Closing the Quality Gap: Medication Adherence for Diabetes (MAD)

Medication Adherence for Medicare Advantage (MA) patients with Diabetes.

What is Diabetes?

Diabetes is a chronic health condition that affects how a body turns food into energy. With diabetes, the body does not make enough insulin (a hormone produced in the pancreas which regulates glucose in the blood) or cannot use it effectively. The total cost of diabetes in 2022, including direct and indirect medical costs, was over $412 billion. While there is no cure, there are measures that can be taken to keep it under control. These measures include losing weight, eating healthy, being active, and taking medication as prescribed.

Medication Adherence

One of the most important ways patients with chronic diseases can manage their health is by taking their prescribed medication as directed. Medication nonadherence can lead to potentially preventable hospitalizations and emergency department visits, disease progression and complications, potential harm to the patient, and increased costs. A patient is nonadherent when they take less than 80% of prescribed medications. Nonadherence is common among diabetes patients, with about 50% of patients not taking their medications as prescribed.

Medication Adherence for Diabetes (MAD)

Medication adherence measures are used in Medicare Advantage (MA) health plans to help increase the number of patients taking their diabetes medications as prescribed. In quality programs, this measure is triple weighted in quality programs, meaning it contributes more heavily to STAR ratings (the CMS calculation of quality of care and measurements of customer satisfaction) than other quality measures. Adherence is evaluated using the proportion of days covered (PDC). The Centers for Medicare and Medicaid Services (CMS) consider patients adherent if their PDC, based on prescription claims processed at the pharmacy under the Part D benefit, is 80% or more at the end of the measurement year.

Plan AffectedQuality Program AffectedCollection & Reporting Method
MedicareCMS Star RatingsPart D Prescription Claims: Pharmacy Data

Medication adherence for Diabetes (MAD) is defined as:

“Percentage of members ages 18 and older who adherence to their diabetes medication at least 80% of the time in the measurement period.”

The following classes of diabetes medications are included in this measure:

  • Biguanides
  • DPP-4 Inhibitors
  • GLP-1 Receptor Agonists
  • Meglitinides
  • SGLT2 Inhibitors
  • Sulfonylureas
  • Thiazolidinediones

Exclusions include:

  • Members in hospice or using hospice services
  • End Stage Renal Disease
  • Dialysis
  • One or more prescription claims for insulin

Improving Medication Adherence

Barriers to adherence include a lack of understanding of the diagnosis or the inability to obtain the medication due to cost, access, scarcity, or time. Patients often feel embarrassed by nonadherence and are reluctant to tell a healthcare professional if they do not take their medication. Providers can increase trust with diabetes patients and drive medication adherence by:

  1. Considering medication nonadherence as the first reason a patient’s condition is not under control.
  2. Developing a process for asking patients about medication adherence.
  3. Creating a shame- and blame-free space to discuss medications with the patient.
  4. Identifying why the patient is not taking their medication.
  5. Responding positively and thanking the patient for sharing.
  6. Tailoring the adherence solution to the patient.
  7. Involving the patient in their treatment plan.
  8. Setting the patient up for success.
  9. Addressing adherence barriers such as cost or transportation.
  10. Discussing continued therapy, timely refills, and extended supply prescriptions.

Reference: 2024 UHC Quality Reference Guide

About the Author

Tresa Shaw, MSN, RN

Tresa Shaw, MSN, RN

Director of Quality at CHESS