Medication nonadherence is a significant health problem today. Between 25% and 50% of patients worldwide do not take their medications as prescribed and 125,000 deaths in the U.S. have been attributed to nonadherence, according to the CDC on the new landscape of medication adherence improvement. That said, the “negative public health effects of nonadherence are entirely preventable”.

Medication-related behaviors are woven throughout star ratings

Medication adherence is also an issue that directly impacts health plan performance. A health plan’s ability to improve its member outcomes relies heavily on increasing medication adherence. Additionally, many conditions can be prevented and successfully managed with medication, including diabetes, high cholesterol and hypertension. In fact, it is so important, CMS considers medication adherence critical to a health plan’s performance and is reflected in a plan’s star rating.

Medication-related behavior influences about 50% of star ratings support health plans ability to support their members in taking their prescription medications. Of note, CMS can change these measures and weights year-to-year. Below are the 17 medication-related measures and what they pertain to:

  • Eight measures are tied directly to medication adherence
  • Five measures focus on specific health impacts (e.g. controlling blood sugar)
  • Two measures relate to the patient experience (how easy is it for consumers to get prescription drugs and the experience the consumer has with the drug plan)
  • Two measures pertain to the year-over-year medication improvement impacting the health plan’s overall improvement.
  • Triple-weighted measures include medication adherence for diabetes, hypertension, cholesterol and statin use in persons with diabetes

The power of medication behaviors influencing how a health plan performs cannot be overstated.

Higher star ratings retain members and attract new ones

Medicare Advantage plans rely on member enrollment to stay alive.

Increasing star ratings is key to attracting new enrollees and expanding market share. Improving from a 3- to 4-star rating can increase plan revenue from 13.4 percent to nearly 18 percent from increased enrollment and bonus payments according to a 2018 Navigant study. Plans with a 4-star or higher rating get a 5 percent bonus and plans with a 5-star rating can enroll beneficiaries all year long, not just during the Medicare open enrollment period (AEP).

In 2020, a CMS rule indicated that metrics from the customer experience will begin to carry more weight in determining a health plan’s star ratings. According to CMS, health plans lag behind other industries in the customer experience and new star ratings measures have been set in place this year to change that. Among other things, the customer experience involves helping health plans retain members and customer retention is one measure that is increasing in weight. Member engagement and retention tools help lower operational costs when members stay in network, reduce out-of-pocket expenses for members and build health plan brand loyalty. In fact, retained members account for more revenue than new members on a Medicare Advantage Plan, according to the October 2020 McKinsey article.

 The role of DatabaseRX in improving medication adherence

ConnectureDRX’s DatabaseRX is an extensive repository of therapeutic interchange options. This means a prescriber can change a prescription medication for the member with a chemically different medication that is often a lower-cost option.

But it doesn’t stop there. DatabaseRX is more than just a therapeutic interchange database. It is also a powerful analytics engine that assists health plans with proactive member messaging. These three elements combined are important for health plans and pharmacy benefit managers to build an effective medication adherence program—one that will deliver results for the member in improving outcomes, plan performance and ultimately star ratings.

Key components of DatabaseRX:

  • Extensive repository of therapeutic interchange options – Offering 42,000 NDCs, lower-cost options to help members and health plans save.
  • Powerful data analytics – With health plan (de-identified) member and RX data, DatabaseRX delivers analytics that tells where the health plan can save (based on condition and drugs) and can also drive these analytics to the member-specific level.
  • Proactive member messaging – Armed with these analytics, health plans can connect to members (via text, email, direct mail and through call center operators) about lower-cost therapeutic options they can discuss with their prescribers. Having these options removes barriers to affordable medications and can help improve adherence.Sample text message to member:

Dear Jack, 
You are currently on Crestor 20mg at $100.00 per month.
We recommend you speak to your prescriber about the following options:
atorvastatin Calcium for $5.00 per month or simvastatin for $4.00 per month.

Click here for more information on DatabaseRX, the solution driving improved health plan performance and Star Ratings.