Health

We’re Depriving Underserved Patients of the Best Drugs

During a busy clinic day for patients without health insurance, one of us received a jarring announcement. Certain lifesaving medications that we had previously been able to freely provide to patients were no longer available. the costs of these drugs were far beyond the reach of our patients, and so healthcare teams were forced to switch patients to less effective regimens. We doctors were escalating their risk by switching to cheaper regimens or not being able to start newer, more effective therapies in patients not yet on them.

We did not go to medical school to deprive patients of effective treatments, and yet, there we were, creating harm rather than providing benefit.

As expensive, new medications show their game-changing effects on health, we’re becoming increasingly concerned that innovative breakthroughs, however welcome, may actually worsen disparities.

As policymakers and advocates seek ways to revive the congressional social safety net bill, a measure to curb the cost of prescription drugs continues to receive broad partisan support. However, we have yet to see how this bill, or others like it, can ensure that all Americans, regardless of race, ethnicity, or socioeconomic status, have access to the highest quality medications needed to manage their health needs. This goal, referred to as pharmacoequityis one that has evaded the US for decades.

Several research studies have shown wide disparities in treatment because of medication costs. A study one of us published in 2019 found that 1 in 8 Americans with cardiovascular disease did not adhere to medications because of cost. These individuals shared that they either skipped doses, took less medication, or delayed filling a prescription to be able to save money. The world of oncology has described the financial toxicity that comes with expensive chemotherapy and immunotherapy treatments and the physical and psychological burden these costs place on patients with cancer. Furthermore, to recent analysis from the CDC found that cost-related medication non-adherence was associated with an over 20% higher rate of death for patients with chronic diseases.

Our research has also made it clear that cost is simply one barrier leading to treatment disparities. We have shown that even when adjusting for insurance status, education level, and household income, Black, Hispanic, and Asian patients are less likely to be prescribed novel, evidence-based diabetes drugs as well as stroke-preventing medications. A well described body of research shows that Black patients, including children, are less likely to receive appropriate pain medications for anything from a leg fracture in the emergency room to chronic back pain at their primary care physician. What’s more, the COVID-19 pandemic has further highlighted these disparities, as communities of color experienced poorer access to vaccines and new antiviral therapy to prevent and treat this devastating disease.

Decades of research and experimentation medical racism have wreaked havoc on the trust communities of color have in the medical system. Yet, beyond distrust, limited opportunities to those who are willing and able to begin new therapies abound, including poorer insurance coverage, burdensome copayments, and limited access to the appropriate medical prescribers. Even physical access to pharmacies limits drug access for communities of color who are more likely to reside in so-called pharmacy deserts. This unequal access to medication is made worse by implicit or unconscious bias that results in some medical providers prescribing certain therapies less frequently to lower income individuals and patients of color.

So, how do we achieve pharmacoequity and bring our nation towards a just health system? First, the appropriate prescription drugs must be available for all patients, regardless of the type of clinic or hospital where they receive care or from whom that care is provided. We can achieve this by implementing health system solutions, such as prescribe nudges, to help reduce treatment bias by race, ethnicity, or social class. Second, accessibility to prescription drugs must be improved. To achieve this goal, we must target the initial prescription a patient receives by ensuring all Americans have access to health insurance including through Medicaid expansion or a universal insurance system. We know that such programs work: both the UK’s National Health Service and Australia’s Pharmaceutical Benefits Scheme are able to provide evidence-based therapies at affordable costs to the majority of their populations. We must also bridge the geographic gap that some patients have in receiving medications. We can invest in strengthening medication delivery systems including through collaborations with rideshare companies and direct-to-consumer delivery services such as Amazon’s PillPack.

Finally, affordability of prescription drugs must be addressed. Americans pay more for prescription drugs than any other nation in the world. The high rate of medical debt associated with these costs results in deferred spending on basic needs such as housing, food, and education and will continue to widen the wealth gaps between low-income and individuals of color and their more advantaged counterparts. We need national innovations to reduce the cost burden on individuals, particularly for novel life-saving treatment. These may include some of the strategies within the previous Build Black Better Bill such as improved drug price negotiations by the federal government and caps on spending limits for Medicare enrollees. However, we should also consider broader strategies such as an essential medications list, international reference pricing for drugs, and increased cost regulation across the prescription drug cascade, from drug approval by the FDA to the determination of consumer pricing through intermediaries such as pharmacy benefit managers.

We are on the cusp of a life sciences revolution, but we are stepping into an era that could create ever greater disparities if we do not act immediately. The prescription drug measures within the Build Back Better bill offered insight into what policymakers can do to support affordable healthcare for the most vulnerable, but bolder action is needed. Effectively and equitably distributing novel, evidence-based, and high-quality treatments to underserved patients should be our nation’s priority. In doing so we can achieve pharmacoequity.

Utibe Essien, MD, MPH, is an assistant professor at the University of Pittsburgh School of Medicine. Harlan Krumholz, MD, SM, is professor of medicine at Yale and director of the Yale New Haven Hospital Center for Outcomes Research and Evaluation. He is also a member of the MedPage Today Editorial Board.

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