Evaluating an Intervention to Improve Medication Access and Quality of Care for Underserved Populations With Chronic Conditions

Harvard University D/B/A Harvard School Of Public Health, Boston MA

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Abstract

Underuse of evidence-based medications for chronic disease, driven in part by high out-of-pocket (OOP) medication costs, accounts for substantial preventable morbidity and mortality due to exacerbation of chronic illnesses. This underuse, and the resultant adverse health outcomes, are worse for patients who are Black, Hispanic, or Latino, and those who live in rural areas. Addressing gaps in cost information may reduce OOP spending and improve underuse. Sometimes clinicians prescribe more expensive agents when less costly, equally effective medications exist, in part because, until recently, they lacked information regarding what patients must pay for a particular drug. OOP cost information could also help patients and clinicians make treatment choices that are consistent with patient preferences and goals. In 2019, the University of Colorado Health System (UCHealth) implemented in all ambulatory care sites a Real-Time Benefit Tool (RTBT) that shows clinicians a patient’s OOP medication costs—the cost the patient would pay at a pharmacy—in the Electronic Health Record. Medicare policy supports RTBTs and will increase its implementation. Because cost- related medication underuse is significant among racial/ethnic minority and rural populations, a RTBT has the potential to increase guideline-concordant care in these populations and decrease disparities. On the other hand, use of RTBT may be less frequent among populations with chronic conditions who are Black, Hispanic, Latino, or in rural areas due to differences in where care is received (e.g. telemedicine), health literacy and language, cultural identity and norms, medical system behaviors that erode trust, or interpersonal and structural racism within the health care system. The project will focus on patients with asthma, atrial fibrillation, diabetes, or depression—common chronic conditions for which there are both costly and low-cost clinically effective drugs—and measure (1) outcomes among patients who are Black, Hispanic, or Latino, or who live in rural areas and (2) how these outcomes differ compared with other patients with the same chronic conditions. We will use unique UCHealth data linking clinical medication orders, pharmacy claims, patient data (including race, ethnicity, other demographics, and health status), and RTBT data to assess variation in RTBT use and whether the RTBT is associated with patients’ first medication fills. We will use the Colorado All-Payer Claims data and a difference-in-difference design to measure the impact of the RTBT on use of medications consistent with national evidence-based recommendations and on poor health outcomes. We will characterize via interviews and focus groups whether and how RTBT affects experiences, is consistent with patient preferences in their clinical encounters, and the factors associated with positive and negative experiences. This project will produce evidence on the policy impact of an RTBT on access and quality of care for Black, Hispanic, Latino, and rural patients with chronic conditions and on health disparities, and on implementation strategies to maximize impact.