Medication Adherence in Value-Based Care

Medication nonadherence—patients not taking their medication as prescribed or discontinuing use without consulting their physician—is a perpetual problem in healthcare. It’s not just bad for providers and payers aiming to succeed in value-based care, it’s dangerous for patients.

Studies show that up to 50% of people with chronic diseases like diabetes or hypertension don’t take prescribed drugs as directed. Medication nonadherence contributes to disease progression, lower quality of life, and higher risk of death. At least 125,000 preventable deaths every year can be attributed to it. (Good adherence is associated with a 21% reduction in long-term mortality risk.) 

Providers and payers feel the impact too. In an already overburdened healthcare system, medication nonadherence leads to an increase in the use of emergency departments and $500 billion in preventable medical costs. 

Triple-Weighted, Higher Impact Measure 

Medication adherence has become more important than ever for payers and providers in risk-based contracts. The Centers for Medicare & Medicaid Services (CMS) placed renewed focus on this measure among Medicare Advantage members in 2023.  

As a triple-weighted measure, medication adherence has a much stronger impact on Healthcare Effectiveness Data and Information Set (HEDIS) and Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures. These help determine a health plan’s star rating, which evaluates member experience.  

Star ratings are extremely important to payers and providers, affecting profitability and growth for both. The system encourages providers and health plans to work together to achieve the common goal of high-quality, cost-effective care.

Health plans with at least a 4-star rating (out of the maximum five) capture quality bonus payments from CMS. This helps keep premiums low and plans competitive. CMS also promotes plans with the highest star ratings to enrollees, which boosts membership. When plans move up from a 3- to 4-star rating, they stand to see revenue growth of up to 17.6% through increased enrollment and quality bonus payments.   

Medication Adherence in Practice 

Medication adherence in the Medicare population focuses on three specific areas: diabetes, high cholesterol, and hypertension. 

According to Jayme Jacobo, medication adherence specialist with Innovista Health, keeping patients adherent is all about preventing bigger and costlier problems in the future.  

“When patients are not compliant with their medications, there is a much higher risk of developing more serious issues like heart disease. And if diabetes snowballs out of control, it could lead to multiple major complications,” she says. 

The triple-weighted measure places a lot of emphasis on payers and practices to get patients into a regular cadence with taking their medications as prescribed and refilling in a timely manner. Repeated lack of adherence from even one patient can impact a star rating—so swift, timely action is necessary. 

Jacobo pulls weekly reports from payers to get up-to-date information on medications that patients have been prescribed. She alerts providers of the patients who are at highest risk for nonadherence. (This typically means they failed one or more metric for two consecutive years.)

“I send that list of patients to the practice with highlighted focus points. This usually includes when they’re due to refill their medication, if they’re late with refilling, and if they have less than 90-day prescriptions. We encourage all providers to write for 90 or 100 days because that lessens the number of fills needed for the patient to pass the measure,” says Jacobo. “I advise practices to reach out to these patients. If they need appointments for refills, they need to come in earlier in the year, before it’s too late and they risk failing the measure.”

Jacobo continually reinforces the importance of the data so that staff can positively impact medication adherence among their patients. She will also call pharmacies to inquire about refills and reach out to patients to discuss adherence, remind them to make their follow-up appointment for refill orders, or arrange transportation so they can pick up refills. In these situations, she also seizes the opportunity to educate them about in-network medication delivery services, which eliminate the need to physically go to the pharmacy. 

Jacobo stresses that medication adherence is a measure you need to stay on top of every single day. “It is one of the only measures we can’t close by submitting supplemental data later in the year,” she explains. “It is a day-by-day, real-time measure you have to stay on top of constantly. Patient noncompliance can creep up quickly.”

Success in Houston

The efforts put forth by specialists like Jacobo are worth it when practices succeed in meeting or exceeding the medication adherence measure. This is perfectly illustrated with a huge success in the west Houston area. 

During a meeting with the physicians in this primary care practice, Jacobo says all of them were on board with letting her use their electronic medical records (EMR) to contact every high-risk patient and remind them to pick up their medications. She also left notes for staff with names of patients who were out of their medication. 

Many of these providers were not aware that some patients were not picking up their prescriptions or getting refills from other doctors.  

“The month I did this, every single patient on the report ended up filling their medication,” Jacobo says. Additionally, the practice improved their scores in nearly all measures.

Tips to Improve Medication Adherence 

Contacting patients and keeping providers informed were key plays to this major success—clearly proving that communication is paramount.  

Along with communication, though, there are other things providers and office staff can do to improve medication adherence: 

• Ask patients to bring all medications to appointments (even those from other prescribers). Review each one during the visit. Make sure patients understand how and when to take them. 
• Address social determinants of health that may affect medication adherence, such as financial or transportation issues. 
• Work through other barriers that could lead to nonadherence, including rising costs/copays, fear of side effects, mistrust, misunderstanding of the purpose of the drug, or depression.  
• Write prescriptions for a 90- or 100-day supply. 
• Utilize EMRs for easier tracking of prescriptions. Providers should also send prescriptions directly to the pharmacy versus fax or handing a paper prescription to the patient. 
• Educate patients about (and encourage enrollment in) medication delivery and auto refill programs. 
• Reach out to patients who are due for their annual wellness visit or yearly physical.
• Schedule monthly outreach to high-risk patients via phone or email to check on adherence. 

In fact, Jacobo says practices she works with that have a staff member delegated to medication adherence often see 100% compliance.  

The Bottom Line 

Success in value-based care hinges on a lot of factors centered around patient choices and decisions. Medication adherence is just one example of that. By working with companies like Innovista to proactively improve this measure, providers and payers often see a significant improvement in star ratings, performance, and patient outcomes.