Note: Our definition of “payers” for this research includes private health plans, including Medicare Advantage, as well as government payers like Medicare and Medicaid. The government/government stakeholders may have goals beyond those of Medicare and Medicaid, such as appealing to constituents and getting re-elected. We did not study the impact of behavior changes on these goals in this research. One study we analyzed that was applicable to government payers linked inadequate prenatal care to poorer continuity of care for infants given its correlation with increased rates of dropped Medicaid coverage.
Payers primarily stand to lower spend from behavior changes through members’ lower utilization of high-cost services. Evidence suggests this may happen across many of the behavior changes we examined, both preventive and chronic. The area with the greatest evidence was the impact of chronic medication adherence on private health plans.
Many studies have shown the link between chronic medication adherence and lower payer—often private health plan—spend. These studies found that medication-adherent members with chronic conditions often utilized less health care services, including high-cost inpatient and emergency department care. While preventive care changes also lowered payer costs, the magnitude of evidence for these behavior changes was much lower. It is notable that all the preventive care studies we found focused only on government payers.
Based on this evidence, payers should likely prioritize driving medication adherence among members with chronic conditions as a way of lowering spend.
While lowered spend was the primary impact identified, one study implied that chronic medication adherence—particularly for members with diabetes, high cholesterol, and high blood pressure—could also help with member acquisition and increased revenue for Medicare Advantage (MA) plans. Medication adherence in those three disease areas is a metric CMS uses to calculate Medicare star ratings, and high star ratings can differentiate MA plans for consumer members and affect annual bonus payments from CMS.
Breakdown of evidence-based behavior changes
Tier 1
Behaviors with ≥3 studies each |
Tier 2
Behaviors with 1-3 studies each |
- Chronic medication adherence (case in point below)(mostly private health plan studies with several payer-agnostic studies)
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- Screenings (private health plan study)
- Regular primary care (Medicare study)
- Preventive lifestyle changes (Medicare and Medicaid study)
- Pre-treatment care (payer-agnostic study)
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Case in point
Study objectives and parameters: To assess if there is an association between medication adherence (in three categories: hypertension medications, cholesterol-lowering medications, and diabetes medications) and total cost of care among 20 Medicare Advantage health plans.
Behavior change impact: One percentage point increase in average Proportion of Days Covered (PDC, a commonly used measure of medication adherence) was associated with a total cost of care decrease between $21 and $46 (range across three disease categories) per member per year.
