Medication Adherence: 4 Steps to Improve Patient Outcomes

The $500 Billion Problem: How health Plans Can Finally Crack Medication Adherence

Nearly half of US adults with chronic conditions aren’t taking their medications as prescribed, a silent crisis costing the nation over $500 billion annually and contributing too 125,000 preventable deaths each year. As healthcare costs continue to soar, improving medication adherence is no longer just a matter of patient well-being-it’s a financial imperative for health plans and a critical factor in maintaining quality ratings.

The impact of widespread non-adherence is increasingly visible for health plans, with payors absorbing avoidable costs and facing potential hits to their Star Ratings, limiting incentive opportunities and quality scores. “Once adherence scores slip, recovery can take years, with bonus eligibility lost along the way,” a senior official stated. Despite evolving policies and regulations, a consistent focus on medication adherence remains a strong path forward. Disengagement today risks compounding cost pressures tomorrow.

Instead of retreating, health plans should view recent changes in measure weighting as an opportunity to double down on sustainable, member-centered strategies. These strategies must strengthen outcomes and drive success across all measures, irrespective of short-term scoring adjustments.The framework for success, experts say, begins with four data-driven strategies focused on:

Step 1: Data-Driven Risk Stratification – Identifying Those Who need help Most

effective adherence programs start with a clear understanding of individual member needs. plans must move beyond basic demographic data and leverage advanced analytics to identify members at highest risk of non-adherence. This requires combining behavioral readiness and social risk,and blend claims,pharmacy,and clinical outreach data for a 360-degree view of risk levels.

Step 2: Omnichannel Outreach – Meeting Members Where They Are

Adherence is a continuous process, built one conversation, one refill, and one dose at a time. Prosperous programs treat adherence as a dynamic journey requiring consistency, creativity, choice, and care.

True success means meeting members on their terms, mixing digital and customary methods while adapting to changing preferences. When health plans offer multiple connection points-live calls, mail, SMS, and digital options-engagement soars. Plans should prioritize outreach flexibility and use response data to guide the next step (e.g., a text message after a missed refill), avoiding friction and building trust through simple, encouraging language.

Step 3: Infusing Behavioral Science – Transforming Transactions into Relationships

Weaving behavioral science into outreach transforms interventions from transactional to relational. Conversations led by pharmacists, nurses, and care navigators trained in motivational interviewing and behavioral insights can transform member hesitation into confidence.

By addressing socioeconomic and behavioral barriers, these professionals can build trust and translate advice into action. “It helps when clinical outreach staff utilize strong ‘soft skills,’ such as the ability to express genuine empathy and create authentic connections,” according to a company release. Staff should be encouraged to communicate like humans, not from scripts, offering clear, supportive guidance focused on individual possibilities. Behavioral science isn’t just about better conversations-it’s about economics. When motivational interviewing prompts a timely refill, the plan avoids exponentially higher costs associated with deterioration, hospitalization, and disengagement.

Step 4: Activating the whole Team – Expanding the Circle of Engagement

Collaboration is key to consistency and preventing costly errors. Programs integrating provider alerts, electronic health record messaging, and pharmacy interventions ensure everyone has the same data, enhancing the team’s ability to prevent delays, reduce confusion, and avoid adverse events.

Plans must work with providers,pharmacies,community-based organizations,and other care team members to build strong networks,create seamless feedback loops,and coordinate around medication regimens. Aligned and thorough interaction ensures members receive a clear, unified message they can trust.Coordinated communication also prevents duplicative outreach,prior-authorization delays,and refill gaps,minimizing both member confusion and operational waste.

Prioritizing Adherence for Long-Term Success

Even as regulatory priorities evolve, medication adherence should remain a top priority for health plans seeking to maximize Star Ratings, quality Bonus Payments, and overall cost containment. Plans that invest in the technology, staff, and strategies required to prioritize member engagement, access, and support will reap both short- and long-term rewards in health outcomes and financial stability.