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Boost Star Ratings, Improve Care Through Increased Patient Engagement
By Edan Stanley
Jason Rose, CEO of AdhereHealth, a health care technology solutions company, explains what steps health plans can take to enhance their star ratings and boost adherence, as well as addresses the role social determinants play in improving patient outcomes.
Podcast Transcript:
Please introduce yourself and tell me a bit about your background.
I'm Jason Rose. I'm the CEO of AdhereHealth. A little bit about my background is my entire career has been in health care and health care technology. I like to say that I was in the health care technology field before there was a field called health care technology back in the mid 1990s.
My first 10 years of my career, after custom creating my master's program to be focusing into health care technology. I got the George Washington University School of Business to allow me to custom create my degree program to focus on health care tech. They didn't have a program for that back in the day.
As a part of that, I did a graduate internship at Cerner Corporation, so I'm actually the first graduate intern for Cerner—maybe the only one, [laughs] but I know I'm the first one.
The next 10 years, I really spent on technology. I was on the career path to being a CIO, was a CIO and management of technology infrastructure processes and systems.
In the mid-2000s, I had an opportunity to start creating products and client solutions and focusing more on the managed care side of the house to coordinate with physicians, coordinate with consumers directly to improve outcomes.
Really, that's been my entire career in a nutshell in a lot of ways, is that looking back, I'm definitely a data-driven, technology-focused executive that judges results based on outcomes.
That is where I think health care is today—what it should be. That's what it always should be, is focusing on, are we moving the dial? Are we reducing unnecessary costs to care, are we improving quality of care, and how are we measuring those outcomes, and are we moving towards this value-based care system?
That is what AdhereHealth does, more focused on medication adherence, but really, that defines my career as well.
Can you highlight some of the categories that Medicare Advantage plans struggle with the most in terms of their star ratings?
It's no secret but not publicized a lot that medication adherence, as a whole, is one of the largest problems in the United States health care system today. I'll step back. Not just for Medicare Advantage, but for all of health care.
Over half a trillion dollars a year, about almost 20%, of the US health care spend in total is avoidable by getting consumers to be more adherent to their medications. I consider that a national priority. I think that that should be really, if not the, most important topic in health care today certainly amongst the top couple or so.
If we're to get consumers to be on the right medications and taking them in an adherent manner, which is typically 80% of the time. Some drugs are higher, like HIV is more in the 90% to 95% but most drugs are 80% or higher and considered adherent.
Then we would literally save half a trillion dollars a year. CMS [Centers for Medicare & Medicaid Services] agrees with that because if you look at the Medicare Advantage star rating system, 50% of the overall waiting is on medication adherence.
Again, that's not something that you're going to see written down a lot for some reason, but if you just simply do the math, and we've published a document a few weeks ago in early August in the American Journal of Managed Care the detail of those.
Literally 50% of the entire weighting for Medicare Advantage star ratings is focusing on medication adherence. That happens to also be the primary area where plans struggle with because it's hard. Because getting patients to take their drugs or know which drug they should take is really challenging.
Overcoming social determinants of health, barriers to care, access to doctors, to pharmacies is really challenging. NIH National Institutes of Health] also published an article, which you've probably seen as well, is that most Americans young and old only take their medications 50% of the time correctly.
There's a big gap that 50% of the time that they're taking their medication causes over half a trillion dollars of unnecessary cost. CMS put their money where their mouth is and said, “We’re focusing on med adherence.”
They've triple-weighted the three of the Part D measures, which is Ras statins, and diabetes. Those three measures are all triple-weighted. The HbA1c is also triple-weighted. There are a number of measures that are related to medication adherence and plans do struggle with that and it's been a challenge for them.
Studies show that nearly three-quarters of the members choose plans with ratings of four stars or higher. In order to maintain that four-star or higher rating, what should health plans focus on?
Great point. Navigant did that study a couple of years ago. Also, I've seen that study done six, seven years ago. That's pretty consistent now for almost nine years, is that consumers want to be working with higher-quality plans.
At the end of the day, why is that? Because if they can work with a plan that cares about them and their quality of care, then that is the plan that they should go to.
I think that my perspective is, and this is best practice, right in enrollment, the most important thing that a health plan could and should do is they should make sure that the consumer is aware of their benefits.
The tip of the spear for any new member in a health plan, whether the Medicare Advantage or any other health plan, is typically actually buying their medications, as most people are already on some drugs at some point. And when they go to the pharmacy to go buy their drugs, that's their first interaction to whether or not it's going to be approved or denied and what the copay or coinsurance is going to be, if anything.
Medications is the tip of the spear first interaction that a plan will have with its member and ensuring that the member has a really good understanding of those benefits is really critically important. I would say that would be the first part.
The second part is that when you're dealing with these consumers who are having medication adherence issues, which is a very large amount of them, they really want to be working with those who care about them. If you know that they speak in Mandarin, then you should be calling them with someone who speaks Mandarin, the first call.
There are system flags you can put in place to say, this person is Russian, this person is Taiwanese, or this person is Vietnamese and out of the gate instead of calling them with an English speaking person, know out of the box that they're speaking a different language and you should embrace that.
In addition to that, if a consumer is designated to be a low-income subsidy (LIS), then you should be focusing on areas that are applicable to them. We see the best way to engage with the consumer is actually focusing on what they care about.
If a consumer doesn't have food in the refrigerator, they don't have access to their doctor, they're worried about—and we had a consumer impact story on this a couple of weeks ago—they're worried about their dog eating more so than taking their drugs.
Really focusing on what matters to them. What's in it for me? So to speak. W-I-I-F-M. What's in it for me? What matters to them. First and foremost, engage with the consumer. Then from there, you can build upon other areas like medication adherence.
"Do you have food in your fridge? You don't have food in your fridge? Let's go help you take care of that. Let's get, whether be Meals on Wheels or Mom's Meals or what have you. Let's take care of that." There are community food pantries, there are places that you can get free dog food, for example, so they can take care of their pets.
These are the, what I always like to say, Maslow's hierarchy of needs, food, water, shelter. That shows the consumer that you care about them, you want to engage with them and then that builds trust, and that trust can translate to helping build some momentum for quality-of-care improvement.
What strategies do you suggest that health plans implement to improve struggling ratings, or continue to boost well-performing categories?
What we often see, almost always, in all candor, is that most health plans today have built great analytic capabilities. They have a good sense of cohorts of patients within our populations.
They may have a good understanding of those who are struggling with certain measures, whether it be medication adherence for the three triple-weighted RAS, statins, diabetes, or they are diabetic. Is it on a statin, which is a sub-D, Part D measure, or their A1C for blood sugar glucose, etc.
They have pretty good analytics for that, but what they do from there is I think almost absurd, is that they'll take that data and they'll dump it into Excel or Access—Microsoft Access database. Then they expect that their clinical team will just call them and check the box and fix it. It's just, life doesn't work that way. I would think about what I just described about engaging with a consumer. You don’t get there on looking at an Excel file and seeing that the patient has a gap in their taking their diabetes medication.
If you're calling them and talking about, "Do you have food in your fridge? Do you have access to your doctor? Can you pay for your transportation to see your physician, or get to your pharmacy? Can you walk to your mailbox to pick up the pharmacy if it was mail-ordered? Do you need it home-delivered to you? Do you have a credit card? Do you need to pay in cash?'
These are all really, really important areas that are problematic in terms of the health plans' boosting their actual performance, and you're just not going to get that out of Excel. What a best practice is to treat the consumer holistically. Treat the consumer as a human being and use a clinical workflow platform.
We have our own system that we use, the Adhere platform. Those analytics get fed on a nightly basis into our clinical workflow system, gets assigned to the right type of clinician—whether it be a pharmacy technician, a pharmacist, a nurse, nurse practitioner, depending upon the type of issue we're trying to resolve, or the complexity of the consumer themselves. It documents the interaction that we have with the consumer, or their doctor, and has a workflow system that will trigger back to say, "OK, well..." Let's say John Smith is the consumer, and he said that he didn't have food in his refrigerator.
We got him connected, either through our own assets or with Aunt Bertha, which is a website service that has community-based resources to overcome things of that nature. Or we work with the health plan to get Meals on Wheels delivered to their house.
Then we call them back. The systems flags for someone in our call center to call back the consumer in seven days and make sure, "Did you get food delivered to your refrigerator so you're not worried about eating?" "Yes, I did."
OK, now let's talk about your medications. Do you understand why you were prescribed them, why your doctor believed that you should get these issues resolved? Then we focus on getting him enrolled in the right pharmacy.
You're just not going to be able to have that kind of workflow in Access or in Excel, and you can't track these things either, from a HIPAA perspective. It really doesn't treat the patient as a live human being that has their own issues that need to get resolved over time, because it's not a one-and-done kind of interaction.
We think it's an ongoing engagement throughout the course of the year. You get the consumer on the drug the first time, maybe in March. Well, you have to keep them on the drug all year long to meet the guidelines with CMS, which is 80% proportion days covered, or PDC.
Monitoring that on a daily basis is really critical. I would say, engaging with the consumer holistically is also important.
What are some the biggest mistakes that a health plan can make during this time, especially when ratings are just around the corner?
Most health plans—They may have good analytics, but they're using lagging indicators. CMS has a system that is the judge and jury, so to speak, of whether or not the plan performed well on these medication adherence issues called Acumen.
Acumen has always lagged a couple months behind in terms of which consumers are performing well on PDC, which is medication adherence indicator, and which ones are not. If you're always two months behind, then it's too late.
You only get 292 days of the year that you have to get the consumer compliant. If you're 60 days behind, always, all year, then you're really setting yourself up for failure. Not depending on the lagging indicator of Acumen, but really using a real-time clinical analytics workflow that gets updated minimally every week, is really important. That way, you have an accurate representation of right now, today, who needs help? Who can I just monitor and surveil with my data, and what do I need to do when I actually get them engaged, whether it be in person or on the phone, or through the doctor, or whatever alignment or strategy that you have in place, but having that real-time data -- I'd say that'd be the first thing.
The second thing would be with respect to campaigns. If you remember the old thought process way back with disease management, which was a failed concept from 10 or 15 years ago. Disease management was very campaign-oriented. It was breast cancer awareness month. It's diabetes awareness month. It's lung cancer awareness month.
It's just marketing, punching out phone calls, and IVRs, and mailers on a particular disease or issue, but it doesn't really speak to the consumer directly about them.
Maybe there's a reason why they're not taking their diabetes medications. It's probably that they can't afford them or have other priorities, or they don't understand it. Doing a diabetes awareness month once a year isn't going to cut it.
Holistically, throughout the year is my theme. Engagement with the member about them personally where—these are one of the transition points that health plans are trying to pivot to, is engagement with the consumer. I think campaigns are not a good strategy to do that. It should be ongoing for the consumers' issues themselves.
Jason, thank you so much for taking the time to speak with me today. Is there anything you’d like to add?
Jason: I think that the one area that I wanted to highlight, and I referenced this a little bit in our dialogue, is that when you have an opportunity to engage with a consumer, then—there's a balance to this, of course—but what are all the things that you want to cover in that dialogue with the consumer?
We talked about if you have them engaged and you want to focus on, what do they need to feel like there's some momentum in terms of quality? Food in the refrigerator. That is important to this particular person? Let's do that. Maybe it's transportation to the doctor.
But a piece that I haven't seen other than AdhereHealth, is that what we do uniquely, in addition to everything we just described, is that we also take the opportunity that if we've gotten the consumer to the point where they acknowledge that medications adherence are important and they need to focus on it, which might take a couple of phone calls after we overcome the other barriers of care, that's the right timing to now engage them in the right pharmacy, too.
Certainly, mail order is the least expensive way to get a consumer on a pharmacy for a 90-day fill, but that may not be the best pharmacy for everybody.
There are compliance packaging companies out there that are great because it shows adherence in terms of packets of pills that they take throughout the course of the day, and then you just rip off the next pouch and you take those pills. Then we have a pharmacy called AdhereRx, which is a patient that may not be in the same medications every month is very volatile.
We're needing to coordinate with the doctor and the consumer to make sure they're on the right drugs for this month and hoping that we can actually reduce the number of drugs that they take, get them on the right drugs, and then have a comprehensive medication review with a pharmacist every single month.
Not everyone needs that level of oversight and coordination with a pharmacist, but a lot of people do. I think that when you have the opportunity to engage with the consumer, actually enroll them in the pharmacy right then and there.
In our case, our system has integration with national pharmacies and our own pharmacy, of course, where we can do that. Then that way, it's a closed-loop system. So we not only overcame the barriers of care and the social determinants of health, but we actually got them on the pharmacy right then and there, and collect their credit cards.
All the pharmacy does is fill the drugs, vs hoping that they go to Walgreens or CVS or they go to the mail order. We try to do it right then and there to close the loop. That gets the claim to drop nearly immediately with respect to getting a credit with CMS for the drugs being dispensed and getting the improvement on the PTC for star ratings.
Also, at the end of the day, you got the patient their medications that they need and you did it quickly, vs hoping that they figure that out on their own.
