We deprive underserved patients of the best medicines
During a busy clinic day for patients without health insurance, one of us received a shocking announcement. Some life-saving drugs that we could previously provide to patients free of charge were no longer available. The costs of these drugs were far beyond the reach of our patients, so healthcare teams were forced to switch patients to less effective regimens. We doctors were increasing their risk by switching to cheaper regimens or not being able to start newer, more effective therapies in patients who were not yet on treatment.
We didn’t go to medical school to deprive patients of effective treatments, and yet we were there, creating harm rather than benefit.
As expensive new drugs show their game-changing effects on health, we are increasingly concerned that innovative breakthroughs, however welcome they may be, could actually worsen disparities.
As policymakers and advocates seek ways to revive Congress’s social safety net bill, a measure to lower 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 highest quality necessary to manage their health needs. This goal, called pharmacoequityis the one that eluded the United States for decades.
Several research studies have shown large disparities in treatment due to drug costs. A study one of us published in 2019 found that 1 in 8 Americans with cardiovascular disease were not adhering to medication because of cost. These people reported skipping doses, taking less medication, or delaying filling a prescription so they could save money. The oncology world has described the financial toxicity that accompanies expensive chemotherapy and immunotherapy treatments and the physical and psychological burden these costs place on cancer patients. Additionally, a recent CDC analysis found that cost-related medication nonadherence was associated with a more than 20% higher death rate in patients with chronic conditions.
Our research has also made it clear that cost is only one of the barriers leading to treatment disparities. We showed that even controlling for insurance status, education level, and household income, black, Hispanic, and Asian patients are less likely to be prescribed new evidence-based diabetes medications as well. than stroke prevention drugs. A well-described body of research shows that black patients, including children, are less likely to receive appropriate pain medication for anything from a broken leg in the emergency room to chronic back pain at their doctor’s office. first resort. Additionally, the COVID-19 pandemic has further highlighted these disparities, as communities of color have experienced more limited access to vaccines and new antiviral therapies to prevent and treat this devastating disease.
Decades of research experimentation and medical racism have taken their toll on communities of color’s trust in the medical system. Yet beyond the distrust, limited opportunities for those willing and able to start new therapies abound, including weaker insurance coverage, onerous co-payments, and limited access to appropriate medical prescribers. Even physical access to pharmacies limits access to medicines for communities of color who are more likely to reside in so-called pharmaceutical deserts. This unequal access to medicines is compounded by implicit or unconscious biases that cause some healthcare providers to prescribe certain therapies less frequently to low-income people and patients of color.
So how do we achieve pharmacoequity and move our nation towards a just healthcare system? First, appropriate prescription drugs must be available to all patients, regardless of the type of clinic or hospital where they receive care or from whom that care is provided. We can do this by implementing health system solutions, such as prescriber nudges, to help reduce treatment bias by race, ethnicity or social class. Second, accessibility to prescription drugs needs to be improved. To achieve this goal, we must target the initial prescription a patient receives by ensuring that all Americans have access to health insurance, including through Medicaid expansion or a universal insurance system. We know these programs work: 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 also need to bridge the geographic gap that some patients have in access to medicines. We can invest in strengthening drug delivery systems, including through collaborations with ride-sharing companies and direct-to-consumer delivery services such as Amazon’s PillPack.
Finally, the affordability of prescription drugs needs to be addressed. Americans pay more for prescription drugs than any other country 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 wealth gaps between low-income people and people of color and their more favored counterparts. We need national innovations to reduce the financial burden on individuals, especially for new life-saving treatments. These may include some of the strategies from the previous Build Black Better bill, such as improving federal drug price negotiations and capping spending limits for Medicare enrollees. However, we should also consider broader strategies such as an essential drugs list, international reference prices for drugs, and increased cost regulation across the entire prescription drug cascade, from drug approval drugs by the FDA to consumer pricing by intermediaries such as pharmacy benefit managers. .
We are on the cusp of a life science revolution, but we are entering an era that could create ever-widening disparities if we don’t act now. The prescription drug measures under the Build Back Better Bill have given a glimpse of what policymakers can do to support affordable health care for the most vulnerable, but bolder action is needed. Effective and equitable delivery of innovative, evidence-based, high-quality treatments to underserved patients should be our country’s priority. By 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 a Yale Professor of Medicine and Director of the Yale New Haven Hospital Center for Outcomes Research and Evaluation. He is also a member of the MedPage today Editorial Committee.