The Quintuple Aims of Improving Health Care Outcomes and the Impact of Medication Adherence

Jason Rose, CEO of AdhereHealth, shares how social determinants of health, such as access to transportation or affordable housing, significantly impact medication adherence by creating barriers for patients in terms of obtaining and taking their medications as prescribed.

Please share a little bit about yourself. 

My name is Jason Rose and I'm the CEO of AdhereHealth. I've spent my entire career in health care technology, nearly 30 years now. Before that I designed and received my graduate degree in health care technology from the business school of George Washington. There wasn't a health care technology degree back then or really even a health care tech space. Then I spent the next 10 years working primarily on the IT side of the provider space. I was a graduate intern for the Cerner Corporation, worked with Cerner, and was a client of Cerner at a big hospital system called Ardent. I moved into the payer side of what is now called value-based care in the 2000s and worked at length with a company that I helped build called Inovalon, which most people have probably heard of, before joining AdhereHealth.

You describe the quintuple aims of health care and the 5 driving forces of value in the health care ecosystem. Could you elaborate on what these are and their connection to medication adherence?

Back in 2008, Don Berwick coined the term the triple aim of health care. That includes lower cost of care, better patient experience, and better health care outcomes. Back then, people said, "You can't do that. You can't aim at three things at the same time." However now, people really focus on value-based care and these aims that are the framework of what's been going on in health care for the past 15 years.

About 5 years ago, pre-pandemic, a fourth aim was added: improving the clinician experience. Post-pandemic a fifth aim was added too: a focus on health equity. These last two are more pathways that make it possible to improve lower cost of care and bring about better outcomes and patient experience. Looking at the industry today, all 5 of these things are topical.

I believe that clinicians go into practicing medicine because their goal is to improve care. If they don't have the right data and workflow tools, they're asked to do things that are not supportive of better patient care and are going to be dissatisfied in their job. Decreases in clinician experience effectively create burnout. Related to this, concerns have been raised in recent years about doctor's time being consumed with EHR administrative tasks. EHR has transferred paper documentation to electronic documentation but we're still in silos of data. It's just digital silos instead of paper silos.

An example of this issue is that an average Medicare patient may see five and a half doctors a year and each doctor may be in a different EHR system. So if I'm a clinician, I only see the patient data from my practice or in my health system. Even in a good ACO, 60% of the patient visits are typically outside of the ACO. A patient may have a cardiologist, dermatologist, primary care doctor, an urgent care doctor, and none of these doctors are talking to each other. If a patient has an exacerbated event and they go to the hospital, I've heard as many as 40% of the readmissions from a hospital stay are due to medication non-adherence. That's because the hospital didn't know all the drugs that the patient was on when they got there and had to do their best with the available information. This is a data problem and it is frustrating for both patients and physicians. These issues lead to bad outcomes, high rates of readmission, waste, cost, mortality risk, and more. 

How do social determinants of health (SDOH) influence medication adherence? Are there specific SDOH factors that are particularly crucial in this context?

Social determinants of health, which is a fancy way of saying barriers of care, are issues that prevent a patient from getting good care, Think about Maslow's hierarchy of needs (food, water, shelter, etc) and apply it to health care. Food insecurity means that patients can't eat or don't have access to healthy foods. There are people who can't access safe drinking water or shelter in the US. On the next layer of the hierarchy is patient safety and issues such as access to a doctor, access to care, access to pharmacies, and health literacy.

About 70% of a patient's health care outcomes are not based on their genetic code, it's based on their zip code. If a clinician says "You need to take this medication, it's really important" but you don't have food on the table, which concern is your highest priority? Or even if in a low copay situation where a patient's only paying a few dollars doesn't sound like enough for you or me, but if I'm on 10 medications and welfare or have low income, my health care costs can be unmanageable. 

Can you share some key insights or strategies that have proven effective in improving medication adherence?

Every year there are half a trillion dollars of medical costs associated with medication non-adherence. For context, that's about 20% of the US health care spending. This is from the Annals of Pharmacotherapy study done in 2018. While that study was several years ago, the numbers have only gone up and it's probably closer to a trillion. This means unnecessary surgeries, unnecessary mortality, unnecessary hospitalizations, and more. And this is not about drug pricing, this is specifically related to unnecessary health care utilization, and medical costs because the patient wasn't adherent to their drugs.

About 50% of chronic disease patients fail to take their medications as prescribed. Among different age groups, geriatric patients do pretty well compared to others because they're more focused on their health, and it's more urgent. However, 50% of Americans with chronic diseases fail to take their medications as prescribed. And then on top of that, only 50 to 70% of prescribed medications are picked up. About 30% of those prescriptions picked up are taken as directed, and then only 15 to 20% of those are refilled. It's because of social determinants of health, these other things in patients' lives that are taking a higher precedence. 

Let's talk about strategies. Clinical data siloed in EHR systems is important, but not comprehensive. The best source of complete and timely data is from payers. Payers have medical and pharmacy claims data, eligibility data, and hospital discharge information. Medical claims are going to consist of things such as new diagnoses and pharmacy claims show persistence of a new drug therapy taken or lack of therapy taken based on the diagnosis. We need to gather the payer data every day because pharmacy claims are adjudicated daily and understand the analytics about patients' drug interactions, contraindications, and how adherent they are based on evidence-based guidelines. We can evaluate if there are regulatory value-based care incentives like Star Ratings with Medicare that incentivize adherence. This data also shares the cost of care. 

If a patient has been diagnosed with epilepsy but has never picked up their anti-seizure medicine, the PBM isn't aware that the patient has epilepsy because they never got a pharmacy claim and the doctor is probably not incentivized to follow up with the patient on whether or not they ever picked up their medication. This is a very common and preventable situation. We need to think about incentives and access to timely data. With timely data, then you can create a workflow and it shouldn't be a spreadsheet. Believe it or not, the vast majority of health plans in the country and PBMs handle all their data with Excel, not in their EHR. You need a workflow that organizes the data, My company has built one, but it doesn't really exist outside of AdhereHealth. 

Outside of my company there also isn't a great example of medication adherence, value-based care health care patient relationship management (PRM). What we do is take everyday pharmacy data, medication, medical data, eligibility data, hospital discharge data, and other quality measurement data from the plans, providers, and PBMs. We analyze information, identify gaps, and then create a nice clean workflow with clinician input.

Knowing that social determinants of health need to be addressed, you can integrate free tools like food banks to help patients into your workflow that ultimately address medication adherence. Remember that these are not one-time shot solutions, these are perpetual problems. Check up on patients, see what the data shows, and adjust accordingly. 

What role can MA plans play in promoting medication adherence?

The ultimate payer is CMS, but what can CMS do to influence MA plans to drive more outcomes? Over the last several years, the Star Rating measure has been weighted more and more towards health care improvement, adherence, and quality outcomes and they're shifting away from administrative issues and patient experience. These changes directly influence the Medicare Advantage plans. This is important because if you don't have a quality product, members don't choose you as their plan. Every year studies show a 10% higher enrollment rate for a Star Rating. For example, when members see that a plan is a three-star versus a four, they choose the four-star plan 10% more of the time. This is Darwinism in health care: only the strongest will survive. Because of this, it is important to invest in patient relationship management platforms, analytics, and partnering with providers to drive outcomes. The members unable to meet medication adherence goals are those most vulnerable and have SDOH problems such as low-income that need the most help. 

How do you envision the future of medication adherence support and its role in value-based care? Are there emerging trends or technologies that could further enhance adherence and health care outcomes?

Beyond EHR data I think that there are federal and private initiatives at play to increase access to clinical data in a more usable format that can be combined with claims data to drive better outcomes. It has been a long time in the making but the technology has improved and health systems, payers, and those who are at risk are demanding that they find other avenues to drive outcomes. The market may push towards systems that look at a more comprehensive data footprint for a patient that combines the holy grail of clinical and claims data coming together because it doesn't exist anywhere today. Overall, I'm very optimistic about things to come.

While there are concerns and pessimism about inflation, I think that sometimes you need to get to a point where you have no choice. For example, the Medicare trust fund is supposed to go bankrupt in 2026 and that's going to cause problems to get fixed. The call to action is right now because we're at a point where the gravy train is over. Better outcomes, lower cost of care, better patient experience, and lower costs need to happen now because the country is not going to survive without change. I think people are starting to recognize, including AdhereHealth, that medication adherence is a primary component of these larger issues. I'm very optimistic that with time we will see positive changes.