Racial and social inequities in medication use: A review of articles responding to the Journal of Managed Care + Specialty Pharmacy’s Call to Action

Abstract

This article provides a summary of Viewpoint and Research articles responding to the 2020 Journal of Managed Care + Specialty Pharmacy Call to Action to address racial and social inequities in medication use. We find great heterogeneity in terms of topic, clinical condition examined, and health disparity addressed. Common recommendations across Viewpoint articles include the need to increase racial and ethnic diversity in clinical trial participants, the need to address drug affordability and health insurance literacy, and the need to incentivize providers and plans to participate in diversity initiatives, such as the better capture of information on social determinants of health (SDOH) in claims data to be able to address SDOH needs. Across research articles, we also find a large range of approaches and study designs, spanning from randomized controlled trials to surveys to observational studies. These articles identify disparities in which minoritized beneficiaries are shown to be less likely to receive medications and vaccines, as well as less likely to be adherent to medications, across a variety of conditions. Finally, we discuss Healthy People 2030 as a potential framework for future health disparity researchers.

Plain language summary

We examined articles responding to the journal’s call for articles on racial and social inequities in medication use. Our article highlights widespread disparities in medication use across clinical conditions and among different subgroups. Articles use a wide range of approaches, and we discuss a framework for future work on health disparities.

Implications for managed care pharmacy

Individuals and organizations operating within the field of managed care pharmacy have an important role to play in addressing racial and social disparities. Common recommendations relevant for managed care pharmacy include addressing drug affordability and simplifying benefit design. Additional recommendations include reducing nonfinancial barriers to medication access and adherence (such as by improving health insurance literacy and trust) and incentivizing providers and plans to also engage in diversity improvement efforts.

In 2020, Dr Kogut published an article in the Journal of Managed Care + Specialty Pharmacy (JMCP) highlighting racial disparities in medication use and identifying ways that the profession of managed care pharmacy could help address these disparities. These included (1) acknowledging that racial disparities in medication use are pervasive; (2) including the voices of community members in decision- making related to coverage policies, program designs, and quality initiatives; (3) reducing patient cost sharing for essential medications; and (4) incorporating information about race in reporting and quality improvement activities.¹ Subsequently, JMCP released a call for submissions of research articles and commentaries on racial disparities and related interventions in the medication use system and encouraged submissions related to all areas of discrimination.² The objective of our review is to summarize articles related to racial and social inequities in medication use that have since been published in JMCP.

In this narrative review, we summarize 22 articles that were published in JMCP between November 2020 (the call for articles) and September 2023 that were categorized as addressing racial and social inequities in medication use. These articles were categorized through a hybrid approach, including JMCP staff evaluation and authors self-identifying on submission to JMCP (ie, by answering “yes” to the question, “Does your manuscript address the subject matter of racial and social inequities in medication use?”). Eight were Viewpoint articles and 14 were Research articles.

Summary of Viewpoint Articles

Approximately half of the published Viewpoint articles focused on race and ethnicity, whereas others discussed health inequity more broadly and/or examined other social determinants of health (SDOH) (Table 1). Common topics included health equity as related to benefit design, formulary coverage of medications, and value assessment. One of the earliest articles by Diaby et al discussed ways to incorporate health equity into value assessment approaches, such as a 2-part health technology appraisal, the use of distributional cost-effectiveness analysis, and equitable multicriteria decision analysis.³ The next Viewpoint article focused on the coverage of specific treatments for systemic lupus erythematosus (SLE) based on a recent Institute for Clinical and Economic Review (ICER) report. In this article, Newman et al urged researchers to provide real-world evidence using data from Black and Hispanic individuals, since such individuals are underrepresented in clinical trials and yet more likely to have SLE.⁴ Authors also urged manufacturers to address drug affordability challenges, such as by avoiding extending patents, and urged for payer policies and quality measures to account for race and ethnicity. In a later article summarizing an ICER report of tirzepatide for treating type 2 diabetes mellitus, Nikitin et al advocated for broader coverage criteria and similarly recommended that manufacturers lower their prices and increase the diversity of clinical trial participants.⁵ These topics–ensuring that medications are affordable and the need to increase representation of racial and ethnic minoritized groups in clinical trials–were prevalent themes.

TABLE 1.

Summary of Commentaries (n = 8)

Author year	Topic	Key recommendations for managed care pharmacy	Health inequity focus
Diaby et al, 20213	Incorporating health equity into value assessment	2-part health technology appraisal Distributional cost-effectiveness analysis Equitable multicriteria decision analysis	Race and ethnicity SES
Newman et al, 20214	Coverage of SLE treatments	SLE disproportionately affects Black and Hispanic individuals, yet there was little enrollment of such individuals in clinical trials; urges researchers to provide real-world evidence to help fill gap. Urges manufacturers to not extend patents (drug affordability a bigger challenge for minorities) and for payer coverage policies to consider race and ethnicity Urges quality measures to account for race and ethnicity	Race and ethnicity
Alpern et al, 20216	Medicaid benefit design	Advocates for: In the setting of COVID-19, that all states relax their 30-day dispensing limit and extend to all chronic medication to allow for a 90-day supply Postpandemic Maintain COVID-era policies that relaxed 30-day dispensing limit Reexamine existing policies that allow 90-day limits to cover all chronic diseases Conduct research to examine impact of policies on costs, waste, and adherence; variation by state during Covid may provide natural experiment	SES
AMCP Partnership Forum 20227	Racial health disparity considerations in formulary and benefit design	The forum provided a glossary of useful terms, presented 2 frameworks addressing bias and microaggressions, and highlighted several priorities related to data, formulary process, benefit offerings, and patient access among others	Race and ethnicity
Ding et al, 20228	Racial and ethnic disparities in medication adherence	Specific to integrated medical and prescription plans, notes benefits of aligned incentives, access to data, and ability to coordinate care. Data to support the following below were provided: Address affordability (eg, copay assistance, benefit design) Improve access (eg, mail order) Improve engagement, education and trust (eg, representative workforce, motivational interviewing, leverage existing relationships)	Race and ethnicity
Nikitin et al, 20225	Coverage for tirzepatide in T2DM	Broaden coverage criteria, ideally eliminating step therapy with metformin to avoid limiting access to vulnerable patients Several recommendations for manufacturers (eg, lower prices, increase diversity in clinical trials)	Race and ethnicity
Schulte et al, 202210	Improving health equity in patients with T2DM through collection of SDOH information	Managed care organizations should consider using financial incentives to encourage providers to submit SDOH Z codes on claims	SDOH
Brixner et al, 20229	Improving benefit design to address health inequities	Focus groups recommended the following research aims related to health inequities: Understand how the ability to navigate managed care tools among diverse patient populations may impact health inequities Understand the connection between health inequities and medication adherence and define managed care–specific quality measures that incorporate SDOH Determine how SDOH, such as race, ethnicity, and socioeconomic status, impact a patient’s ability to afford medications across different benefit designs	SDOH

ICER = Institute for Clinical and Economic Review; SDOH = social determinants of health; SES = socioeconomic status; SLE = systemic lupus erythematosus; T2DM = type 2 diabetes mellitus.

The next set of articles focused on medication benefit design. Alpern et al proposed specific changes to Medicaid, such as relaxing the 30-day dispensing limit to a 90-day supply both during and after the COVID-19 pandemic.⁶ A broader scope was taken by the Academy of Managed Care Pharmacy (AMCP) Partnership Forum in March of 2021, which brought together more than 40 managed care experts.⁷ The article contains a glossary of terms, which helps distinguish between terms such as “health disparity” and “health care disparity.” During this forum, experts also developed a list of priority considerations related to data, formulary process, benefit offerings, patient access, and more. Key recommendations on data included increasing diversity in clinical trial enrollment, improving subgroup reporting and heterogeneity response detection, augmenting data (eg, demographic) collection within health care delivery systems, and recognizing potential biases in current algorithms and artificial intelligence platforms. Recommendations related to the formulary process included incorporating robust diversity data into drug monograph tools, providing annual equity training for pharmacy and therapeutics committee members, adding committee minority representation, and creating an equity subcommittee in formulary decisions. Key recommendations on benefit offerings included acknowledging that racial disparities may exist in the benefit design process, considering differential cost sharing and premiums based on income, offering free or low-copay preventive medication, and adjusting cost-sharing models in disease states that disproportionately impact minority or other at-risk populations. Recommendations related to patient access included considering benefit flexibility, using automated tools for easy access, expanding access to the care delivery network and enhancing care coordination, and developing patient outreach programs to improve health and health insurance literacy. Additional recommendations were related to developing programs that would incentivize health care providers to participate in equity efforts and sharing best practices in peer-reviewed journals such as JMCP.

Ding et al focused on racial and ethnic disparities related to medication adherence and highlighted issues with drug affordability, expanding access, and improving engagement, education, and trust.⁸ In an AMCP initiative led by Brixner et al, focus groups were conducted to develop research aims related to a research priority focused on improving benefit design to address health inequities.⁹ The 3 research aims were to (1) understand how ability to navigate managed care tools among diverse patient populations may impact health inequities; (2) understand the connection between health inequities and medication adherence and define managed care–specific quality measures that incorporate SDOH; and (3) determine how SDOH, such as race, ethnicity, and socioeconomic status, impact a patient’s ability to afford medications across different benefit designs. In another article, Schulte et al urged managed care organizations to provide financial incentives to encourage providers to submit SDOH Z codes on claims as a critical step to being able to identify at-risk populations and subsequently address their SDOH needs.¹⁰

Since JMCP’s Call to Action, responding Viewpoint articles have addressed health disparities in various topics, commonly including pharmacy benefit design, formulary coverage of medications, and value assessment. Recommendations included increasing representation of racial and ethnic minoritized groups in clinical trials, as well as providing real-world evidence to help fill the gap in evidence; improving access to medications by addressing both financial and nonfinancial barriers (eg, improving engagement, health and health insurance literacy, and trust); and incentivizing providers and plans to participate in health equity efforts, such as SDOH data collection or quality measures and reporting that incorporate race and ethnicity.

Summary of Research Articles

In the next section, we summarize Research Articles received in response to JMCP’s Call to Action by highlighting study approaches and findings.

APPROACHES

More than half of research articles (8 of 14) focused on race and ethnicity, and the remainder focused on other SDOH, such as income, employment disability, education, and rurality (Table 2). Research articles examining racial and ethnic disparities often adjusted for other characteristics, such as age, sex, geographic region, rurality, comorbidity burden, insurance type, income, disability, and residence in a health professional shortage area.

TABLE 2.

Summary of Research Articles (n = 14)

Author year				Study type & data source				Study population				How article relates to inequities				Key findings				Health inequity focus
Chou et al, 202016				Survey delivered by 4 Medicare Part D plans to a national convenience sample of beneficiaries who received a CMR as part of a MTM program in 2017-2018				Medicare Part D beneficiaries who received a CMR (to qualify, must have had multiple chronic conditions, multiple drugs, and high drug spend) (n = 434)				Describes characteristics of survey respondent population: race and ethnicity, education, geographic region, rurality, and county-based indicators, such as economic dependence, low employment population loss, retirement destination, and poverty level over 3 decades.				Most survey respondents were White (83%) and the majority had at least a college education (67%) and lived in large metropolitan areas (58%); 50% were male. Black and Hispanic individuals (8%) and those whose counties were characterized by low employment (7%) and persistent poverty over 3 decades (2%) were underrepresented in the survey population.				Race and ethnicity Gender Education Geographic region, rurality County-based indicators of economic dependence, low employment population loss, retirement destination, and poverty level over 3 decades
Sherman et al, 202215				Cross-sectional analysis of 2018 claims (Marketscan) data				Patients with rheumatoid arthritis, atopic dermatitis, multiple sclerosis, psoriasis (plaque psoriasis and psoriatic arthritis), Crohn’s disease, and asthma who filled 1+ specialty medication for an autoimmune disorder (n = 17,096)				Compares specialty medication use and resource use among 5 different income groups				Lower wage was associated with less specialty medication use (percentage with use: P < 0.0001; days supply: P < 0.001) and adherence (P < 0.001) and greater number of inpatient admissions (P = 0.002) and ED visits (P < 0.0001).				Wage Adjusted for: age, sex, zip code–based median household income, geographic area, health plan contract type, net deductible as a percentage of wage, CCI, Psychiatric Diagnostic Groupings, employee, part of a union, rurality
O’Malley et al, 202231				Retrospective cohort study of 2016-2020 EHR (Illumination Health) data linked to claims (Health Core Integrated Research Database and fee-for-service Medicare medical and pharmacy claims) data				Two cohorts were established for comparison: the AVISE testing strategy cohort (n = 2,437) and the tANA testing strategy cohort (n = 5,364). Patients may or may not have SLE diagnosis/medication.				Mentions that the condition of interest, SLE, disproportionately affects Black and Hispanic women, so “efforts to improve outcomes in lupus lend themselves naturally to reducing historical social inequities in care.”				Compared with tANA-positive patients, AVISE-positive patients were more likely to be diagnosed with SLE and start SLE medication. AVISE tests may have improved negative predictive value compared with tANA tests.				Race and ethnicity
Jiang et al, 202211				Retrospective cohort study of 2014-2019 claims (Marketscan) data				Newly diagnosed AF cohort (for secondary objective: n = 156,732)				Secondary objective is to assess for differences in health care resource use and costs between rural vs urban among a newly diagnosed AF cohort.				Rural patients had fewer outpatient visits (1.99 fewer, 95% CI = -2.26 to -1.71) and lower total cost (mean = -$751, 95% CI = -1,227 to -228) but more ED visits (0.05 more, 95% CI = 0.02-0.08) than urban patients.				Rurality Adjusted for: age, sex, insurance type, health plan type, CCI, number of medications, calendar year, and geographic region
Brown et al, 202221				Online, cross-sectional survey at 2 time points (T1: February/March 2021 and T2: November 2021)				US adult population (n = ~2,000 T1, n = ~1,000 T2)				(1) Assesses COVID-19 vaccination rates and trust levels for vaccine information by race at 2 time points (2) Identifies factors associated with receipt of vaccine				At T1 and T2, lower proportions of Black respondents (9.6% and 74.4%) were vaccinated relative to White (23.2% and 72.0%) and other race (14.4% and 75.2%) respondents (P < 0.05). Black race (P < 0.001), median household income <$100k (P < 0.001), and residence in the Northeast (P = 0.003) or Midwest (P = 0.003), relative to the West, predicted lower likelihood of receiving vaccine at T1. Trust scores were lowest for respondents of other race, as compared with Black and White individuals.				Race Assessed for other possible predictors: income, sex, geographic region, marital status, education, CCI, smoking status, and physician trust score
Allaire 202323				Retrospective cohort study of 2014-2019 claims data from 2 health systems participating in Dispensary of Hope, a charitable medication access program				Patients with no insurance, low incomes, and chronic conditions, which include patients who were enrolled in the Dispensary of Hope program from 2 sites (n = 880 and 3,059), and propensity score–matched comparison groups (n = 6,714 and n = 579)				Reports program outcomes from enrollees, all of whom have low incomes and no insurance				In site #1, per-person annual costs were $3,161 (P < 0.05) lower from preenrollment to postenrollment as compared with the comparison group. Number of inpatient stays also decreased by 200 stays per 1,000 patients per year (P = 0.02). However, ED visits increased by 0.32 (P < 0.01). No results were statistically significant for site #2.				Income
Shapiro 202324				2019 National Health and Wellness Survey (online, nationally representative, self-administered)				Migraine cohort (n = 1,962) and propensity score–matched cohort (n = 4,429)				Assesses association between migraine frequency and employment disability				Finds that headache frequency is associated with employment disability (P < 0.001).				Employment disability
Almodóvar 202332				Social needs screening survey administered during a CMR by one MTM program in 2020				Medicare-Medicaid dually enrolled patients who received a CMR (to qualify, must have had multiple chronic conditions, multiple drugs, and high drug spend) (n = 358)				Describes social needs of dually enrolled Medicare-Medicaid patients				Top 5 identified social needs included not having enough money to pay bills (49%), lacking support to perform daily activities (47%), running out of food (23%), lacking companionship (23%), and feeling isolated (23%).				Income
Wong 202313				Cross-sectional analysis of claims (IQVIA Longitudinal Access and Adjudicated Dataset) data linked to Experian consumer data				Patients who had claims for selected branded drugs from 2 therapeutic areas: rheumatoid arthritis (n = 67,674) and oral oncolytics (n = 9,560)				(1) Assesses disparities in copay assistance use and prescription abandonment across race, ethnicity, or income (2) Assesses association of copay use with prescription abandonment and whether this differs across race, ethnicity, or income				For patients who were prescribed RA medications and not using copay assistance, Black patients, Hispanic patients, and those with household incomes <$50k were more likely to abandon prescriptions (P < 0.01, P = 0.03, and P < 0.01, respectively). For oral oncolytic medicines, patients with household incomes <$50k were more likely to use copay assistance (P < 0.01) but also more likely to abandon their prescription if not using copay assistance (P < 0.01). For both therapeutic areas, copay assistance was associated with >70% lower odds of prescription abandonment (P < 0.01), and this did not differ by race, ethnicity, or income (P > 0.05).				Race and ethnicity Income Adjusted for: sex, age, region, prescribing provider type, drug, year, initial OOP cost, and rurality
Chang et al, 202312				Cross-sectional analyses of 2010-2019 claims (Medicare) data linked to registry (SEER) data				Breast cancer survivors with depression (n = 9,452)				Secondary objective is to identify factors associated with nonadherence to newly initiated antidepressant medication.				Black race and Hispanic ethnicity were associated with higher odds of nonadherence (P < 0.05).				Race and ethnicity Assessed for other possible predictors: age, marital status, disability status, LIS and dual Medicaid eligibility, rurality, residence in a county with low education, and residence in mental HPSA
Lucero et al, 202322				Retrospective cohort study of Veterans Affairs EHR data (2013 to 2017)				Veterans with CLL (n = 565)				Determines if uptake of novel agents for first-line treatment was similar in Black vs White patients				Black patients were less likely to receive novel CLL agents compared with White patients (14% vs 26%; P = 0.02) but gap narrowed over time (eg, 2014: 4% vs 17%; 2015: 13% vs 25%; 2016: 17% vs 33%; 2017: 31% vs 33%). Health outcomes resource use (eg, ED visits) and complications (eg, secondary cancers) were similar.				Race
Ogunsanmi et al, 202317				Retrospective cohort study of EHR (Tennessee Population Health Data Network) data				Patients with type 2 diabetes who have been on metformin for 1+ year and started a second-line diabetes medication (n = 7,723)				Identifies predictors associated with receipt of newer second-line diabetes medications				Patients living in neighborhoods with higher percentages of college graduates were more likely to receive newer second-line diabetes medications (quartile 3 vs quartile 1: P = 0.010; quartile 4 vs quartile 1: P = 0.004).				Education Assessed for other possible neighborhood-level (based on census tract or zip code) predictors: income and residence in primary or mental HPSA
Prioli et al, 202333				Cluster-randomized trial from 2017-2020				Adults aged 50+ years who were recruited from 12 sites that predominantly served Black communities (n = 287)				Reports outcomes from trial comparing 2 interventions in adults recruited from sites that predominantly served Black communities				The 2 tested interventions (peer-led [PEER] and pharmacist-led [PHARM] vaccine education programs) led to improved disease knowledge scores and vaccination trust.				Race
Ingham et al, 202314				Retrospective cohort study of 2019-2021 claims (IQVIA Longitudinal Access and Adjudicated Dataset) data linked to Experian consumer data				Patients younger than 65 years with therapeutic areas of interest (ie, cardiovascular and metabolic diseases, immunology, infectious diseases, multiple sclerosis, oncology, pulmonary arterial hypertension, and schizophrenia) (n = 4,073,599)				Compares use of copay assistance and exposure to CAP (which exclude copay assistance from deductibles and OOP cost maximums) between White and non-White patients				Among copay card users, non-White populations were more likely to be exposed to CAPs and need to pay higher OOP cost sharing than White populations. No difference in copay card uses.				Race and ethnicity Adjusted for: age, gender, income, state of residence, whether that state had an existing legislative ban on CAPs, drug cost exposure in the previous year, and pharmacy benefit manager

AF = atrial fibrillation; AVISE = AVISE Lupus test; CAP = copay adjustment program; CCI = Charlson Comorbidity Index; CLL = chronic lymphocytic leukemia; CMR = comprehensive medication review; ED = emergency department; EHR = electronic health record; HPSA = health professional shortage area; LIS = low-income subsidy; MTM = medication therapy management; OOP = out-of-pocket; RA = rheumatoid arthritis; SEER = Surveillance, Epidemiology, and End Results Program; SLE = systemic lupus erythematosus; T1 = time point 1; T2 = time point 2; tANA = traditional antinuclear antibody.

Across the research articles, there was great heterogeneity in study population, approach, objective, study type, and data source. Study populations included older adults with multimorbid conditions who are eligible for Medicare’s medication therapy management program; patients filling a specialty medication; patients with specific clinical conditions, such as SLE, atrial fibrillation, migraine, chronic lymphocytic leukemia (CLL), type 2 diabetes, breast cancer, and depression; and general populations. Of the 14 articles, one was a randomized controlled trial, 4 were surveys, and 9 were observational studies using claims or electronic health record data. Two studies had a health disparity focus as a secondary objective.^11,12 Outcomes of interest included medication adherence, health care use and costs, social needs, and trust in physician.

Several of the research articles linked data from different sources to capture SDOH factors, as some of these factors are not typically captured in claims or electronic health record data. For example, a breast cancer study using Medicare data linked to the Surveillance, Epidemiology, and End Results registry data.¹² Two other studies used IQVIA pharmacy claims data and linked to deidentified Experian consumer demographics data collected from a variety of public and proprietary sources to estimate race, ethnicity, and income data.^13,14 One other study using IBM Watson Health MarketScan claims data limited the population to those in a self-insured health plan for whom wage data were available.¹⁵ We share these examples to help researchers who are interested in studying health disparities.

Several studies also included geospatial information, such as employment, education, poverty, and access to health professionals at the zip code, census-tract, or county level, which indicate neighborhood socioeconomic status.^12,16,17 These data are provided through various sources, such as from the US Department of Agri-culture Economic Research Service, National Historical Geographic Information System, and Centers for Medicare and Medicaid Services Health Professional Shortage Area Designations,^18-20 and allow for the exploration of new questions related to how environmental factors can affect outcomes and health care use.

FINDINGS

Across studies examining racial and ethnic disparities, the following disparities were identified: (1) Black respondents were less likely than White respondents to receive the COVID-19 vaccine²¹; similarly Black patients were less likely than White patients to receive novel CLL medications, but the gap narrowed over time in both studies²²; (2) Black and Hispanic patients were more likely than White patients to abandon branded medications for rheumatoid arthritis¹³; (3) Black and Hispanic breast cancer survivors with depression were more likely than White survivors to be nonadherent to antidepressants¹²; (4) and racial and ethnic minority patients were more likely than White patients to be exposed to copay adjustment programs (which lead to higher out-of-pocket [OOP] costs) and have to pay higher OOP cost sharing for medications across a variety of clinical conditions (eg, cardiovascular and metabolic diseases, immunology, infectious diseases, and more).¹⁴

In studies looking into the impact of income on medication use, lower wage was associated with less specialty medication use and adherence, as well as a greater number of inpatient admissions and emergency department visits.¹⁵ The top 5 identified social needs among dually enrolled Medicare-Medicaid patients were not having enough money to pay bills (49%), lacking support to perform daily activities (47%), running out of food (23%), lacking companionship (23%), and feeling isolated (23%).²³ Those with household incomes less than $50,000 were more likely to abandon prescriptions for rheumatoid arthritis and if not using copay assistance; this was also true for prescriptions for oral oncolytics.¹³ For both therapeutic areas, copay assistance was associated with lower odds of prescription abandonment, and this did not differ by race, ethnicity, or income.

Beyond differences by race, ethnicity, and incomes, studies examined additional health inequities, such as by rurality, educational level, and disability. When it came to urban-rural differences, rural patients had fewer outpatient visits and lower total cost but more emergency department visits than urban patients.¹¹ Patients living in neighborhoods with greater proportions of college graduates were more likely to receive newer second-line diabetes medications.¹⁷ In another study, headache frequency was associated with employment disability.²⁴

Beyond Viewpoint and Research articles published in JMCP, AMCP has also developed an online resource center. This center houses documents such as the Health Disparities Landscape Assessment White Paper, as well as a series of Health Equity Briefs in a variety of topics including, SODH; sexual orientation and gender identity; race, ethnicity and language; disabilities; and geography and formulary management.²⁵

Broader Initiatives: Definitions and Goals of Healthy People 2030

As we continue to study and address racial and social inequities in medication use, it is helpful to use a framework to categorize different types of inequities. Below we discuss a framework that may be useful to future health disparity researchers.

One of the overarching goals of the US Department of Health and Human Services’ Healthy People 2030 is to “[e]liminate health disparities, achieve health equity, and attain health literacy to improve the health and well-being of all,” in which a health disparity is defined as “a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage.”²⁶ Healthy People 2030 goes on to describe that health disparities “adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.”²⁶

To eliminate health disparities, Healthy People 2030 targets health literacy and SDOH. 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.”²⁷ They can be categorized into 5 domains: (1) economic stability, (2) education access and quality, (3) health care access and quality, (4) neighborhood and built environment, and (5) social and community context. Examples include safe housing, transportation, and neighborhoods; racism, discrimination, and violence; education, job opportunities, and income; access to nutritious foods and physical activity opportunities; polluted air and water; and language and literacy skills. Encouraging accurate capture of individual-level SDOH data, such as by incentivizing providers to submit Z codes, as well as by using neighborhood measures to fill in any missing data in the meantime, are proposed ways forward by Viewpoint articles and what we have seen done in Research articles responding to the JMCP Call for Action.

As defined by Healthy People 2030, personal healthy literacy is the “degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others” and organizational health literacy is the “degree to which organizations equitably enable individuals to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.”²⁶ The separation of these concepts demonstrates an acknowledgment that organizations have a responsibility to address health literacy. In the context of managed care pharmacy, health insurance literacy, or “a person’s ability to seek, obtain, and understand health insurance plans, and once enrolled use their insurance to seek appropriate health care services,” is a noteworthy problem in the United States, where a majority of individuals do not understand basic insurance concepts.^28-30 Our review also highlighted that racial and ethnic disparities exist in that non-White patients were more likely to be exposed to copay adjustment programs, a newer and complex benefit design, and higher OOP cost sharing, which may lead to greater degrees of prescription abandonment and nonadherence. Given that drug affordability remains a significant issue, reducing the cost of prescription medications (as called for by many Viewpoint articles), simplifying benefit design, and helping beneficiaries to understand their insurance (and expected cost sharing) is a responsibility that plans should take on to help address inequities.

Conclusions

There was great heterogeneity across responding Viewpoint and Research articles with regard to the health inequity examined and approach. Progress has been made at JMCP in a period of 3 years in terms of content and volume of manuscripts published following a call to action to submit papers addressing racial and social inequities in medication use. That said, work lies ahead in continuing to study these disparities given the multifaceted nature of the topic and the different approaches that can be taken to help close these gaps.

Funding Statement

The authors have no study funding to disclose.