Promoting Health Equity and Achieving Pharmacoequity to Ensure Medication Access for All

Innovations and concepts around improving patients’ access to affordable services and medications are not new, but they are gaining new momentum after the COVID-19 pandemic thrust health disparities into the forefront. During the 2023 virtual Value-Based Insurance Design (V-BID) Summit, hosted by University of Michigan’s V-BID Center, panelists highlighted the role of various stakeholders in promoting health equity, as well as how to achieve pharmacoequity.

In the keynote session, speakers from local and federal government and CVS Health how health equity is been advanced.

Christen Linke Young, JD, deputy director, Domestic Policy Council for Health and Veterans, highlighted the work at the federal level, noting that equity has been part of the Biden administration’s work since President Joe Biden’s first day in office, when he signed an executive order for all agencies to use policy levers to drive equity in their decision making.

Enrollment in Affordable Care Act plans and Medicaid is currently at an all-time high with the uninsured rate at an all-time low (8%). However, state Medicaid agencies will begin making redeterminations for the first time in the start of the COVID-19 pandemic, which will result in enrollees being rolled off.

Recent reforms around prescription drug costs will cap costs at the pharmacy at $2000 and cap a monthly supply of insulin at $35 for Medicare beneficiaries. The government’s move on insulin prices seems to have inspired pharmaceutical companies as Eli Lilly, Novo Nordisk, and Sanofi all announced insulin price caps.

Finally, the administration has been working on Medicaid waiver programs, demonstrations, and investments to support social determinants of health so states can invest into the drivers of health, such as housing, food instability, and transportation.

At the state level, Grace Arnold, MPH, commissioner, Minnesota Department of Commerce, and cochair of the Special Committee on Race and Insurance at the National Association of Insurance Commissioners (NAIC), highlighted the work of Minnesota and other states through NAIC.

Minnesota is also addressing insulin with an affordability program, but it’s trying to take some of the tactics used during COVID-19 to get people tested and vaccinated even if they didn’t have insurance and replicate the work with basic care.

“It’s an equity proposal,” Arnold said. “It’s also one that can advance a lot of the goals of adding value and adding prevention into our system.”

NAIC is looking to create a toolbox for state regulators to utilize and choose the actions they can take to address the issues specific to their state. Part of that requires intentionally engaging with communities to understand what they need rather than making assumptions.

Finally, Joneigh Khaldun, MD, MPH, vice president and chief health equity officer, CVS Health, highlighted the long road it has been for health equity. Aetna, which merged with CVS Health in 2018, began its work in equity back in 2002 when it was collecting race and ethnicity data, something that faced a lot of pushback at the time. However, collecting that data meant uncovering disparities and being able to develop specific initiatives to address those disparities.

The work was furthered in 2021 when Khaldun was hired to fill the brand new executive position created to align health equity efforts across the organization. Data and measurement continue to be crucial, she explained. Success in the space can only be determined by measuring live user data to see if the gaps are closing.

“Health equity is certainly not a zero-sum game,” Khaldun said. “It’s not a competition. It’s not about taking away from one group to give to another so that one group gets less health. It’s about raising all boats and making sure there are no gaps, and we get everyone what they really need.”

In another discussion at the V-BID Summit, speakers discussed how to advance pharmacoequity and enhance access to medications. Pharmacoequity was coined by Utibe Essien, MD, MPH, in 2021, and is defined as “ensuring that all individuals, regardless of race and ethnicity, socioeconomic status, or availability of resources, have access to the highest-quality medications required to manage their health needs.”¹

Research is an important step to highlight the issues, show the negative consequences, and propose policy solutions, before disseminating the work, explained Jalpa Doshi, PhD, professor of medicine at the Perelman School of Medicine, director of Value-Based Insurance Design Initiatives at the Center for Health Incentives and Behavioral Economics, and director of the Economic Evaluations Unit of the Center for Evidence-based Practice, University of Pennsylvania.

In 2011, Doshi’s team conducted research into the Medicare Part D benefit. While some of the issues in the Part D benefit had recently been addressed, such as the closing of the so-called “donut hole” or coverage gap, there remained the problem of beneficiaries being required to pay too much too soon in the year. Even if an annual out-of-pocket (OOP) maximum was in place, beneficiaries on expensive medications would have to pay the entire amount in January.

“This was a critical issue, because many Medicare beneficiaries…cannot afford to pay that kind of money in January at the beginning of the year,” Doshi said.

Her team’s research ultimately came up with a solution called “smoothing,” in which a patient with an annual OOP of $2000 would be able to spread the money owed in January out over the entirety of the year. This solution will be enacted January 1, 2025, as part of the Inflation Reduction Act (IRA).

The Patient Access Network (PAN) Foundation, which provides charitable assistance to help patients pay for the medications, helped advocate for an OOP maximum and for smoothing. However, there is more to be done, explained Amy Niles, chief advocacy and engagement officer for the Patient Access Network (PAN) Foundation.

Even when the IRA goes into effect, more than 200,000 Medicare beneficiaries will have to spend more than 10% of their income on prescription drugs, according to research from Avalere Health that PAN Foundation sponsored.²

A national poll from PAN Foundation also found that 75% of adults on Medicare will still find it difficult to afford $2000 in OOP prescription costs annually.³ These concerns were especially high among Black and Hispanic adults.

“So, the analysis and the polling reinforces, at least for us, that we think there's going to be continued need for financial assistance and that the PAN Foundation will continue to play a critical role providing the safety net,” Niles said.

Over at National Pharmaceutical Council (NPC), there is research being conducted that has identified the impact wage status has on specialty drug utilization and overall health care costs, said John O’Brien, PharmD, MPH, president and CEO of NPC.

Ongoing research into co-pay accumulator adjustment programs has so far shown these programs affect people or color worse than a matched White cohort.

In other research, non-White individuals with autoimmune conditions are less likely than their White counterparts in all but the top wage category to fill prescriptions for specialty medications. As a result, these non-White individuals had higher hospitals admissions and emergency department use.

“So, the population of folks who needed the medicines most were using them least and ultimately costing the system more and suffering health-related complications,” O’Brien said.

References

1. Essien UR, Dusetzina SB, Gellad WF. A policy prescription for reducing health disparities—achieving pharmacoequity. JAMA. 2021;326(18):1793-1794. doi:10.1001/jama.2021.17764

2. Stengel K, Yip R, Donthi S, Brantley K. Some enrollees may face affordability challenges under Part D redesign. Published January 17, 2023. Accessed March 24, 2023. https://avalere.com/insights/some-enrollees-may-face-affordability-challenges-under-part-d-redesign

3. National polling: adults face challenges affording prescriptions, even with $2,000 Medicare Part D cap. PAN Foundation. November 15, 2022. Accessed March 24, 2023. https://www.panfoundation.org/national-polling-adults-face-challenges-affording-prescriptions-even-with-medicare-part-d-cap/