For the past couple of years, payers have been focusing more attention on health inequities related to race, income and other factors by hiring staff and investing money in programs to improve access to care and lower costs. More recently, they have adopted similar strategies to address inequities in the pharmacy side of their businesses, according to health plan executives who spoke at a conference last month at the University of Pittsburgh.
The push among payers is known as “pharmacoequity,” a term popularized by Utibe Essien, M.D., an internal medicine physician and assistant professor at UCLA. Essien, who moderated the panel with the payer executives, defines pharmacoequity as “equity in access to pharmacotherapies or ensuring that all patients, regardless of race and ethnicity, socioeconomic status, or availability of resources, have access to the highest quality of pharmacotherapy required to manage their health conditions.”
Michelle Gourdine, M.D., senior vice president at CVS Health Corp. and chief medical officer at the CVS Caremark PBM, noted during the conference that health equity is becoming a priority for the company thanks to an internal emphasis from senior executives and outside factors. For instance, starting in 2027 insurers that offer Medicare Advantage plans — including CVS-owned Aetna — will be rewarded by CMS for addressing disparities in certain quality measures through a new health equity index.
Gourdine added that health equity measures are part of CVS’s Net Promoter Score, a popular metric that assesses customer experiences, while accreditation organizations such as URAC and the Joint Commission have implemented health equity requirements, too.
“The financial business case of health equity is really, really important,” Gourdine said. “Beyond [being] the right thing to do…tying [health equity] back to the financial imperative and the business case I think is extremely important. We can’t ignore that.”
Health Inequities Drive Up Spending
A Deloitte report from last year estimated that health inequities related to race, socioeconomic status and sex/gender accounted for $320 billion in annual health care spending for five high-cost diseases: breast cancer, diabetes, colorectal cancer, asthma and coronary heart disease. That inequity-driven extra spending could rise to $1 trillion by 2040 and drive an average $2,000 increase in health spending per person in the U.S. if those issues are not addressed, according to the consulting company’s actuaries.
Major payers have poured more resources into dealing with such inequities. For instance, CVS Health, Elevance Health, Inc., UnitedHealth Group, Humana Inc. and Centene Corp. in the past two years have created C-suite positions related to health equity.
Darrell M. Gray, II, M.D., who joined Elevance in August 2021 as its first chief health equity officer, said during the conference that “health equity is tied to our core business.” He added that while the Black Lives Matter movement of 2020 brought mainstream attention to racial inequities and other protests that year “highlighted kind of the moral and social imperative [of inequalities]…what can be lost on many is the business imperative of advancing health equity, as well.”
Elevance has focused on three areas of health equity: maternal health, behavioral health and access to evidence-based medical therapy. A posting on Elevance’s website cites a 2021 JAMA study that Essien authored that found Asian and Black patients with atrial fibrillation in the Veterans Health Administration system were significantly less likely to receive anticoagulants than white patients. To combat such inequities, Carelon Rx, Elevance’s in-house PBM, launched a pharmacist-led case management program where pharmacists contact members who are not taking their medications and ask whether they are experiencing any issues accessing the medications.
“One of the things that I and others were very intentional in saying is, we don’t want health equity to be a separate vertical of business,” Gray said during the conference. “Health equity is not a program. It is not a service. It is how we approach everything that we do, from how we design our products, our programs, our practices, how we review medical policy that has certain implications, how we deploy services through our PBM. It cuts across all of that.”
Programs Address Inequities in Underserved Communities
At CVS, Chief Health Equity Officer Joneigh S. Khaldun, M.D., and her team created a pharmacoequity tool that analyzes publicly available data on social determinants of health in certain neighborhoods across the U.S. and integrates it with CVS’s pharmacy claims data.
Gourdine said such a tool helps CVS “lay out a picture of our members and helps us to be able to identify where are the greatest opportunities for us to be able to go in and intervene either ourselves as a company or in partnership with others?”
Earlier this year, CVS launched a Community Equity Alliance focused on addressing barriers to care in certain parts of the country. The company has initially partnered with: Meharry Medical College in Nashville, Tennessee, to recruit and train community health workers; Sinai Chicago health system to provide residents with resources to address health disparities; and Wayne State University in Detroit to train faculty, staff and community members to combat health differences among racial groups. The programs will initially focus on mental health and heart health, but CVS will expand it to other disease states and other institutions.
Gourdine said that Khaldun “has done a great deal to ensure that health equity is not just some marginalized program and some marginalized office but permeates every single thing that we do.”
UnitedHealth is another major payer that has increased its health equity initiatives, including with the hiring two years ago of Joy Fitzgerald as senior vice president and chief diversity, equity and inclusion officer. Optum Rx, UnitedHealth’s PBM, last month launched a program in seven states where it works with community pharmacists that serve Optum members in rural and underserved communities. The pharmacists will help the members connect to Unite Us, “a nationwide technology platform that identifies social care needs to connect people with community services and resources at a local level,” according to a UnitedHealth press release.
The program initially focuses on people with diabetes and pregnant women in North Carolina, Nebraska, New Jersey, New Mexico, New York, Texas and Louisiana. UnitedHealth plans on expanding the initiative nationwide this fall.
This month, Optum Rx is introducing a Maternal & Fetal Health program that “will support pharmacists in encouraging pregnant women to seek preventative prenatal care to decrease both pre-term labor and pregnancy complications to help ensure a healthier newborn.” And this fall, Optum Rx is launching a Pharmacy & Provider Desert program that “will ensure members who live in health care deserts receive access to pharmacy and other health care services they need to promote optimal health outcomes.”
Optum Rx plans on making the programs available to pharmacies across the U.S. later this year and says the pharmacies “will receive appropriate reimbursement for supporting patients in accessing medically necessary services that improve their health outcomes.”
BCBS of Massachusetts Reveals Health Equity Report
Regional insurers are paying closer attention to inequities, as well. Blue Cross Blue Shield of Massachusetts, for instance, publishes a health equity report on its website, where it publicly discloses 70 performance measures related to chronic conditions, mental health, prevention, tests and treatments, women’s health, and patient engagement. The results are stratified by race: Asian, Black, Hispanic and white.
Mark Friedberg, M.D., senior vice president of performance measurement and improvement at BCBS of Massachusetts, noted that the transparency initiative coincided with a decision by the health plan’s board of directors in 2020 to add “structural racism and inequities in health” as one of its strategic focus areas.
Late last year, BCBS of Massachusetts signed value-based agreements with four major health systems in the state that will reward them for “eliminating racial and ethnic inequities in care.” The contracts with Steward Healthcare Network, Beth Israel Lahey Health, Mass General Brigham and Boston Accountable Care Organization, Inc. deal with colorectal cancer screenings, blood pressure control and diabetes care. BCBS of Massachusetts noted that the University of California-Berkeley’s School of Public Health will evaluate the payer’s efforts to advance health equity.
“The providers didn’t take any convincing to engage on equity with us,” Friedberg said during the conference. “I think sometimes the word ‘incentive’ conveys this false notion that the providers didn’t care about equity and now we have to pay them. That’s definitely not it. They, by and large, with very few exceptions, really did care. What we’re trying to do now is create a financial business case for the CFO [chief financial officer] of a large provider system to make investments that they might not have been able to make previously with a guarantee of an ROI [return on investment] from us should they be successful in improving the equity of care.”
Is Health Equity a Fad or Long-Standing?
Friedberg noted that he gives a quarterly update to the BCBS of Massachusetts board of directors on how the company is progressing toward its health equity goals. However, he said “something that concerns me is, how long before [health equity] is unfashionable again or isn’t an organizational priority? I would say a lot of what we did in 2020 and 2021 was about making commitments that are very hard to step back from in public and in a very clear way, so that when the going gets tougher, it’s hard for the company to back down, despite changes in leadership, changes in the market and changes in national politics. We want to make it as hard as possible for that to occur. But yeah, it’s a real concern.”
Gray shared similar concerns, although he noted Elevance has shown its commitment to health equity and pharmacoequity by hiring him and others who solely focus on the issue and make it a priority across the company.
Gray said he and other top executives are already looking ahead to 2024 and asking questions such as, “how is health equity incorporated into our annual business planning? What are the things that are part of our routine?…There certainly is concern around sustainability. But that’s why I think it’s lit a fire under us to ensure that we are putting systems in place that when the term ‘health equity’ is not in vogue anymore, that the work can still continue when we change it to another term.”
This article was reprinted from AIS Health’s biweekly publication RADAR on Drug Benefits.