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 their medications as directed. For patients, 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 medication nonadherence. (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.
Medication adherence has become more important than ever for payers and providers in risk-based contracts. The Centers for Medicare & Medicaid Services (CMS) has 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. Ultimately, this determines a health plan’s star rating, which evaluates a member’s experience with their health plan and provider.
Star ratings are extremely important to payers and providers, affecting profitability and growth for both.
Health plans with at least a four-star rating (out of the maximum five) capture quality bonus payments from CMS, which 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.
The star rating system encourages providers and health plans with which they’re contracted to work together to achieve the common goal of high-quality, cost-effective care.
CMS’ attention to 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.
“With these three conditions, medication adherence could save patients a lot of trouble down the road. When they’re not compliant, 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.”
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.
To do this, Jacobo pulls weekly reports from payers to get the most up-to-date information on medications that patients have been prescribed.
She alerts providers of the patients who are at highest risk for nonadherence (meaning they failed one or more metric for two consecutive years). “I send that list of patients to the practice with highlighted focus points, like 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’ll leave a note for the practices to reach out to these patients or to make sure that if they need appointments to get refills, they come in earlier in the year, before it’s too late and they risk failing the measure.”
In addition, Jacobo assists medical offices in any way she can. She educates staff about how to use the reports and understand the data she provides so they can move the needle on better medication adherence among their patients.
She will also call pharmacies to inquire about refills, and even reach out to patients directly to discuss adherence, remind them to make a follow-up appointment so they can get their 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, because patient noncompliance can creep up on you and they can quickly fail the measure.”
The efforts put forth by specialists like Jacobo are worth it when practices succeed in meeting or exceeding this important 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 the physicians, telling them which patients were out of their medication.
As busy physicians, many of these providers were not aware which patients were not picking up their prescriptions, getting refills from other doctors, and other important data that pertains to adherence.
“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.
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:
In fact, Jacobo says practices she works with that have a staff member delegated to medication adherence often see 100% compliance.
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. But by taking a proactive approach to improving this measure by working with companies like Innovista, providers and payers often see a significant improvement in star ratings, performance, and patient outcomes.