Medication adherence programs are gaining prominence as a key driver of improved outcomes and reduced costs, especially within value-based care (VBC) models. VBC entities, including accountable care organizations (ACOs) and health systems, are increasingly motivated to address adherence issues with remote therapeutic monitoring (RTM) and medication adherence devices. This is because poor adherence is directly linked to higher emergency room visits, hospitalizations, and other costly interventions. A strong adherence strategy not only supports better health outcomes but is also reimbursable through Medicare.
This article explores how medication adherence programs drive improved adherence, patient outcomes and financial savings within value-based care models. It focuses on their application in accountable care organizations and health systems through reimbursement mechanisms, technology integration, and strategic targeting of high-risk populations. returns.
Payment Mechanisms for Medication Adherence Programs
Payment structures for medication adherence programs can generally be divided into two categories: fee-for-service (FFS) and value-based care. Both models provide unique opportunities to incorporate medication adherence devices, such as the Tenovi Pillbox, PatchRx, and Adherium’s Hailie Sensors, for more reliable patient medication management.
Fee-For-Service
Under the fee-for-service model, reimbursement for medication adherence programs is available via the remote therapeutic monitoring codeset. This mechanism supports RTM medication adherence devices for data collection and transmission for musculoskeletal and respiratory conditions, which can be paired with other chronic care management services (CPT code 98977). This approach allows care providers to support adherence while gaining reimbursement for using medication adherence devices and monitoring. Many state Medicaid programs, Medicare, and some commercial payors cover this reimbursement pathway for eligible conditions.
Value-Based Care
Medication adherence devices offer an even broader range of benefits in value-based care settings. VBC entities operate under capitated payment models and quality rating systems that reward cost containment and improved patient outcomes. Medication adherence programs targeting high-cost events, such as hospital readmissions and emergency room visits, provide a pathway to achieving these goals.
For instance, hospitals penalized under the Hospital Readmission Reduction Program (HRRP) could see significant financial relief from reduced heart failure readmissions. Even small reductions in heart failure readmission rates (1% or more) can yield substantial payment adjustments from Medicare, benefiting both the hospital and the patient population.
Economic and Clinical Evidence for Medication Adherence
Improving medication adherence can lead to both economic and clinical benefits. A 2018 systematic review across 14 disease groups found that medication non-adherence costs range from $5,271 to $44,190 per person per year, depending on the condition. Patients with chronic diseases like diabetes and hypertension who adhere to their medication have significantly fewer ER visits and hospitalizations, resulting in considerable cost savings.
Specific studies further emphasize these benefits:
- In a study of chronic vascular disease patients, medication adherence resulted in medical savings by reducing hospitalizations, yielding a benefit-cost ratio exceeding 13:1 for hypertensive patients over age 65.
- For patients with heart failure, remote monitoring technology reduced the risk of all-cause hospitalizations by 80%, demonstrating both the financial and clinical advantages of adherence-focused interventions.
Medication Adherence Populations in Value-Based Care
Some medication adherence devices can track pillbox opening and closing events. This gives physicians data on how often patients take their prescribed medication. Certain patient populations and value-based healthcare initiatives may be more likely to benefit from implementing a medication adherence program. The following sections identify these populations.
Heart Failure Patients
Given the high rates of readmissions among heart failure patients, they are ideal candidates for medication adherence programs, especially within hospitals penalized under the HRRP. Reducing heart failure readmission rates even marginally, can lead to financial improvements for hospitals by reducing penalties and improving reimbursement rates across inpatient services.
Accountable Care Organizations
ACOs can benefit from adherence tools and solutions that prevent unplanned admissions and improve shared savings rates. For example, each avoided heart failure admission can potentially save an ACO more on average than the costs of adherence program implementation. The targeted enrollment of high-risk patients, particularly those recently discharged, aligns adherence programs with ACO goals, which focus on both cost reduction and improved patient outcomes.
High-Risk, High-Cost Populations
Other populations with high medication adherence barriers, such as patients with diabetes, schizophrenia, and hypertension, also stand to benefit. Non-adherence in these groups leads to higher emergency and inpatient care rates, driving up costs. Addressing these gaps can prevent progression to more severe health conditions, reducing long-term healthcare expenditures.
Why Medication Adherence is Essential for Value-Based Care Success
For value-based care entities, the impact of non-adherence is profound. Improving adherence can reduce avoidable events, such as hospitalizations and emergency visits, among the most costly in healthcare. Medication adherence devices, such as PatchRx, Tenovi Pillbox, and Adherium Hailie Sensors, identify high-risk patients and enable intervention that directly impacts clinical outcomes. The PatchRx platform is largely automated, requiring minimal clinical oversight, making it an efficient solution for organizations with limited resources.
In summary, medication adherence programs are uniquely positioned to support the goals of VBC by improving patient outcomes, reducing costs, and increasing quality scores. As adherence technologies evolve, they offer valuable tools for VBC entities to achieve meaningful results in both cost savings and patient care.
