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.

Agents have the conversation. Pharmacists, prescribers and member services resolve what they hear.

Members with gaps in fills. Pharmacy claims flag members whose days covered are falling behind, by measure.

A two-way check-in. The agent asks whether the member is still taking the medication and, if not, why, using scripts your team approves.

Side effects go to a clinician. Side effects and dosing confusion are routed to a pharmacist or the prescriber by rule.

Cost and access go to member services. Copay, formulary and pharmacy access questions go to the team that can resolve them.

Follow-up until it’s resolved. Two-way reminders confirm the refill or the next step.

Agents escalate, clinicians decide. Agents follow the escalation rules your team sets and hand clinical questions to a licensed clinician. They don’t diagnose or recommend treatment.