AMCP Nexus 2021: The Disparate Ways of Addressing Health Disparities

The varied ways of addressing health disparities were on full display during the first day of the AMCP Nexus 2021 meeting in Denver on Monday.

The four members of the first panel discussion of the pharmacists meeting discussed everything from how prior authorization might exacerbate disparities to comprehensive medication management to COVID-19 strategies designed to close vaccination gaps. A heavy reliance on data and data analytics and the need to foster collaboration among different parts of a healthcare organization were among the common threads of the presentation during the afternoon session.

Aimee Loucks, Pharm.D., BCPS, manager, specialty pharmacy programs and formulary, Kaiser Permanente Washington, described a program to identify whether health plan practices, such as prior authorization and utilization management edits, might inadvertently contribute to healthcare disparities.

Kaiser Permanente analysts tackled the issue by comparing white patients with Hispanic/Latinx patients and whether they failed to follow through and get a diabetes drug prescription after experiencing a prior authorization rejection for a diabetes drug. Loucks noted that utilization management edits for diabetes medications have been estimated to reduce the drug spend by $3 per member per month, so tight utilization of diabetes medication is common among health plans.

The results she shared showed that in 2019 a larger proportion of Hispanic/Latinx patients than white patients didn’t get a prescription after a prior authorization rejection for a diabetes medication (42% vs. 29%). Loucks said that Kaiser Permanente’s analysis also found that this disparity existed among patients seen by Kaiser Permanente’s integrated care system clinicians, although it was greater among those covered by the organization who get care outside the Kaiser Permanente system.

Loucks said the project also involved Kaiser Permanente’s consumer experience team conducting focus groups to help identify issues that might explain why people didn’t pursue a prescription. The focus groups identified trust issues about prescription approvals and healthcare coverage — and some misunderstandings. Loucks said one participant thought that all prescriptions were automatically rejected.

Kaiser Permanente is now in what Loucks called the “ideation/design” phase about how to respond to these findings and build trust with patients. She recommended that other organizations examine how utilization management might contribute to healthcare disparities. If such disparities are identified, she recommended working with patients to gain insight into how they might be remedied.

Kat Wolf Khachatourian, Pharm.D., MBA, chief quality integration officer and chief executive director of employee health plans for PSW-MultiCare Health System, an 11-hospital, not-for-profit healthcare system in Washington state, described a program to increase the prescriptions of drugs that will reduce the chances of people with diabetes developing cardiac and renal complications. The MultiCare program homed in on the roughly 5% — a proportion that has been edging up — of the system’s 25,000 employees and their dependents insured by the healthcare system. The program moved two classes of drugs — SGLT2 inhibitors and GLP-1 agonists — into a preventive drug category. The program increased the proportion of people with diabetes prescribed an SGTL2 inhibitor or an GLP-1 receptor agonists from 21% (274 of 1,277) in 2019 to 34% (462 of 1,367) this year.

Khachatourian said use of data from the Dartmouth Atlas of Health Care helped MultiCare identify diabetes and chronic disease prevention as an area on which to focus. Actuaries helped build a case for large cost savings from the medications because fewer patients would be at risk of developing more serious cases of chronic kidney disease.

“You WILL see increased pharmacy costs,” was a bullet point on Khachatourian’s “lessons we learned” slide, adding that “justifying the big picture and real-world application of clinical trial data helps your cause.” She also mentioned that it was crucial to incorporate changes into the electronic medical record (EMR) systems such as Epic, so clinicians are presented the prescription of preventive medication as an option. “EMR builders are crucial,” said Khachatourian.

Edward Jai, Pharm.D., senior director and chief pharmacist of the Inland Empire Health Plan, a not-for-profit, public health plan in Riverside and San Bernardino counties in California, described the results of a comprehensive medication management in Medicaid population and medication reconciliation program among dual eligible — people who are covered by Medicare and Medicaid. Jai discussed the obstacles to medication management for such beneficiaries, ranging from not having a permanent residence to language barriers to not having a phone number.

Still, Jai said showed results of a successful Inland Empire medication management program that were published in the September 2021 issue of the Journal of Managed Care Specialty Pharmacy (Jai is one of the co-authors). The program, which comprised about 2,100 Medicaid beneficiaries, was designed to go beyond typical medication management to manage diseases, not merely medications, and to focus on the “whole person.” Unlike most such comprehensive medication management programs that embed pharmacists in a clinic, this program operated as a remote telephonic service. The program also used an artificial intelligence platform. The before-and-after comparison found that the program cut the cost of medications by 17% ($192 per member per month) and the total cost of care by 19% ($554 per member per month) and had a 12:1 return on investment.

Jai also discussed a successful medication reconciliation program that engaged people while they were still in the hospital. He shared data from a matched cohort study that suggest the medication reconciliation program is very effective in reducing hospital readmissions.

Sharon Jhawar, Pharm.D., MBA, BCGP, chief pharmacy of SCAN Health Plan, a Southern California Medicare Advantage, discussed the plan’s COVID-19 vaccination efforts, some of which focused on narrowing the disparities in vaccination rates. The efforts ranged from at-home vaccination for home-bound members to outreach efforts to Black churches to arrangements with hospitals serving underserved populations to reserved blocks of appointments for SCAN members. According to Jhawar, the efforts contributed to narrowing the gap in vaccination rates among Black members compared with white members from 17% to 3% and the gap between Latinx members and white members from 11% to 4%.

Jhawar said SCAN also created a vaccine dashboard to monitor progress in vaccination rates. Routing software helped make the at-home vaccination program more efficient by designing the itineraries of EMTs who delivered the shots. “We used data to design our outreach,” she said.

SCAN had set a goal of 70% vaccination, reflecting the proportion often cited as necessary to achieve the herd immunity needed to blunt the transmission of the virus that causes COVID-19. By the end of July 2021, 71.3% of SCAN members were vaccinated, Jhawar said.