There is agreement in health care that social determinants of health (SDOH) play a role in a person’s health and can prevent people from receiving an equal opportunity to be healthy. During a panel at Academy of Managed Care Pharmacy’s annual meeting, speakers representing payers and pharma highlighted how data can be used by both stakeholders to address racial and ethnic health disparities.
Addressing SDOH may help to reduce health disparities, so while there are a number of factors outside of health care that lead to health disparities, it’s on those in the health care industry to mitigate them as much as possible, said Jessica Cherian, PharmD, RPh, vice president of content and strategic services, ICON Market Access.
“Beyond being driven by what’s fair and equal, we should also be driven by the fact that racial and ethnic disparities are documented, and they are documented as being both substantial and pervasive in the country,” said Cherian.
In October 2021, ICON conducted a survey to examine pay perceptions related to racial and ethnic health disparities. A total of 32 payer responses were included. These respondents not only belonged to a payer organization, but they were also directly involved in the organization’s decisions related to addressing health care disparities.
The question domains fell into 5 areas:
- Gathering and tracking SDOH
- High-priority disease states
- Need for assistance with addressing disparities
- Impact of disparities on medication access and utilization
- Current and future efforts and partnerships
While the number of respondents was small, Renee Rizzo Fleming, RPh, MBA, president, PRN Managed Care Consulting Services, LLC, said, “We feel that a lot of the input that we got is very helpful. And it’s the starting point for all of us.”
Currently, payers gather data and track SDOH through a variety of means, including patient surveys, screenings, claims information, demographic information, zip codes, age, and Z codes. However, they hope to gather even more information over time so they can find the best ways to identify the needs of their populations and the best ways to deliver to them, Rizzo Fleming said.
The conditions the respondents noted were a high priority were diabetes, maternal health, heart disease, psychiatric disorders, and hypertension, which are similar to those being focused on in disease management and population health initiatives, she noted.
The respondents felt like they could use additional support to address racial and ethnic health disparities in the areas of budgeting, personnel to implement programs, technology, and data acquisition.
Eighty percent believed racial and ethnic health disparities have moderate to significant impact on medication access and utilization, and lack of affordability and lack of medication adherence had the greatest impact on medication access and utilization, according to the payer respondents.
The areas where payers feel they can most impact disparities in medication and access and utilization were patient education and transportation issues. Conversely, they felt the areas they could impact the least were lack of insurance coverage and prescribing bias.
The survey found payers feel more confident that the initiatives they are undertaking to address racial and ethnic health disparities will have a positive impact on medication access and utilization over the next 1 to 3 years. The current perception is neutral, explained Rizzo Fleming, but when they look to the future at the programs they are initiating or what they know will be rolled out, they feel more positive.
“We know that they’re making progress, and they’re optimistic that the future will be bright,” she said.
When it comes to the partnerships being built to address these disparities, payers are focused on community outreach programs and data tracking for specific concerns, but there are opportunities to build relationships with partners in technology and the pharmaceutical manufacturer spaces, Rizzo Fleming explained.
Traditionally, pharma companies have built the patient journey by focusing on diagnosis through treatment and outcomes; however, when it comes to marginalized and underserved patients, that journey has to begin earlier by first establishing trust and removing the barriers these patients face, explained Juny Simpson, health equity director, Genentech.
She pointed out that there is an opportunity for payers and pharma to partner together, improve quality of care and outcomes, and eliminate the advancement of chronic diseases those payers consider a high priority.
“These patients are waiting, because they lack trust and are reluctant to engage health care earlier,” Simpson said. “And I believe the opportunity is to educate and to remove these barriers for these patients who are typically showing up at the most expensive point of care.”
The lack of trust in these marginalized communities is the result of a “history of mistreatment” experienced by these communities, she said.
Effecting change externally first requires looking internally, she said. Genentech has established a diversity and inclusion approach to better advance health equity that is centered around 3 pillars:
- Fostering belonging through integrating inclusive behaviors and having representation throughout the company
- Advancing inclusive research and health equity through diversifying clinical trials so they accurately reflect the world
- Transforming society through supplier diversity goals and investments in communities
In 2020, Genentech launched its Health Equity study of 2207 patients, including 1206 who identified as medically disenfranchised and belonged to 1 of 4 groups: Black, Latinx, LGBTQ+, and low economic status. The study was relaunched in 2021 to analyze year-over-year changes.
The 2020 data showed 1 in 3 medically disenfranchised individuals did not participate in clinical trials and 52% believed the system was flawed and out to get them. In 2021, half continued to feel the system was rigged against them and half stopped seeking care or didn’t ask questions because they feared not being understood or being seen as unintelligent.
“And so, the bottom line is that we still have a problem,” Simpson said. “And patients do not believe that they are being treated fairly when they do show up to seek care.”
Utilizing data from claims, it’s clear that there are disparities in time to treatment after diagnosis and proportion of rejection/denied claims for medication, explained Ki Park, vice president, PHORCE, consulting payer brand and commercial consulting services, Symphony Health Solutions, an ICON company.
Symphony conducted a study of claims looking at patient populations for asthma and ulcerative colitis/Crohn disease (UCCD). The focus was on the asthma population with UCCD as a comparator.
For SDOH, the study looked at 4 factors: housing instability, access to medication, food insecurity, and access to transportation. A high score meant greater negative effects, while a lower score meant minimal effect. The Black population had the highest percentage with a high score in housing instability, transportation, and access to medication. The Hispanic population had the highest percentage with a high score in food insecurity.
While half of all ethnicities received the first asthma treatment between 1 and 6 days after diagnosis, Black patients had a delay of 6 days vs only 1 to 2 days for the other groups. When it came to receiving care from a specialist, the Asian population has the highest percentage of patients being treated by a specialist while the Black population had the smallest percentage.
Similarly, the Asian population had the highest percentage in commercial plans vs the Black population, which had the lowest. Only 8% of the Asian population was on Medicaid compared with 21% of the Black population. There was a similar pattern for medication claims being rejected or denied, with Black patients having more rejections and denials and Asian patients having the least.
In UCCD, there were similar trends, although Hispanic patients had the longest time between diagnosis and first treatment (79 days). Overall, half of all ethnicities received their first treatment between 42 and 79 days after diagnosis of UCCD.
The disparity in payer coverage was not as wide as the asthma market, but there was still a gap. Only 12% of Asian patients were on Medicaid vs 17% of Black patients. The rejection/denial of claims was highest among the Black population and lowest among the Asian population.
According to Park, patterns of SDOH factors in terms of which ethnicities were affected that most were validated by the metrics in the claims data, and everyone knows the data exist.
“As we think about these disparities and trying to figure out what to do with it, now you have a tool in your arsenal to actually measure your program,” Park said. “…there’s a lot of data out there; it’s about using it to make sure we address these disparities.”