By Matt Phillion
The healthcare industry still has a medication adherence problem. It’s come up time and time again in recent years, but progress is slow, particularly among patients living in pharmacy deserts or facing other geographic or socioeconomic challenges. Meanwhile, avoidable medical costs due to nonadherence make up 20% of healthcare spending in the U.S. How can technology address these gaps?
A recent report from McKinsey looks at overcoming social determinant of health (SDoH) barriers through federal funding and partnerships. In particular, the report discusses managed care initiatives related to federal grants: “Many stakeholders know of available funding for delivering services such as food assistance, housing support, and transportation. However, options for funding data, analytics, and technology infrastructure that can optimize efforts to deliver services are less well-known. But this funding does indeed exist. And it can be used to support data integration (collating social-needs data alongside clinical and other data) and screening and referral capabilities (business processes and capabilities that include SDoH data sets to drive enrollment into targeted case management profiles for patients’ risk profile).”
“There are gaps in technology, and it’s just part of the problem. Patients may not have food, water, shelter, and we need processes in the clinical workflow to connect with these resources,” says Jason Z. Rose, CEO of AdhereHealth. “It’s very much a data-driven need to move the dial.” That kind of change takes a national focus, Rose notes, and medication adherence and SDoH aren’t always in the spotlight.
Medication nonadherence cost the industry $500 billion seven years ago, Rose says—and that number is likely to near a trillion dollars as baby boomers continue to age. “It’s a massive problem,” he says, one that mainstream discussion isn’t concentrating on enough.
Rose references a Health Affairs study from October 2022 that talks about the costs of nonadherence: “…each year there are an estimated 275,000 deaths and $528.4 billion wasted in the US due to suboptimal medication use through inaccurate prescribing, medication errors, adverse drug reactions, skipped doses, or treatment failures.” These negative outcomes disproportionately affect socially marginalized populations.
Organizations like AdhereHealth look to create innovative technology that can influence provider prescribing patterns so they focus on members who need the most help.
Who has the data?
Back in 2008, Donald Berwick of the Institute for Healthcare Improvement wrote about the Triple Aim of healthcare: better outcomes, lower costs, and better patient experiences. “Those three things still apply 15 years later,” says Rose.
Achieving the Triple Aim has to start with the payers, he adds. “They have all the risk with medical and pharmaceutical costs, so they are naturally incentivized to reduce the cost of care. They’re responsible for risk, have access to medical claims data, who’s prescribing, who’s diagnosing: They have available data that’s near real time.”
The average Medicare patient sees over five doctors, who often work in disparate systems. But the payer has the claims data that can clarify the patient’s current medications and most recent diagnoses. “The incentives are aligned, but they’re just not number one on the list because they’re not thinking about medication adherence as a priority to reduce costs,” says Rose.
Even without government involvement, health plans have the right incentives built in. “It’s pointing out the problem to them with data and demonstrating there’s an ROI if we increase correct adoption for these patients. This will reduce medical costs and then reduce future premiums, curbing medical inflation costs for everyone,” says Rose.
But, of course, the government is getting involved. CMS agrees that medication adherence is a focus, emphasized by its most recent star ratings. “Medication measures get harder and harder every year, and plans get caught flat-footed,” says Rose.
Three medication adherence measures in particular rise to the top of the discussion: hypertension, cardiovascular disease, and diabetes. “Those three measures impact more than just the scoring for triple-weighted measures,” says Rose. “If you’re not doing well with those three, that impacts other measures within stars.”
The Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey and patient experience now account for 33% of weighting, which often comes down to the patient’s experience with their physician and drug program, and are quadruple-weighted. “If you don’t do well with medication adherence, you don’t do well with CAHPS either. If they’re not getting the right medications, they’re probably not happy with the doctor, the drug program, or the plan itself,” says Rose.
Compounding this is the quintuple-weighted quality improvement measure. “If you don’t continue to get better every year, they hammer you on the Part D quality improvement factor,” he explains.
There is also the attrition factor: If a plan’s star rating drops, patients will leave. A landmark 2018 Guidehouse study found that every star earned for medication adherence increased enrollment in the plan by 8% to 12%. Conversely, a drop from a four-star rating to a three-star rating could cost a Medicare Advantage plan millions or billions of dollars.
“It’s a long-standing belief that star ratings are Darwinism in healthcare. If you don’t get the four stars, you’ve lost a percentage of your premium and lost funding to put into the product, and now because you’ve lost that, you’ve also lost membership enrollment,” says Rose. “And because you’ve lost the ability to compete with your peers, it’s going to take two years to come back with a higher star rating.” (Star ratings are based on the previous year’s data and revealed near the end of the year, so plans are under the gun to play catchup if their rating falls.)
“Quality is momentum,” Rose says. “This is a year-round effort. For patients who are not adherent this year, we’re already working with them to become adherent next year.”
There’s no reason to wait, either. Plans know which patients are already nonadherent, and a patient who’s nonadherent now will likely still be nonadherent next year. Better adherence “doesn’t magically happen on its own,” says Rose. “They have to overcome social determinants of health, and that can take several months.”
It’s also key to stay ahead of inflection points that can cause patients to become nonadherent. Rose brings up 90-day fills for prescriptions and how patients have to be adherent for 80% of the year to earn favorable star ratings. “If a patient can’t get that 90-day fill [because of SDoH, such as cost], it may be 120 days when someone calls them to say they haven’t refilled their drug. They already have a 60- or 70-day supply and they’re not incentivized to buy another fill, and by that point you’ve lost five months of adherence,” says Rose. “It’s mathematically impossible to hit that 80% compliance for the year.”
Success comes down to data. By keeping struggling patients adherent, their quality of care rises, ratings improve, and organizations do better financially. “Getting to a lower cost of care because it’s better quality of care, that’s how you get to the solution,” says Rose. “If a patient isn’t happy, they’ll leave, and a lost member is lost revenue. The goal is to bring on more members.”
Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at email@example.com.