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I’ve spent much of my career on the operating side of healthcare, leading hospitals, physician group practices, and a health plan. One lesson has stayed with me: the most expensive problems are often the ones we recognize too late.
But cost is only part of the story. Before a missed refill becomes a quality gap, it may be a person trying to stretch a fixed income, manage an uncomfortable side effect, or make sense of a treatment they don’t fully understand.
By the time that struggle appears in a report, the opportunity to help may already be slipping away.
Medication adherence brings this challenge into sharp focus. In the 2027 Star Ratings, only 37% of Medicare Advantage drug-plan contracts earned four stars or more, down from 44% a year earlier. The three Part D adherence measures for diabetes medications, blood pressure medications, and statins will count triple again when 2027 performance is scored.
Plans are building their 2029 ratings now. But members aren’t thinking about the future Star rating. They’re thinking about whether they can afford, tolerate, and manage the medication in front of them.
That is where plans and pharmacies need to meet.
Adherence is personal. The response should be, too.
The refill is more than a transaction. It is an opportunity to hear what a claims record cannot tell you.
“This makes me dizzy.”
“I thought I didn’t need it anymore.”
“I can’t afford it this month.”
These are not simply adherence failures. They are barriers that deserve a response.
Pharmacists are uniquely positioned to hear them. In a JAMA Network Open study of more than 680,000 Medicare beneficiaries, the median beneficiary made 13 community pharmacy visits a year, compared with seven primary care encounters.¹ For many members, the pharmacist is a familiar, accessible connection to care.
AI can help identify who may need attention. But a conversation can uncover why and help determine whether the next refill happens.
We need both.
The gap is not a lack of commitment
Plans and pharmacies share an interest in keeping people well. Too often, they lack a connected way to act on it.
The plan holds claims, quality targets, and a broader view of the member’s care. The pharmacy holds the immediate opportunity to help: a person at the counter, a question, a concern, a prescription waiting to be picked up.
Those perspectives should reinforce each other. Instead, they too often remain separated by systems designed for different jobs.
Meanwhile, pharmacy teams face thin margins, stretched staffing, and clinical work that is not consistently captured, recognized, or reimbursed.
A pharmacist may resolve a concern that would otherwise interrupt treatment. But if that intervention never reaches the plan, its value remains invisible.
Everyone bears the consequences. Plans lose opportunities to improve quality. Pharmacies struggle to sustain the support they provide. And members are left to navigate barriers that neither organization can fully resolve alone.
We should not ask people to bridge gaps our systems have failed to close.
Let intelligence find the need. Let people deliver the care.
The answer is not to replace pharmacists with technology or add another dashboard to an already demanding day. It is to make the next meaningful action easier to see, take, and complete.
That requires four connected capabilities:
Identify the need. Use AI to surface medication-specific adherence risks and recommend a next step.
Move the work forward. Automate appropriate reminders, outreach, and routine follow-up so teams can focus on barriers that require a conversation.
Equip the person who can help. Give pharmacists actionable information and a clear path to address concerns, coordinate with prescribers, and connect members with support.
Make the work visible and sustainable. Capture interventions in workflows that support applicable documentation, reporting, and reimbursement requirements.
Start with services that fit the pharmacist’s day: adherence interventions, medication reviews, and vaccinations. Build from there.
The goal is not more activity. It is fewer unresolved barriers and fewer members left to manage them alone.
Move beyond pilots. Build a dependable model of care.
Pilots can establish what is possible. They cannot substitute for a durable operating model.
Plans and pharmacies need to answer three questions together.
What will we help members do?
Begin with adherence but define the role beyond dispensing. Consider where services such as GLP-1 support and nutrition support fit the needs of the population and the pharmacy’s capabilities.
Expansion should follow a clear care model, not simply a longer list of services.
What will each side commit to?
Shared data. Defined responsibilities. Sustainable payment. Agreed measures of success.
Partnership cannot mean asking pharmacies to do more while leaving them to absorb the cost. Nor can it mean asking plans to invest without visibility into what happened and whether it helped.
Both sides need accountability. Both sides need a reason to keep investing.
How will we know members are better off?
Quality and financial performance matter. So does whether a member’s barrier was actually resolved.
Did the prescription get picked up? Was the cost concern addressed? Did the side effect reach someone who could help? Was follow-up completed?
The measurement approach must be credible to plan leaders, workable for pharmacy teams, and connected to the member’s experience.
Humans drive. AI is the engine.
The future of adherence is not more technology standing between people and their care.
It is a pharmacist who knows why a member may be struggling. A plan that can see whether help reached them. And a member who does not have to start over, repeat the story, or navigate the next step alone.
At AssureCare, that is the future we are working to build: intelligence that helps people recognize the need sooner, act together, and follow through.
Stars matter. But the work begins with the person standing at the counter and whether we make it easier for them to get the care they need.
¹ Berenbrok LA, Gabriel N, Coley KC, Hernandez I. Evaluation of frequency of encounters with primary care physicians vs visits to community pharmacies among Medicare beneficiaries. JAMA Network Open. 2020;3(7):e209132. doi:10.1001/jamanetworkopen.2020.9132.
