So my name is Dima Kato. I'm PharmD Mph PhD. I'm a pharmacist by training and I'm currently an associate professor at the University of Southern California School of Pharmacy and the director of the program on medicines of Public Health. I'm also a senior fellow at the Leonard Schaeffer Center for Health Policy and Economics. And a lot of my research focuses on access to medications and disparities and the role of pharmacy access in addressing barriers to medication using minority populations. And that's what we'll be talking about today, particularly the role of structural racism in our understanding of pharmacy access in the United States. So we're going to talk about the role of structural racism and pharmacy access in the United States. Over the last several years, if not before, that pharmacies have been closing across the country. Many neighborhoods, particularly minority neighborhoods, are pharmacy desserts and. Making access to medications increasingly worse in the communities that in the populations that live in these neighborhoods. We found that many pharmacy desserts are indeed segregated black and Hispanic are minority communities. And it's these communities are also affected by pharmacy closures. So even though the number of pharmacies are closing are increasing overall, there's huge variation across neighborhoods. And we argue that that's related to structural racism, particularly segregation and policies being implemented by federal and state agencies that really make it difficult for pharmacies to stay open. Especially pharmacies serving publicly insured populations even before Covid pharmacies got more attention during the Covid pandemic because their role in the community was recognized. And they were closing but they've closed also and they were accessible to many people in minority neighborhoods prior to Covid. These are just new snippets prior to the Covid pandemic from NPR and US news and tribune. Chicago tribune that really highlights the problem of pharmacy desserts and pharmacy closures in minority neighborhoods and how they may be contributing to health disparities. In our more recent work we found, one of the initial arguments around pharmacies is they're plentiful there's so many across the US. And they're growing and I was interested in knowing whether or not they're growing equitably across the US. Hypothesized that they were not on a national and sub national scale, given that we identified one pharmacy desserts in Chicago. But also that there are persistent disparities and medication adherence. So we thought that perhaps pharmacy access is an overlooked barrier to disparities and medication adherence. Similar to disparities in primary care and poor preventative care utilization of preventative care or even treatments. I thought that you can't really get your medications filled or at least it's not as convenient for you. If you don't have a pharmacy nearby that you could actually use and fill your medications act. So we looked at trends and not only the number of pharmacies but closure rates. The number of pharmacies that close over time and the number of pharmacies that open. And what we found was that yes pharmacies are growing, there are a lot of pharmacies but there are also a lot of pharmacies that are closing. And we found that these closures are happening more in urban areas, particularly minority neighborhoods in urban areas, neighborhoods that already have fewer pharmacies to start with. And that really brought us to kind of this idea that let's focus on urban areas. Let's focus on cities in the US and look at how segregation residential segregation impacts pharmacy accessibility including closures across the cities by the racial ethnic composition of the neighborhoods. And we've published this in health affairs in June of 2021 and we found that indeed there are not, there are fewer pharmacies are growing even in cities. This is for the top 30 cities in the country. So the most of the urban areas, we found that most cities have on average one pharmacy per census tract or neighborhood. However, we consistently found across all cities that there are fewer in black and Hispanic neighborhoods and more pharmacies are available and white and diverse neighborhoods. The way we define neighborhoods biracial ethnic composition is based on kind of a predominant race in or ethnicity in that neighborhood. So neighborhoods that had more than 50% of the population white were considered white neighborhoods. We then use geospatial methods for these different neighborhoods to look at pharmacy desserts, which it's important because it's not just the number of pharmacies right in the neighborhood. It's how far you have to travel to get to that pharmacy. We defined pharmacy desserts using a half a mile and one mile, kind of cut off where neighborhoods were defined as desserts. Neighborhoods here, census tracts, if the majority of the population in that neighborhood had to travel more than a mile. If most households on a car or more than half a mile, if most households in that neighborhood don't have a car. And we found across all cities, this is the list of cities that while the prevalence of pharmacy desserts in a specific city varied the disparities really persisted across. So you see here that charlotte north Carolina overall had the largest number of percentage of neighborhoods that were pharmacies at desserts. And even in that city, there was a gap between black, which was closer to 90, more than 90% of black neighborhoods. I lived in a pharmacy desert compared to a little over 50% black neighborhoods. Whereas in New York city, which we know is geographically dunce there was a gap, but it was much smaller and the overall prevalence of pharmacy dessert was much smaller. And because we use kind of the same cut off across all cities I think there might be. There's opportunity to kind of do more city specific analyses that accounts for differences in population density for these cities. But regardless across all cities, there were gaps, so almost all black neighborhoods. Had fewer, had more pharmacy desserts than all white neighborhoods in all US cities. Which really supports our claim that and this these findings persist even when we restricted to low income neighborhoods. So it's not just income, it's about race. And medically underserved areas, it's not just because they're medically underserved. There's plenty of medically underserved areas that are not medically underserved in minority neighborhoods that are also pharmacy desserts. The gap was wider in Chicago between you see here white neighborhoods, less than five percent black neighborhoods over 30%. So this is the largest gap and the prevalence of pharmacy desserts or pharmacy accessibility between black and white neighborhoods in these 30 cities. So this is a map of Chicago which is the city with the worst disparities in pharmacy desserts as we saw. And these are what you see highlighted and red and orange are the pharmacy desert neighborhoods for 2015. And if you know Chicago, this is the south side, this is the west side. These are predominantly black neighborhoods. And these little dots you see are where the pharmacies were located are located. This is just a depiction of how, when someone asks you or anyone pharmacies are accessible, are available in Chicago and they're growing. Yes, they are. But they're not growing equally everywhere. In fact, they're closing more in minority neighborhoods including in Chicago than elsewhere. So making the pharmacy desert problem not better, but actually worse. And this is what you see here in this slide, which is pharmacy closures which could worsen pharmacy deserts. Right? So, if pharmacies are closing and many neighborhoods already have poor access, it really doesn't improve access to medications. It disrupts access to medications. And we see this, we saw this amplified really during the COVID pandemic, during the George Floyd protests, where a lot of retailers including pharmacies were closing in response. And we've seen it actually even before then, where pharmacies just kind of closed because the retailers and it really disrupts access to especially to the elderly and people that really need to take their medications on a regular basis to stay healthy. And this is happening almost exclusively in black neighborhoods in the US which worsens health that improves it. So back to this figure. This looks at closure rates by city in various neighborhoods based on the racial ethnic composition. And similar to the pharmacy desert figure pharmacy closures again, this is just kind of documenting the problem are happening more frequently in black and hispanic latino neighborhoods than they are in white or other neighborhoods that really persists across all cities. Some cities that may have other predominant Asian group ethnic groups like Asian or pacific islander or a diverse, depending on that composition, it really varies across city. So then that begs the question what pharmacy community or market factors are associated are to blame really for this increased risk of closures, which makes the pharmacy desert problem worse in the US. So we sought to do that using national pharmacy data. And what we found was that in urban areas and rural areas and independent pharmacies were the most at risk for closures, not chains, so not your Walgreens or CVS, but you're independent stores. And we found that minority counties that were predominantly minority, we're also increased risk with closure, which is something we expected. We also looked at the uninsured and the ratio the private public insurance. Public insurance being Medicaid or Medicare, which was important to look at because a lot of anecdotally and based on survey data, independent pharmacies report, loaf reimbursement from Medicaid and Medicare for and as well as PBMs and all these other fees that they have to pay. And inequity in transparency with pricing as a key factor for their closure and their lack of profitability. And we did find that indeed pharmacies that have the lowest, so who served more publicly insured neighborhoods were the most at risk. And this is this group in with less than two private to public insurance is the most at risk for closure. But what we thought was interesting is that these factors to uninsurance more publicly insured populations and having more minorities, the pharmacy serving more minorities. We're really only associated with urban closures and not non urban which is rural as well as suburban. And that could be due to the fact that many rural states already have policies, especially Medicaid policies that pay pharmacies more if they are located in an area that has few pharmacies already. Right, so pharmacy desert or they have, they fill fewer prescriptions and therefore may not make enough money to stay open. They pay them more per prescription. They pay higher, they reimburse pharmacies higher dispensing fees in order to ensure they stay open. So there's existing policies really in at least 10 to 15 world states. Medicaid state policies, Medicaid policies that modify reimbursement. It's a tiered reimbursement model. Four prescriptions dispensed at pharmacies, both chain and independent if they're serving if they are located in these areas based on their Medicaid prescription volume. And while it hasn't been tested or studied, that could be a factor that plays a role in preventing at least not impacting the association between public insurance and closure rates in non urban areas. So we talked about the problem pharmacy deserts. They persist, their pharmacies are closing, mostly in minority neighborhoods, across US cities, and they're mostly independent pharmacies that are closing. And these closures are often associated with a low reimbursement for Medicare and Medicaid. Which we found to predict closures in urban areas and not rural areas. So the next question is what is the impact of these closures on medication adherence? in order to kind of understand the potential health effects of disruptions and pharmacy access. And what we found gun using national data among older adults in the US. And this is based on IQVSLRX pharmacy claims which captures prescriptions dispensed in retail pharmacies as well as mail order across the country. It's not limited to private payers or Medicare or Medicaid includes all payers and it's dispensing data. It's not medical claims which is great because we're looking at a pharmacy closures and we want to know what happens to people. People's medication used after they experienced a closure. So not only does this matter in terms of understanding the impact. But also understanding potentially the impact in minority neighborhoods that are more likely to experience closures are more likely to be pharmacy desserts. So we found that this this first figure a figure 2A is all patients that used statin medication which is used in preventing. And treating cardiovascular disease and figure 2B is limited to patients that use statins. But we're also fully adherent at baseline and adherence here. So they took their medications on time at least 80% of the time. So that's how we define adherence. Which is they had their prescriptions filled sufficiently where 80% of the days they were supposed to be taking their medications they took them. So as you see here, it's closer to 90% should be at least 80%. So these are fully adherent patients and figure to be for your to a these are all patients that use at least one stand and this is when their pharmacy closed. We identify the date of the pharmacy that closed based on prescription fills. So a pharmacy that's permanently stop filling medications was defined as a pharmacy that close. And the date for by which it stopped filling medications was the date of the closure. And we examine then adherence and this closure cohort. So we had a closure cohort which our patients to fill out a pharmacy, the clothes. And a non closure cohort which are patients that fill the staten but filled at a pharmacy did that, stayed open. And what we found was that pharmacy closures have an immediate effect that persists on adherence. And so this decline in adherence persists also among patients that were adherent prior to their pharmacy closing. Which suggests that pharmacy closures disrupts medication adherence beyond barriers that we otherwise think are associated with non adherence because these are people that were adherent. And the only thing that really changed was that pharmacy closing. When we examined what groups were the most at risk or experience the most declines in adherence. We found that it was predominantly black and Hispanic neighborhoods, they had the largest declines including and especially in those that were fully adherent. We found people with Medicaid insurance and as expected, those that lived in neighborhoods that had fewer pharmacies. Which is Quanta one here, which is measured as a pharmacy density variable. Individuals filling at independent pharmacies also experienced data greater declines in adherence closer to 8%, when the average was 6. And we suspect that's related to the fact that when independent pharmacies are closing their usually in neighborhoods that already have fewer pharmacies. And it's not easy 1 and 2, it's not easy unlike chains to transfer to another pharmacy. So that disruption and independent pharmacies is worse on patients in terms of their medication adherence than other types of pharmacies. We also found that people that use mail order, which is when they get the prescription mail to their home. While it's only 4% of the population, it's those people that really have the lowest decline in adherence after the pharmacy closes. And that could be because they just transition to male or they're already used to filling their prescriptions in multiple places because we found that people that filled at multiple stores. Or the ones that had the least deterrence the least declines in adherence. So people that filled all their prescriptions, 100% of their prescriptions at that pharmacy, they're closed or their index pharmacy had the largest decline, whereas people that filled at multiple stores. So, had the lower had lower declines, especially if they filled less than half of their medications at one store. So these are just kind of you know fast forward. A few years after we did our study or one year, we have the George Floyd protests. We also had COVID and all these pharmacies started closing on well they're temporarily or permanently and there is increasing concern about pharmacy access for medications. But then we had COVID testing and people were relying at least the government officials were thinking of ways to get people tested. And one of the first things they thought about was getting retail pharmacies involved. Which really highlights the important role of pharmacies play not only in dispensing medications. But providing other emergency and preventative care including COVID testing and now COVID vaccine. But I think what people didn't realize is this problem that we just talked about which was there aren't pharmacies aren't equitable. Their access isn't equitable across neighborhoods in the US. With minority neighborhoods having fewer of them. And if that's the case then when we think about the COVID pandemic and inequities and not only testing. But most importantly and the COVID infection itself hospitalizations due to COVID and mortality due to COVID what does that mean if right now for trying to vaccinate people using pharmacies. And pharmacies are equitable are not available. And even when they are they're mostly independent stores that don't really participate in these programs are not giving the vaccine. That may worsen inequities in COVID. But even before COVID, [LAUGH] we only looked at medication adherence. But as pharmacies role expand beyond just medication dispensing to include other services, including the immunizations. I'm offering naloxone for opioid overdoses, emergency contraception and many other services. Their access matters, ensuring that they are available in all communities equally and when they're not, it really may worsen this kind of persistent problem with health disparities across the country. And in response to the COVID pandemic and in order to ensure access to medications and disrupted, pharmacy retail is responded by waving drug delivery fuse for several months. And CMS relaxed certain rules including the use of out of network pharmacies, so people were able to use pharmacies that they otherwise weren't able to use because they weren't in their network. And if they used these out of network pharmacies, they had to pay more, so their cost sharing was higher. And these other ones like early refills, and lifting restrictions, and home delivery, and mail order. So I highlight these because they're important. Most people think about pharmacy to access, and they're like, we can just do mail order, right? And I think that's an inappropriate response to inequities and pharmacy access, mail order is not the same as having a pharmacy in the community. And they made some preliminary studies already suggests that actually lifting this mail order exemption from Medicare widen disparities because it made it more convenient to people that already weren't affected, right? And for pharmacies at home delivery at no cost, it really just changed that even though independence have been offering home delivery for a long time, it's not new. But chains aren't really the pharmacies that are the most accessible, and many minority populations don't use chains. And [COUGH] it wasn't a consistent persistent response. So we're interested in looking at whether home delivery itself addressed this gap, in terms of adherence once the pharmacy closes. But I think the story is more that if we're going to have pharmacies offering services beyond just medications, they really need to be located and available in these neighborhoods. And these mitigation measures like home delivery and mail order, maybe short term solutions and it emergency situation, but at the community level they're not really promoting equity. And these are just examples of how policies set by CMS by pharmacies which are often unregulated because they're part of the private sector really promote structural racism and its impact on health disparities in the US. It's because of CMS we found in the data and their reimbursement policies that pharmacies are closing in minority urban areas and not in White neighborhoods, not in privately insured neighborhoods. And you know that blacks are more likely to be publicly insured, particularly with Medicaid than whites. We know that Hispanics and Latino populations are more likely to be uninsured. And we found those two factors to be associated with closures. We also found that pharmacy desserts are persistently more prevalent in segregated minority neighborhoods and it's getting worse, it's not getting better. And these policies that are set by federal and state governments are really the underlying cause of these problems and pharmacy access, which we found to impact adherence. Which in turn if we think about just Medicare payment models, they reimburse pharmacies based on their patient adherence. So their reimbursements are even maybe even lower because their patients aren't adherent, because this movement towards value based reimbursement. So what are the potential implications of these policies and pharmacy interventions on disparities in access? That's kind of the future research direction, but I suspected it really made things worse and not better.
