The challenge of health equity in pharmacy

By George Van Antwerp, managing director, Deloitte Consulting LLP

Systemic barriers to clinically appropriate medications can disproportionately affect people based on their race, gender, income, ethnicity, and other factors. These barriers are often reflected in health coverage and can be the result of policies and procedures. They can be made even more formidable by the physical location and hours of retail pharmacies and other Drivers of Health such as income, transportation, and housing stability. However, I believe it is possible to identify, monitor, and remove these barriers. It is not easy, but institutions focused on health outcomes should embrace this challenge.

What is health equity? According to the Deloitte Health Equity Institute it is “the fair and just opportunity for everyone to fulfill their human potential in all aspects of health and wellbeing…Health and wellbeing include not only clinical issues traditionally addressed by the health care system, but also a person’s mental, social, emotional, physical, and spiritual health.”

Specific to pharmaceuticals, the term “pharmacoequity” was coined by Utibe Essien, M.D., MPH., an assistant professor of medicine at the University of Pittsburgh, and a health disparities researcher in the VA Center for Health Equity Research and Promotion. Dr. Essien noted that prescription drugs play an important (and growing) role in the management of acute and chronic diseases. “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 is paramount,” he wrote.¹

Health equity is not a nice to have for our society. It is an imperative. No one’s lifespan should be linked to their Zip code.² A person’s gender³ or sexual preference⁴ should not limit their access to care. A false belief that Black people feel less pain should not influence a clinician’s prescribing patterns.⁵ It is also important to acknowledge that health care inequities add about $320 billion a year to health spending, according to a new report from Deloitte actuaries. If left unaddressed, our actuaries predict the cost of health inequities will top $1 trillion by 2040.

Race, ethnicity can affect prescription drugs

How do race and ethnicity impact access to prescription drugs? Consider these four examples:

• Financial barriers: Financial or health insurance barriers delay or prevent Black patients from obtaining prescription drugs 70% of the time, vs. 55% of the time for white patients.⁶
• Pharmacy deserts: Pharmacy deserts can lead to lower drug adherence. A 2020 study of Los Angeles County showed that Black and Hispanic people are more likely than white people to live in pharmacy deserts.⁷ These residents also tend to speak English as a second language, often do not have a high school diploma or own their own vehicle, live below the federal poverty line, and lack health insurance.
• Pharmacy schools: Of the more than 54,000 students who enrolled in 143 pharmacy colleges and schools in 2018, just 6% were Black; 4% were Latino/a; and 0.6% were Native American, according to data presented at the 2020 meeting of the American Association of Colleges of Pharmacy.⁸
• Limited stock: A report on medication deserts found that pharmacies in poor communities were 24% more likely than other pharmacies to be out of stock or have limited stock for the 13 most-commonly prescribed medications. These pharmacies were also more likely to have limited hours of operation.⁹

Pharmacies should make equity a priority

Pharmacy is the most used health care benefit. But many groups face barriers based on their race, ethnicity, socio-economic status, gender or sexual preference. For example, studies continue to show that LGBTQ+ emerging adults are at disproportionate risk for negative health care experiences and underuse of care. Moreover, both LGBTQ+ youth and adults have a higher risk of suicide than other populations.^{10, 11}

Another important factor is the language used by clinicians and pharmacists to talk to and describe patients. The implicit bias associated with describing someone as a “substance abuser” or “drug seeker” is much different than describing them as someone with “substance-use disorder.”¹² It can also be easy to miss some of the microaggressions that can be embedded in the way people describe health benefits. A common term in pharmacy is to grandfather someone. I’m not sure people are always aware of the racial history associated with the verb “grandfather.” This term had once been used to prevent Black people from voting.¹³

While these topics are important, we should also examine how disease-state biases can be compounded as new drugs enter the market. For example, as new drugs become available for breast cancer, will existing biases mean that 40% more Black women [than White women] will continue to die from the disease due to less genetic screening and more limited access to appropriate care, or will our strategies evolve?¹⁴ Additionally, will clinicians be less willing to prescribe emerging obesity drugs if they believe patients are overweight because they make bad choices?¹⁵ Addressing these issues at the systemic level (and even during clinical training) is important.

This issue of genetic testing is also important as we think about The Future of Pharmacy and how precision medicine will grow in the next decade. We’ve long known about the importance of diversity in clinical trials, but this will likely become increasingly critical. In 2019, research showed that 78% of existing genetic data was from people of European decent, while that group made up just 16% of the global population.¹⁶

Where should you begin? Consider these three key steps:

1. Measurement: Step one is to understand and begin to measure disparities and biases. Are you tracking adherence by ethnicity (for example)? Have you looked at your prior authorization (PA) approval rates by gender…or even gone back to see if patients request PAs at different rates based on income, gender, sexual preference, or other factors?
2. Root causes: Once you have the data, you can begin to understand the root cause of the issue. Is it education? Is it data? Are your algorithms biased? How will you begin to change?
3. Vision: Now that you have data and understand root causes, it’s important to set bold goals and align the organization to achieve them.

We look forward to expanding on these strategies in collaboration with our clients and our Deloitte Health Equity Institute team. Their frameworks about the need to think of four domains of action (organization, offerings, community, and ecosystem) helps frame how expansive our thinking should be.

 “Of all the forms of inequity, injustice in health care is the most shocking and inhuman,” Dr. Martin Luther King, Jr.

Endnotes:

¹ A policy prescription for reducing health disparities—achieving pharmacoequity, JAMA, October 22, 2021

² Life Expectancy: Could where you live influence how long you live?, Robert Wood Johnson Foundation 

³ Gender and health, World Health Organization, May 24, 2021

⁴ A systematic review of the discrimination against sexual and gender minority in health care settings, International Journal of Health Services, November 4, 2019

⁵ Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites, Psychological and Cognitive Sciences, April 4, 2016

⁶ 2019 National Healthcare Quality and Disparities Report, Agency for Healthcare Research and Quality, June 2021

⁷ Social Determinants of Pharmacy Deserts in Los Angeles County, Journal of Racial and Ethnic health Disparities, October 27, 2020The pharmacy student population: Applications received 2018-19, American Journal of Pharmaceutical Education, July 2020

⁸ Medication deserts: survey of neighborhood disparities in availability of prescription medications, International Journal of Health Geographics, November 9, 2012

⁹ The pharmacist as an LGBTQ ally, American Journal of Pharmaceutical Education, July 2020

¹⁰ Differences in Healthcare Access, Use, and Experiences Within a Community Sample of Racially Diverse Lesbian, Gay, Bisexual, Transgender, and Questioning Emerging Adults, LGBT Health, December 1, 2016

¹¹ Do words matter? Stigmatizing language and the transmission of bias in the medical record, Society of General Internal Medicine, January 26, 2018

¹² The racial history of the ‘grandfather clause,’ National Public Radio, October 22, 2013

¹³ More Black women die from breast cancer than any other cancer, American Cancer Society, February 14, 2022

This publication contains general information only and Deloitte is not, by means of this publication, rendering accounting, business, financial, investment, legal, tax, or other professional advice or services. This publication is not a substitute for such professional advice or services, nor should it be used as a basis for any decision or action that may affect your business. Before making any decision or taking any action that may affect your business, you should consult a qualified professional advisor.

Deloitte shall not be responsible for any loss sustained by any person who relies on this publication.

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