Disparities in Chronic Disease Outcomes Require Solutions

Six in 10 Americans have a chronic disease, and 4 in 10 have received a diagnosis of 2 or more chronic diseases.¹ Millions of Americans live with and manage cancer; diabetes; epilepsy; Alzheimer disease; heart, lung, and kidney disease; rheumatoid arthritis; and other conditions. Many participate in ongoing medication therapy, prescribed regimens, and regular medical support.

However, best outcomes are out of reach for some of them. For myriad reasons, health care professionals may be unable, unaware, or unsure of how to manage their illnesses, resulting in outcome disparity.²

A 2017 publication by the National Academies of Science, Engineering, and Medicine cited 2 root causes for inequitable health outcomes: systemic mechanisms that organize power and resources unevenly across class, gender, and race; and an unequal allocation of power and resources that manifest as unequal economic, environmental, and social conditions.³

Other factors may include patients downplaying or ignoring symptoms, having to travel long distances to doctors or hospitals, living alone without support, being financially insecure, and having unreliable transportation.

Health system–owned integrated specialty pharmacies (ISPs) have experience managing and improving outcomes with complex diseases4 and are poised to lead the change necessary to address chronic disease outcome disparities.

As a collaborative team that includes traditional dispensing pharmacists, drug contracting access experts, health outcomes managers, in-clinic liaisons, and payer contracting experts, ISPs are fully embedded in integrated care teams. They have the access, desire, knowledge, and structure to help bridge the gap between diagnosis and outcome.

Community Outreach

UMass Memorial Health is the largest not-for-profit health care system in central Massachusetts with more than 15,500 employees and 2100 physicians, many of whom are members of Harrington Physician Services and UMass Memorial Medical Group. The health care system is the clinical partner of the UMass Chan Medical School. The health care system makes health and wellness services available to everyone in the community whether at the clinic or at home, advocates for social equality, and provides economic stability and opportunity.

UMass Memorial Health has many services and tools to increase visibility and reduce barriers to access by being flexible and meeting patients where they are.⁵ These include a hospital-at-home program; vaccination mobile; and e-visit, telehealth, and telemonitoring programs, which have been expanded for patients because of the COVID-19 pandemic.⁶ Early evidence shows that telehealth is a win-win scenario, decreasing costs for hospitals while improving outcomes for at-risk patients.⁷

Access

Pharmacists are consistently viewed as some of the most accessible health care providers. In addition to community pharmacies, there are pharmacies embedded within health system organizations that offer mail-order services, provide discharge prescriptions for patients as they leave the hospital, and support employee prescription programs. Pharmacists serve a critical role in patient care with access, education on therapies, medication review and verification, and targeted care services for conditions such as asthma and diabetes.

The ISP focuses more of its care model on access to specialty medications that are more complex regimens with higher costs and significant education requirements. Although there are not specialty pharmacies in every neighborhood or town, it is critical to have local access to health system–owned specialty pharmacies where patients benefit from higher acuity care and specialty clinicians. A patient’s specialty medication should come from local health care providers and not be shipped by large fulfillment centers across the United States.

The ISP has additional resources beyond the traditional community pharmacy, including access to the electronic medical record documenting pharmaceutical care into the patient’s care plan and direct interaction with provider colleagues at the health system, including embedded clinical pharmacists and pharmacy liaisons who work with patients directly during their appointments. The integration of pharmacy services and medical care is proving successful. Evidence already shows better outcomes, improved medication adherence, and reduced costs, specifically with Medicaid patients.⁸ Because of accreditation requirements, payer and limited drug distribution contracting, and other complexities of specialty pharmacy services, the infrastructure on this model is much greater than at a community pharmacy. The model provides resources that focus on health outcomes and further evaluate access to care in the scope of health disparities. The Health System Owned Specialty Pharmacy Alliance offers more information on this topic.⁹

Advocacy

After more than a decade of debates and discussions, the right pieces for integrated, whole-person care are in place. There is still work to be done, however, to ensure that the parts work together effectively and that efforts to expand the approach to health care grow in the right direction.¹⁰ Pharmacists must resist the easy tendency to become routinized and siloed. If internal teams constantly seek and have access to the bigger picture, then pharmacists may realize that their biggest problem is not the department down the hall, but the data showing that millions of individuals deserve and need better outcomes. Advocacy, improvement, and innovation must be normalized.

Do not sit back and wait for hospital leadership to guide the way. Specialty pharmacy leadership can formulate goals and advocate within their own systems, demonstrating new ways to be involved, and resolving outcome disparity.

Strong communication can oil the new gears of integrated care. For example, team members, both within the specialty pharmacy and as part of the larger care team, should use the same language and terms to describe patient problems and solutions. Make sure that terminology does not cause confusion but increases clarity.

When data in specific departments show that certain chronic disease states disproportionately affect non-White or underinsured populations, recognize the opportunity. Seek creative ways to engage with the team and educate disassociated patients. For example, are there any start-ups or technology companies offering beta programs for more affordable smart watches and other wearables? Research from the American Diabetes Association shows the benefits of continuous glucose monitoring.¹¹ Educate health care team members and patients with engagement to optimize care.

Find ways to proactively eliminate barriers to care with at-risk populations. Adopting a spirit of innovation makes it easier to envision possibility and find new solutions to familiar problems.

Patient-centered models within UMass Memorial Health and other systems have an opportunity to narrow and close the disparity gap. At each postdiagnosis patient interaction, there are on-the-ground and philosophical opportunities for specialty pharmacies to improve outcomes by educating at-risk individuals about the benefits of following courses of care, encouraging the filling and taking of prescribed medications, and establishing and taking pride in ease of access and a supportive “Care is there” environment.

Neil A. Gilchrist, PharmD, MBA, BCPS, DPLA, is chief pharmacy officer at UMass Memorial Medical Center in Worcester, Massachusetts, and a board member of the Health System Owned Specialty Pharmacy Alliance.

REFERENCES

1. Chronic diseases in America. CDC. January 12, 2021. Accessed December 16, 2021. https://www.cdc.gov/chronicdisease/resources/infographic/chronic-diseases.htm

2. Thomson GE, Mitchell F, Williams MB, eds. Health disparities: concepts, measurements, and understanding. In: Examining the Health Disparities Research Plan of the National Institutes of Health: Unfinished Business. National Academies Press; 2006.

3. Weinstein JN, Amy Geller A, Negussie Y, Baciu A, eds. The root causes of health inequality. In: Communities in Action: Pathways to Health Equity. National Academies Press; 2017.

4. Donovan J. Quality initiative demonstrates the benefits of integrated pharmacy care model. Pharmacy Times®. June 10, 2021. Accessed December 16, 2021. https://www.pharmacytimes.com/view/quality-initiative-demonstrates-the-benefits-of-integrated-pharmacy-care-model

5. Coppock K. Understanding health disparities in pharmacy. Pharmacy Times®. July 22, 2020. Accessed December 16, 2021. https://www.pharmacytimes.com/view/understanding-health-disparities-in-pharmacy

6. Medicare telemedicine health care provider fact sheet. CMS. News release. May 17, 2020. Accessed December 16, 2021. https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet

7. Wicklund E. Telemedicine study cites tele-ICU’s positive impact on patients. mHealth Intelligence. January 25, 2017. Accessed December 16, 2021. https://mhealthintelligence.com/news/telemedicine-study-cites-tele-icus-positive-impact-on-patients

8. Pruisner T, Rickert S, Cohen M. The value of integrated pharmacy benefits in Medicaid managed care. Wakely. June 15, 2020. Accessed December 16, 2021. https://www.wakely.com/sites/default/files/files/content/value-integrated-pharmacy-benefits-medicaid-managed-care-20200615.pdf

9. Health System Owned Specialty Pharmacy Alliance. Accessed December 16, 2021. https://hospalliance.org/

10. Antrim A. Specialty pharmacists are essential patient advocates. Pharmacy Times®. July 14, 2021. Accessed December 16, 2021. https://www.pharmacytimes.com/view/specialty-pharmacists-are-essential-patient-advocates

11. Better blood glucose meters and more. American Diabetes Association. Accessed December 16, 2021. https://www.diabetes.org/healthy-living/devices-technology