Medicine Abandonment is a Barrier to Health Equity

By: Ranier Simons, ADAP Blog Guest Contributor

One of the most important developments in medical science is the evolution of pharmaceuticals. Prescription drugs are used to treat and cure disease, prevent disease, slow aging, govern family planning, and even enhance biomechanical functioning. The United States spends more on over-the-counter and prescription drugs than any other country. In 2020, the U.S. spent $348.4 billion on prescription drugs.[1] America's drug prices are 250% higher than 32 countries that are a part of the Organization for Economic Co-operation and Development known as the OECD.[2]

Researchers are increasingly focused on exploring the relationship between drug finance and care access. Inquiry shows that drug prices and the pathways in which patients pay for medications result in unequal access to care. Unequal access to care results in health inequities. Care disparity is the subject of a report recently published by the Pharmaceutical Research and Manufacturers of America, known as PhRMA. PhRMA is a non-profit advocacy group that lobbies on behalf of its member biopharmaceutical companies. It believes in advancing innovation, making medicines more affordable, and improving access for all. The report, entitled "Understanding Medicine Abandonment as a Barrier to Health Equity", uses real-world data to highlight health disparities.

Abandonment, in this report, is defined as when a patient does not fill a newly prescribed brand-name medication within 30 days of approval from their insurance. The report's 2020 IQVIA sourced data showed that African-Americans were disproportionately likely to abandon new prescriptions than their white counterparts. Additionally, the results indicated that people with lower incomes have a higher likelihood of medication abandonment than those with higher incomes.[3] Research has shown that regular adherence to medication regimens is almost more important than the medication itself.[5]

African-Americans were overall seven percent more apt to abandon new prescriptions. However, that percentage was higher regarding specific diseases. The rate increased to 20 percent for insulin usage, 31 percent for atypical antipsychotic drugs, and 41 percent for HIV Pre-Exposure Prophylaxis (PreP) usage.[3] Rates of abandonment, in regards to insurance cost-sharing, also followed the same trend among racial lines. African-Americans were 10 to 34 percent more likely to abandon medication when the out-of-pocket price was $125 or more after insurance than white patients.[3] Similar results were observed regarding income in the absence of race. Patients with commercial insurance who had an annual income of less than $50,000 were more likely to have medication abandonment than those making over $100,000. In general, those earning less than $50,000 were 16 percent more likely not to fill prescriptions than those annually earning $100,000 or more.

The report is an acceptable baseline of inquiry. However, it cannot prove direct causal relationships of inequality. The analysis compares differing rates of abandonment by race and income. It does not include the influence of confounding variables such as racism, health status, education, and social determinants of health.[3]

"Social determinants of health (SDOH) are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks."[4] It is vital to explore how these things influence health inequalities and contribute to medicine abandonment.

Photo Source: Healthy Mendocino

One important SDOH is culture. The study showed that African-Americans had a 31 percent higher likelihood of medicine abandonment regarding atypical antipsychotic drugs. In addition to the cost factor, there is documented stigma African-Americans associate with mental issues. One such study showed that 63 percent of African-Americans surveyed believed that mental health issues are a sign of personal weakness.[6] This sentiment would indicate that an African-American patient would likely not fill a needed mental health prescription even if they were fearless enough to seek help. 

Racism is another SDOH. Institutionalized racism in medicine contributes to a pervasive African-American distrust of doctors and medication.[7] Racial differences in medical care and inclusion or lack of inclusion in medical research are part of medical institutional racism. The Tuskegee Experiment, gynecology’s roots of torture in slavery, and the poor representation of African-Americans in clinical trials are just a few examples.

Outside of race, the issue of drug pricing is also not binary. The PhRMA report showed a correlation between the income of insured patients and the likelihood of medicine abandonment. However, price is complex. The way patients pay for medication is also a source of concern. Patients pay monthly premiums for their insurance that include differing drug coverages. However, in addition to their premiums, they must pay copays for their medications. Those copays are often part of a matrix, including high insurance deductibles. 

In an effort to help patients afford their medications, many drug manufacturers have copay assistance programs. These programs are supposed to pay for the patients’ copays to the insurance company to reduce the financial burden and increase adherence. However, copay accumulator programs presently are a challenge to those efforts.

The Hepatitis B Foundation defines copay accumulator as "a strategy used by insurance companies and Pharmacy Benefit Managers (PBMs) that stop manufacturer copay assistance coupons from counting towards two things: 1) the deductible and 2) the maximum out-of-pocket spending."[8] This results in patients paying even more for their medications, with the insurance companies paying less. This phenomenon is supported by the PhRMA report, which shows that medicine abandonment increases as the amount of out-of-pocket expenses to the patient increases.

The intersection of race, economics, healthcare finance, and SDOH is a complex web. PhRMA's report is a solid stepping stone on which to wade through the constantly moving stream of health equity reform discourse and change. The report is available online here.

[1] Centers for Medicare & Medicaid Services (2021, December 15). NHE Fact Sheet. Retrieved from https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NHE-Fact-Sheet#:~:text=Prescription%20drug%20spending%20increased%203.0,the%20households%20(26.1%20percent)
[2] Mulcahy, A. (2021, January 28). Prescription drug prices in the United States are 2.56 Times those in other countries. Retrieved from https://www.rand.org/news/press/2021/01/28.html
[3] Pharmaceutical Research and Manufacturers of America. (2022). Understanding Medicine Abandonment as a Barrier to Health Equity. Retrieved from  https://phrma.org/-/media/Project/PhRMA/PhRMA-Org/PhRMA-Org/PDF/S-U/Understanding-Medicine-Abandonment-as-a-Barrier-to-Health-Equity_2022.pdf
[4] Cherry, A. (2021, October 14). The social determinants of health: why they matter to improving health outcomes. Retrieved from https://maximus.com/article/social-determinants-health-why-they-matter-improving-health-outcomes
[5] DiMatteo MR, Giordani PJ, Lepper HS, et al. Patient adherence and medical treatment outcomes: a meta-analysis. Med Care. 2002;40(9):794-811
[6] Ward, E. C., Wiltshire, J. C., Detry, M. A., & Brown, R. L. (2013). African American men and women's attitude toward mental illness, perceptions of stigma, and preferred coping behaviors. Nursing Research, 62(3), 185–194. https://doi.org/10.1097/NNR.0b013e31827bf533
[7] Institute of Medicine (U.S.) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care; Smedley BD, Stith AY, Nelson AR, editors. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington (D.C.): National Academies Press (U.S.); 2003. The Culture of Medicine and Racial, Ethnic and Class Disparities in Health Care. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK220349/
[8] Hepatitis B Foundation. (2020, March 4). Copay accumulators – What they are and what they mean for your prescriptions. Retrieved from https://www.hepb.org/blog/copay-accumulators-mean-prescriptions/

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.