The U.S. healthcare system is at a critical inflection point, especially when it comes to managing chronic disease, which is why the new administration in the U.S. is beginning deep-dive discussions on how best to tackle the growing issues — both human and cost related — tied to chronic diseases, like diabetes.
With over half of adults living with at least one chronic condition — and more than 38 million Americans diagnosed with diabetes — the economic and human cost is staggering. Nowhere is this more evident than in Medicare, where diabetes-related complications are a major driver of hospitalizations and healthcare spending.
One underappreciated but high-potential lever in changing this dynamic is the consistent use of technology like continuous glucose monitors (CGMs). These devices have revolutionized diabetes self-management, offering real-time insights and tighter glycemic control. But like any medical intervention, CGMs are only effective if patients actually use them — and that’s where the system often falls short.
Data suggest that Medicare beneficiaries using CGMs are at risk of discontinuing therapy. This is not a failure of the technology itself, but rather a breakdown in follow-up care, patient support, and system-level coordination. When people stop using their CGMs, they’re more likely to experience preventable complications, ER visits, and hospitalizations — costing the healthcare system millions annually and compromising quality of life.
So how do we address this challenge? One promising answer lies in the use of AI-powered predictive analytics coupled with behavioral insights to anticipate and prevent nonadherence before it happens.
Predicting and Proactively Addressing Patient Drop-Off
A new analysis involving more than 55,000 Medicare fee-for-service patients found that using CCS’s predictive model to identify individuals at risk of stopping CGM use — and then intervening with targeted support — could significantly improve adherence rates and cut costs. In this case, roughly 14,400 at-risk patients were identified using behavioral, socioeconomic, and clinical data. Tailored outreach strategies based on patient-specific needs improved adherence in over a third of this group and led to an estimated $10 million in savings to Medicare.
What’s notable is that these interventions weren’t generic reminders or mass communications. Instead, they were highly tailored outreaches — powered by AI — and they were designed using behavioral insights grounded in holistic data assets. For example, when messages aligned with patients’ trust in their healthcare providers, adherence improved by 46%. Also, among rural patients, emphasizing the availability of at-home support options boosted adherence by 30%.
These results underscore the power of precision communication — using data not only to identify who needs help, but also how best to engage and motivate them with personalized, consumer-led content delivered at the right time, with the right message, and via the best channel to drive awareness and intended change in behavior.
Bringing Value to Chronic Care for the Medicare Population
This kind of proactive, data-informed approach couldn’t come at a more important time. The U.S. healthcare system is slowly moving toward value-based care, where providers are reimbursed based on outcomes rather than volume. But for this model to succeed, especially in managing chronic disease, health plans and clinicians need better tools to identify risk, intervene early, and sustain patient engagement.
Unfortunately, the infrastructure to support this kind of personalized, preventive care remains patchy at best. Many providers lack the technology or capacity to monitor thousands of patients in real time. And traditional suppliers — once seen as logistics vendors — have been excluded from the broader care conversation, despite having frequent, direct contact with patients.
Today, home-based interventions, remote monitoring, and personalized education and coaching have become essential parts of the healthcare toolkit. If predictive analytics can flag who’s likely to disengage from a critical therapy like CGM, and if a coordinated care team (including educators, suppliers, and clinicians) can respond appropriately, then we move closer to the kind of connected, proactive care that chronic disease demands.
A Team-Based Approach to Chronic Care Management
To confront the diabetes epidemic and the broader chronic disease burden in the U.S., we need a more integrated and patient-centric model of care. That means breaking down traditional silos — between provider and payer, between pharmacy and supplier, between clinic and home.
Predictive analytics, applied thoughtfully, offers one path toward this vision — especially for the high-risk, high-cost Medicare population. By using data to anticipate problems before they escalate and by deploying personalized interventions that actually resonate with patients’ lived experiences, we can not only improve health outcomes, but also relieve pressure on an already overburdened system. If we want a future where the healthcare system is proactive, then helping Medicare patients living with diabetes stay on track with tools like CGMs is a smart and cost-effective place to start.
About Richard Mackey
Richard Mackey leads the IT organization at CCS, including digital strategy and infrastructure as Chief Technology Officer. His 20 years of experience managing technology at various leading organizations — including a strong focus on agile transformation, business analytics, and digital innovation — have enabled him to consistently and effectively improve organizational efficiencies and accelerate growth.
At CCS, Richard has been instrumental in reshaping the company’s systems and processes in order to improve the experience for patients, payors, providers, and employers. Richard and his team have been mission-critical in the company’s efforts to defragment the care experience for patients living with chronic diseases.
He helped transition CCS from a 30-year-old, traditional durable medical equipment company to an innovative, end-to-end chronic care engagement platform — integrating medical supplies, coaching, education, and more to optimize outcomes for those living with chronic diseases, while also reducing total costs of care.
Previously, Richard was Senior Vice President, Technology and Products at Intalere, now a part of Vizient — a national healthcare group purchasing organization that also offers strategic services and solutions to companies across the healthcare spectrum. Prior to this, he has worked for a number of global life sciences and medical device companies, including Pfizer, Philips, and Novartis.
