COST CONTAINMENT vs. CARE EQUALITY: How Health Disparities Among Chronic Health Conditions & Rare Diseases are Fueled by Payor-Driven Barriers
****Reprinted with permission from PlusInc****
By: Brandon M. Macsata and Marcus J. Hopkins
Despite being among the wealthiest and most educated societies, health disparities in the United States are a consistent risk among specific population groups.[1] Black and brown Americans don’t enjoy the same access to care as their white counterparts; women experience more years of poor health than men;[2] age impacts health outcomes,[3] as do gender identity,[4] sexual orientation,[5] and geographic location.[6] The humanistic and environmental factors driving health disparities are only made more complex by the fragmented healthcare delivery system, which is known for payors, including public and private health insurers, putting up barriers between patients, their providers, and the treatments and medications they need.
Aside from institutional bias (i.e., racism, agism, and other stigmatizing attitudes toward specific barriers and characteristics), emerging provider deserts where patients live without access to hospitals, primary care physicians, and pharmacies,[7] as well as the lack of affordable food, housing, and transportation, there is a direct correlation between health insurance coverage and health disparities in this country.[8] According to the Centers for Disease Control & Prevention (CDC), “Insurance coverage is strongly related to better health outcomes. Substantial disparities in uninsured rates were observed among all the demographic and socioeconomic groups.” In 2022, approximately 7.9 percent of the population was uninsured, down by 0.4 percentage points from 2021.[9] Health insurance coverage in and of itself, however, doesn’t necessarily result in equitable access to healthcare services or equitable health outcomes because often it is an insurance policy’s benefit and payment parameters that open the door to such disparities.
The so-called “cost containment tools” utilized by health insurance companies and pharmacy benefit managers (PBMs) are hurting patients.[10] Notably, they are driving and exacerbating health disparities. Some of the most common payor-driven barriers encountered by patients include prior authorization (PA), step therapy, copay accumulators, health insurance plan design, and an emerging one: prescription drug affordability boards (PDABs). This article highlights why these cost-containment strategies are problematic for patient access, affordability, and equity.
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[1] National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Committee on Community-Based Solutions to Promote Health Equity in the United States; Baciu A, Negussie Y, Geller A, et al., editors. Communities in Action: Pathways to Health Equity. Washington (DC): National Academies Press (US); 2017 Jan 11. 2, The State of Health Disparities in the United States. Available from: https://www.ncbi.nlm.nih.gov/books/NBK425844/
[2] AXA; Bogataj, Marie. 2019, Jun 16. Women vs. men: is there a health equality gap? Available from https://www.axa.com/en/news/women-vs-men-is-there-a-health-equality-gap
[3] U.S. Department of Health and Human Services; Office of Disease Prevention and Health Promotion; 2023, Sep 14. Social Determinants of Health and Older Adults. Available from https://health.gov/our-work/national-health-initiatives/healthy-aging/social-determinants-health-and-older-adults
[4] Lee Robertson, Ellesse-Roselee Akré, and Gilbert Gonzales.Mental Health Disparities at the Intersections of Gender Identity, Race, and Ethnicity.LGBT Health.Dec 2021.526-535. Available from: http://doi.org/10.1089/lgbt.2020.0429
[5] Hafeez H, Zeshan M, Tahir MA, Jahan N, Naveed S. Health Care Disparities Among Lesbian, Gay, Bisexual, and Transgender Youth: A Literature Review. Cureus. 2017 Apr 20;9(4):e1184. doi: 10.7759/cureus.1184. PMID: 28638747; PMCID: PMC5478215. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5478215/
[6] Institute of Medicine (US) Roundtable on Health Disparities. Challenges and Successes in Reducing Health Disparities: Workshop Summary. Washington (DC): National Academies Press (US); 2008. 2, The Impact of Geography on Health Disparities in the United States: Different Perspectives. Available from: https://www.ncbi.nlm.nih.gov/books/NBK215365/
[7] Horowitz, Brian T; 2022, Jun 2. What Are Medical Deserts, and How Can Technology Alleviate Them? HealthTech. Available from: https://healthtechmagazine.net/article/2022/06/what-are-medical-deserts-perfcon#:~:text=Areas%20without%20access%20to%20hospitals%2C%20primary%20care%20physicians%2C,research%20at%20GoodRx%2C%20a%20consumer-focused%20digital%20healthcare%20platform.
[8] U.S. Department of Health & Human Services; Centers for Disease Control & Prevention; Morbidity and Mortality Weekly Report; 2011, Jan 25. Fact Sheet: Health Disparities in Health Insurance Coverage. Available from https://www.cdc.gov/minorityhealth/chdir/2011/factsheets/insurance.pdf#:~:text=Insurance%20coverage%20is%20strongly%20related%20to%20better%20health,with%20a%20higher%20percentage%20of%20males%20being%20uninsured
[9] United States Census Bureau; 2023, Sep 12. Health Insurance Coverage in the United States: 2022. Available from: https://www.census.gov/content/dam/Census/newsroom/press-kits/2023/iphi/20230912-iphi-slides-health-insurance.pdf#:~:text=The%20uninsured%20rate%20decreased%20by%200.4%20percentage%20points,In%202022%2C%20the%20uninsured%20rate%20was%207.9%20percent
[10] American Medical Association; 2023, May 12. How prior authorization disrupts patient care, Part I. Available from: https://www.ama-assn.org/practice-management/prior-authorization/how-prior-authorization-disrupts-patient-care-part-i#:~:text=Our%20physicians%20are%20saying%20that%20prior%20authorization%20care,that%20prior%20authorization%20leads%20to%20negative%20clinical%20outcomes
