Reducing Costs and Improving Member Outcomes with Medication Optimization Strategies

Published on .

Medication optimization is a key strategy for addressing the high costs and poor outcomes associated with medication nonadherence. How can health plans implement data-driven workflows to ensure members are accessing and adhering to their medications?


Medication nonadherence is one of healthcare’s most significant challenges. Nearly half of all people with chronic conditions do not take their medications appropriately, leading to approximately half a trillion dollars in unnecessary spending, as well as tens of thousands of avoidable deaths each year.

No single entity is wholly to blame for the problem. Patients, providers, health plans, pharmacies, and pharmacy benefit managers (PBMs) each bear some portion of the responsibility when a medication is not taken as prescribed.

To address the issue and avoid negative downstream effects, we must implement clinical and technical solutions that improve communication and education across the entire care continuum. We must ensure all patients are on the right medications, that the medications are accessible and affordable, and potential drug therapy problems (DTPs) are nipped in the bud.

Medication optimization techniques play a key role in achieving these goals. With a combination of advanced analytics and peer-to-peer relationship building, health plans can take the lead on providing safe, cost-effective, and reliable access to medications that help members avoid future spending and potential health deterioration.


Why is Medication Adherence so Difficult to Achieve and Maintain?

Health plan members struggle with medication adherence for several reasons, not all of which are in their direct control. In many cases, interoperability siloes and poor visibility into key data can put members on a path to failure before they even start taking their pills. For example, drug formularies vary widely from plan to plan, making it difficult for prescribers to have clear visibility into cost and coverage at the point of care. Without the right tools to choose an affordable medication—such as a generic or biosimilar—prescribers may inadvertently select a drug that is not accessible for their patients.

This lack of visibility extends even further to health plans and pharmacy benefit managers (PBMs). Due to technical and cultural barriers, neither routinely look at clinical data as part of their workflows, leaving major gaps in their understanding of a member’s health journey.

Typically, a PBM doesn’t know that a member has been diagnosed with a new condition or that a prescription has been written until the member fills that script and triggers a billing event. If the member never makes it to the pharmacy, the PBM may not be aware the member is now nonadherent. This is a complete blind spot.

Health plans also struggle to gain insight into clinical activities that don’t result in claims, increasing the scope of the knowledge gap. This lack of awareness can have serious consequences for some health plans, especially Medicare Advantage (MA) plans, who are held to numerous medication adherence measures through the MA Star Ratings system. Without the ability to stay in the loop, plans risk lower performance scores and higher amounts of avoidable cost.

All these challenges are compounded by social determinants of health (SDOH) barriers such as member ability to access medications, take them as prescribed, and manage their own health. Financial insecurity is a significant driver of poor adherence, but so are food insecurity, housing instability, transportation issues, and other non-clinical factors. Since members are more likely to prioritize items that fill basic human needs, such as groceries and utilities, over their medications, many prescriptions simply fall by the wayside. Without intervention from their providers, health plans, or PBMs, members not taking their medications as prescribed may suffer more crisis-level health events.


Solving for Nonadherence with Data-Driven Medication Optimization

Fortunately, solutions are available to combat the medication nonadherence epidemic. With a two-part process integrating cutting-edge data analytics with person-centered relationship building, health plans can get ahead of common medication problems for their members.

Part 1: Supporting Members

The first step is identifying members who have been guaranteed nonadherent (GNA) in the past or are at risk of becoming nonadherent in the near future. By leveraging analytics to examine key variables, including drug type, known SDOH risk factors, existing diagnoses, and healthcare utilization, health plans can capture high-risk individuals—especially if they are not currently taking a medication that might improve their health. For example, if a patient has been recently diagnosed with epilepsy and has not filled a script for a recommended drug, that could indicate a care gap somewhere along the line.

Developing a clearly defined cohort of people with existing or potential DTPs can also help health plans map members back to the providers who may be contributing to medication-related issues. In other words, if many members with DTPs are all patients at a single practice, the health plan has a clear opportunity to work with that practice on its prescribing habits and prevent future DTPs at the source.

Part 2: Supporting Providers

Engaging identified providers in a non-judgmental, proactive, workflow-friendly manner is the second piece of the puzzle. With the right medication optimization solution, health plans can send lists of patients with potential DTPs directly to providers via fax or other communication channels.

If the provider does not address issues in a timely manner, a call from an experienced nurse colleague can help identify the root of the problem. Did the patient with epilepsy fail to fill a prescription, or was that prescription never written in the first place? Understanding where the gap occurs is crucial for ensuring the member gets the right care and avoids a high-cost health event down the line.

By implementing data-driven solutions to medication optimization, health plans can work with providers, PBMs, and members to create a network of care around each individual. With advanced tools and strategies, plans can create a clear and accessible pathway to improved adherence. Doing so brings benefits across the board: better experiences for patients, better relationships with providers, lower costs for the health system, and higher performance scores for health plans.

To learn more about how to integrate medication optimization techniques to improve quality of care (and medication adherence) while reducing utilization and costs, watch our latest webinar, Medication Optimization: A Key Enabler to Reducing Utilization and Costs.