behavior issue.” But after years in clinical leadership, I’ve learned that this framing misses what actually drives outcomes.

Non-adherence isn’t primarily about forgetting. It’s about friction.

When a medication regimen doesn’t fit into someone’s routine—or doesn’t align with how they see themselves—it quietly falls away. People don’t always make a conscious decision to stop. They drift.

And because many heart health medications don’t produce an immediate, felt benefit, skipping a dose doesn’t feel risky in the moment. That’s how non-adherence becomes a budget leak. It’s invisible until it shows up later as a high-cost claim.

Why Missed Medications Turn Into Inpatient Days

Chronic conditions often worsen gradually, without obvious warning signs. Someone can miss blood pressure or cholesterol medications and still show up for work, exercise, and feel normal. 

But the pattern is predictable: 

Missed medications → gradual loss of blood pressure or cholesterol control → silent escalation with few symptoms → “sudden” hospitalization

By the time a member shows up in the ER, the deterioration didn’t just happen. It built over time, through small, repeated gaps in daily routines that often go unnoticed by the system and by the individual.

For employers and benefits leaders, this matters because the real financial impact of non-adherence shows up in inpatient utilization. 

The Financial Case for Medication Adherence

One of the most persistent misconceptions in benefits strategy is that non-adherence saves money by lowering pharmacy costs.

In reality, it shifts spend into far more expensive medical claims.

When cardiovascular medications are taken as prescribed, an Aon study found:

• 2.1 fewer hospital days per year for members with hypertension.
• 1.5 fewer hospital days per year for members with high cholesterol.
• $3,900 less in total annual healthcare spending per person for members with hypertension.
• $1,300 less in total annual healthcare spending per person for members with high cholesterol.

In other words, while adherence may slightly increase spend on prescription drugs, it ultimately  helps avoid the big medical expenditures that dwarf drug costs.

That’s why the economics of adherence are asymmetric:

• The downside of investing in adherence support is capped and predictable
• The upside is avoiding even one serious medical event that can materially impact a quarter

Why Systems Matter More Than Willpower

If there’s one clinical philosophy for benefits leaders to take seriously in 2026, it’s this:

• Automation works better than coaching
• Nudges work best when they’re embedded in a system
• Measurement works better than anecdotes

When medication adherence depends on effort, results are unpredictable. When it’s built into the system—through automation, defaults, and real-time feedback—failure points are easier to remove.

That’s what it means to move from a voluntary program to a model where heart health management fits naturally into daily life, instead of relying on sustained willpower.

What This Means for Benefits Leaders in Q1

If you’re prioritizing cost containment for 2026, medication adherence deserves real strategic investment. 

Not as a compliance initiative or wellness perk, but as a near-term utilization lever.

The most effective strategies focus on:

• High-risk moments like new prescriptions, medication changes, refill gaps, side effects, and post-discharge transitions
• Systems that make the right behavior easier than the wrong one
• Measurement that surfaces risk earlier—before it turns into an inpatient stay

Heart health is a long game. But the financial consequences of non-adherence often play out much faster.

When we remove friction and help people see how today’s actions connect to tomorrow’s health, we don’t just improve outcomes—we stabilize costs.

Medication adherence isn’t just about care. It’s about cost avoidance.

Curious what this looks like in practice? See how Hello Heart supports employers looking to reduce preventable cardiovascular costs—without adding complexity for benefits teams or members.