Medication Adherence for Chronic Populations

A Medicare Advantage plan managing its Stars medication adherence measures can identify, from pharmacy claims, every member who has not filled their diabetes, blood pressure, or cholesterol medication in the past 30 to 90 days. The PDC calculation is automated. The member list is current. The Stars team knows exactly which members are holding down the adherence measures and by how much.

The question is what happens next. A refill reminder tells the member that their prescription is due. It does not ask whether the member stopped taking the medication because it caused side effects they did not report. It does not identify whether the member cannot afford the copay for a brand-name medication that has a generic alternative they were not offered. It does not surface the situation where a patient is taking the medication but filling it through a pharmacy not captured in the plan's claims — appearing non-adherent in the data when they are not.

Each of those barriers requires a different response. Side effects route to the pharmacist or prescribing provider. Cost barriers route to a patient assistance program or a formulary review. Incorrect claims data requires a pharmacy reconciliation. A misunderstood clinical instruction requires a clinical follow-up. A refill reminder system cannot distinguish between these situations because it does not have a two-way conversation with the member.

The Medication Adherence workflow within the Chronic and Longitudinal Care Management Agent contacts non-adherent members with a two-way interaction that identifies the specific barrier to medication access. Cost barriers route to patient assistance program information. Side effect concerns route to the pharmacist or prescribing provider. Suspected incorrect claims data triggers a pharmacy reconciliation follow-up. Clinical misunderstandings about whether the medication should still be taken are routed to the care team for clarification.

ZynReminder manages the follow-up cadence for members who need a second contact or whose barrier resolution requires a callback confirmation. Every interaction is documented with the barrier type, routing action, and outcome — giving the Stars quality team a breakdown of adherence barrier distribution across the non-adherent population.

For MA plans where medication adherence measures are among the highest-weighted components of the Stars composite, the change in PDC scores is visible at the measure level within a Stars measurement cycle. For the clinical team, the barrier documentation produces a population-level view of why members are not adhering — which is information the pharmacy and clinical programs can use to improve the underlying care delivery.