As healthcare continues to advance with accountable care organizations and value-based care models, the industry is starting to see some real traction after a decade of groundwork in the form of CMS claims for the Medicare Shared Savings Program.
There are some critical elements driving success here. The role of medication adherence and patient engagement are pivotal factors for continuing to achieve ACO and VBC goals. And even modest improvements in medication adherence can drive significant economic impacts for health systems.
Dr. Colin Banas, chief medical officer at DrFirst, a medication management technology company, says these strategies translate into real-world benefits from the “prescriptions perspective.” We spoke with him recently to better understand some of the progress being made.
Q. What has the first decade or so of groundwork in value-based care looked like, and where do we sit today?
A. The value-based care journey spans more than two decades, with early efforts marked by significant challenges. In the beginning, organizations struggled with systems interoperability, data sharing and the high cost of technology upgrades – barriers that complicated the shift from fee-for-service to value-based models, which rely heavily on data analytics and EHR systems.
Initially, the focus was more on reducing costs than improving patient outcomes. Health systems had to navigate two conflicting financial models: fee-for-service, which incentivized volume and procedures, and value-based care, which prioritizes preventive care and keeping patients healthy.
Organizations with capitated payment models, like Kaiser, had an early advantage since they were not financially dependent on high procedure volumes. Meanwhile, smaller providers hesitated to adopt value-based models due to financial risks and limited resources for infrastructure upgrades.
Progress required forward-thinking innovators to take on the growing pains and demonstrate the feasibility of value-based care. Over time, pioneers achieved success, and payers like CMS refined metrics and offered incentives for quality care. These efforts have gradually shifted the focus from cost-cutting to improving patient outcomes, with increasing recognition of the importance of engaging patients in their care.
Today, value-based care emphasizes collaboration among providers, payers and other stakeholders to share best practices and improve care coordination. While steady progress has been made, reconciling fee-for-service and value-based models remains a challenge, as the financial incentives often remain at odds.
Q. What role would you say medication adherence plays as a factor for continuing to achieve accountable care organization and value-based care goals?
A. Medication adherence is essential in any chronic disease management strategy. We’ve all seen the stats on the high costs of nonadherence: the readmissions, emergency visits and complications that arise when patients don’t take medications as prescribed. And we know intuitively – without needing detailed data – that if patients with diabetes skip their insulin, the next stop is likely the hospital.
Outcomes for conditions such as congestive heart failure, COPD, hypertension and cardiovascular disease are tightly linked to medication adherence. Unfortunately, evidence shows many patients only adhere to their medications for chronic conditions about half the time, which means their treatments won’t be effective.
When patients stay on track with their prescriptions, their risk of serious complications drops, which is precisely what value-based care aims to achieve. Even small improvements in adherence can make a significant impact, especially when managing large patient populations. Boosting adherence by just a few percentage points can lead to significantly fewer hospitalizations and better outcomes.
However, achieving this requires a dedicated, multidisciplinary team that includes nursing, pharmacy, remote monitoring and social work to address real-life barriers to access, affordability and adherence.
Sometimes, patients struggle to share what’s getting in the way of taking their medications or don’t fully grasp the impact nonadherence can have on their health. That’s where asking the right questions becomes so important – it helps uncover those barriers.
Education and open communication are key. Patients need to understand their treatment plan, and providers need to recognize that patients’ challenges might change over time. Staying connected and adaptable is what makes a difference in helping them stick with their medications.
I’d also add that accurate data is crucial – you can’t manage what you don’t measure. So, while adherence is a cornerstone of value-based care, it depends on the right team, tools and targeted patient engagement to be effective.
Q. How can even modest improvements in medication adherence drive significant economic impacts for health systems?
A. Improving medication adherence even modestly can be financially transformative for health systems, especially when it impacts quality metrics like those tied to CMS star ratings for Medicare Advantage plans. The difference between a four-star and a five-star plan – where five stars bring greater incentives and better marketability – often boils down to a 1% or 2% improvement in adherence for conditions like diabetes or heart failure.
Even with some uncertainty about how incentives may change with the new administration, if a plan’s adherence rates jump from 80% to 85% or even 90%, it creates a measurable advantage over competitors. Higher ratings draw more plan enrollments and help maintain loyal members.
The financial incentives are clear, but so are the benefits to patient care. By raising adherence rates, health systems not only gain a competitive edge but also reinforce value-based goals with real, measurable outcomes.
Q. What role does patient engagement play as a factor for continuing to achieve ACO and VBC goals?
A. Patient engagement is critical, and today, ACOs have more tools at their disposal than ever before. Ten years ago, telehealth was more of a concept than a reality, and smartphones weren’t nearly as ubiquitous. Interoperability among health IT systems was, at best, a work in progress.
Now, interoperability is improving, and patient portals, digital health platforms and even asynchronous communication with mobile devices are widespread. Providers and patients alike are becoming comfortable engaging outside of in-person visits.
Today’s digital health tools allow for continuous patient engagement. For example, prescribed digital therapies can guide a patient post-surgery or through chronic condition management, offering reminders and tasks to complete on specific days.
Imagine a knee replacement patient receiving prompts to perform mobility exercises or track their blood thinner use. This keeps the patient on track and sends data back to providers, enabling proactive adjustments if a patient’s recovery isn’t going as planned.
Known as patient-reported outcomes, this data can be collected via mobile devices to shed light on a patient’s functional status, symptoms and health behaviors, which is vital for objectively assessing a patient’s progress. With these insights, providers get an understanding of patients’ physical health, pain and overall experience, and how these measures change over their course of care.
Most importantly, the data is gathered in real time, so the doctor doesn’t need to wait until the patient’s one-month follow-up to find out they haven’t been taking their blood thinner, for example, or doing their physical therapy.
A decade ago, this wasn’t possible. Today, engagement with patients goes beyond portals to SMS reminders sent to mobile devices and sensor-based medication tracking systems, which alert both patients and providers if doses are missed. These tracking devices are making a difference by narrowing the gap in data between when patients fill prescriptions and when they actually take the medication.
If a patient should have taken 30 pills over the month, but the pill bottle was opened only 20 times, the provider can surmise the patient isn’t taking their medication as prescribed. This multimodal approach allows healthcare providers to meet patients where they are, using tools already available.
As healthcare continues to adopt these technologies, we’re building the type of seamless ecosystem other industries have had for years, from banking to retail. It’s promising to see healthcare finally catching up in this regard.
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