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Risk Scoring, New Payment Models Can Reduce Medication Non-Adherence

Innovative payment models, more robust risk scoring, and new approaches to prior authorization may reduce medication non-adherence for members with mental health disorders.

Payers can address medication adherence through innovative payment designs and risk scoring.

Source: Thinkstock

By Thomas Beaton

- Adopting new payment models, engaging in targeted risk scoring, and improving prior authorization processes may help payers address medication-non adherence among members with mental health concerns, says a report from the National Council on Behavioral Health (NCBH).  

Nearly half of patients that require a prescription to treat their conditions are not picking up their prescriptions, which increases emergency room utilization and hospital use, NCBH said.

Medication non-adherence creates billions of dollars in avoidable costs.  Non-adherence may be exacerbated by payer formulary policies, insufficient collaboration among providers, and a lack of data analytics tools to create actionable insights.

NCBH outlined several strategies that payers can implement to reverse some of the troubling trends of medication non-adherence for patients with mental health diseases.

“If a substantial portion of the solutions in this report were implemented by 2025, an additional 25 percent of patients would see the value in taking medication as prescribed and we could avoid millions of dollars in medication paid for, but not used,” said Joe Parks, MD, Medical Director at NCBH.

“In addition, [the US] could save $2 billion annually in avoided hospital costs and see improved health nationwide.”

Payers should assess the risk of non-adherence based on the complexity of a patient’s medication regimen and the patient’s history with non-adherence, NCBH said.

Payers may wish to create risk scores based on the patient’s medication regimen.  Using data about the frequency of dosing, potential side effects, and anticipated barriers to medication access can inform a risk score that accurately assesses the patient’s likelihood of falling away from treatment.  

NCBH noted that changes to the reimbursement landscape will also support improved medication adherence.

The group recommended that payers should establish value-based payment models that include performance measures for medication adherence.

NCHB also advised payers to reduce or eliminate copays for certain medications. In addition, payers can address non-clinical barriers to adherence by funding programs that address social determinants of health and educate patients about how to achieve optimal adherence.

The Council advised public payers, private payers, pharmacy benefit managers, and other stakeholders to report and publish pharmacy claims data in an effort to improve transparency and potentially lower costs. Purchasers have access to data that could inform beneficiaries about the most cost-effective prescription options.

“Pricing and out-of-pocket costs should be made more transparent by all insurance companies up front, allowing providers and patients ready access to the cost of various treatments,” NCBH said.

“Providers must ensure that they understand patient preferences in relation to medication out-of-pocket costs and they must assure patients that they are considering these costs and minimizing them as much as possible.”

Payers should support the use of long-acting injectable medications (LAMs) and clozapine to ensure members with mental health diseases have access to effective anti-psychosis medicines, the Council said.

LAMs may be restricted by prior authorization protocols, which could create adherence challenges for members.

Payers can expand LAM access by equipping providers with formulary information about LAMs. NCBH suggested that payers need to lower prior authorization requirements for patients with behavioral health conditions that have maintained high adherence.

The Council stressed the importance of payer-provider collaboration when discussing best practices to limit the burden of prior authorization.

Payers can align inpatient and outpatient formularies so that patients and providers don’t need to re-learn how to access critical prescriptions. NCBH also advised payers to establish protocols that inform both inpatient and outpatient pharmacists about new formulary changes.

The Council emphasized the importance of addressing every possible factor of non-adherence for patients with significant mental health disorders.

“We hope that this report has persuaded the reader to be deeply concerned that non-adherence to prescribed medications is extremely common, frequently undiagnosed and unaddressed, and a major cause of poor treatment outcomes and increased costs,” NCBH said.


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