The adherence paradox: a system designed to fix breakdowns, not prevent them

Healthcare systems concentrate on identifying and intervening on non-adherent patients rather than reinforcing those who are already adherent because incentives, metrics, and operating models are built to close performance gaps—not to preserve stable behaviors.

Most adherence measures—especially those used by the Centers for Medicare & Medicaid Services (CMS) and defined by the Pharmacy Quality Alliance—are threshold-based. Patients are labeled adherent or non-adherent using benchmarks like Proportion of Days Covered (PDC ≥ 80%). Moving someone from 78% to 82% PDC counts as measurable improvement. Moving someone from 92% to 96% generates no additional credit. Rationally, resources flow to patients below the cutoff.

Risk stratification systems reinforce this deficit mindset. Predictive analytics are designed to detect refill gaps, rising risk, and failure states—not early signs of behavioral fragility among currently adherent patients. The infrastructure rewards remediation, not resilience.

Economics compounds the issue. Interventions such as pharmacist outreach, case management, and digital reminders are expensive. In budget cycles tied to quality bonuses, rescuing a non-adherent patient often delivers clearer short-term ROI than investing in someone already doing well. Preventing long-term adherence erosion rarely fits within immediate financial horizons.

There is also a cultural dimension. Healthcare organizations are trained to spot deviations—high A1c, uncontrolled blood pressure, missed refills—and correct them. But medication adherence is fundamentally a habit. Sustaining it depends on reducing friction, embedding cues, and designing supportive environments—not episodic fixes.

A different model—structural enablement—would redesign packaging, workflows, and patient touchpoints so adherence becomes the default. While likely more scalable and durable, this approach requires upstream redesign, coordination across stakeholders, and capital investment—changes that existing performance frameworks are not built to accommodate.

In short, the system prioritizes fixing failure because incentives, metrics, analytics, and operations are engineered to repair breakdowns—not to engineer sustained adherence by design.