At the end of July, CMS published updated data on COVID-19 impacts on the Medicare population, including details on the American Indian/Alaskan Native Medicare beneficiaries for the first time. The new data indicated that this population has the second highest rate of hospitalization for COVID-19 among racial and ethnic groups after Blacks. The updated information further confirms the disproportionate effect the pandemic is having on vulnerable populations.
It is not enough to note the differences, but to address why they occur. According to the CDC, there are several inequities in social determinants of health that put racial and ethnic minority groups at an increased risk of morbidity and mortality associated with COVID-19: discrimination; healthcare access and utilization; occupations; educational, income, and wealth gaps; and housing. With many Americans facing eviction and limited ongoing support for the unemployed, we will continue to see how these disparities are magnified during emergencies.
While the press release did report that the CMS Office of Minority Health was hosting sessions to receive insight into ways in which CMS can address health disparities, no action has been taken. Regardless, it is crucial that all health care providers, including pharmacists, continue to address inequities in social determinants of health. Afterall, the first vow of the Oath of a Pharmacist is to “consider the welfare of humanity and relief of suffering my primary concern.”
In order to ensure fair access to health, specifically during the current pandemic, the CDC made recommendations for various groups, including the healthcare delivery system:
- Ensure that chronic disease management and services to prevent illnesses are maintained and accessible
- Increase availability and accessibility of COVID-19 testing for racial and ethnic minority populations and other populations that are disproportionately affected
- Work with community health workers/promoters, healthcare providers, and patient navigators to connect community members with health resources
- Increase engagement with trusted community and faith-based organizations and institutions that have relationships with local communities
- Provide telehealth options that are tailored to the needs of patients
- Ensure providers show awareness of and respect for culture when providing COVID-19 testing and care
- Train employees at all levels of the organization to identify and interrupt all forms of discrimination; provide them with training in implicit bias
- Increase language access and help adapt public health guidance to local circumstances so that health information and recommendations reach the people who need it the most
Pharmacists role in increasing access to testing
In a previous post, we discussed the gaps in testing for communities of color, namely Black and Latinx, and how pharmacists have the potential to significantly impact the rates of testing. Although pharmacists in every state can provide COVID-19 tests, unfortunately, implementation has stalled for various reasons, including access to testing kits, lack of information on where to send the kits for processing, and guidelines for reimbursement. There is enthusiasm for pharmacists to expand their role, as seen with significantly more pharmacies obtaining CLIA certificates. However, if the proper infrastructure is not in place for processing and payment, these barriers will inhibit pharmacists from being utilized as key players in improving access to testing.
On the horizon: pharmacists to provide COVID-19 vaccines
Although a vaccine is not yet available, there is already concern that communities of color, who have historically been underrepresented in clinical trials and have deeper distrust for healthcare systems, may face greater barriers to obtaining the COVID-19 vaccination once it is available. We do not need to tell you how important pharmacists are in increasing access to vaccinations for the general public, but the relationships pharmacists have with their patients will be even more critical to ensure widespread vaccination against COVID-19. Pharmacists may also consider partnering with other organizations in the communities, such as places of worship, to increase access to testing and vaccinations for these populations.
Many questions still remain as vaccine development continues. Innovative models, such as pharmacy technician administration of vaccines, will need to be considered to ensure access to COVID-19 vaccines, while maintaining vaccination rates for other key illnesses, such as influenza. We suspect there will be more to come on this topic in future blogs (*insert shameless plug about subscribing to our emails here*).
Pharmacist-led disease state management and addressing social determinants of health
Beyond testing and vaccinations, there is a significant opportunity for all pharmacists to improve chronic disease state management and provide patient-centered, prevention-based care, which incorporates recognition and addresses social determinants of health.
Population health initiatives that target patients at highest risk for medication non-adherence or poor outcomes may be employed within local pharmacies and health-systems. Additionally, regular screenings for chronic diseases and education on the importance of preventing and appropriately managing these chronic diseases should be available within pharmacies and other easily accessible locations within our communities.
Outreach activities may include phone calls to patients with uncontrolled blood pressure or diabetes, or to patients prescribed multiple medications for a specific indication. At touch points between patients and pharmacy staff, specific questions can be asked to identify barriers to medication adherence, as well as addressing the factors that may impact a patient’s overall health and well-being. Acutely, unemployment and unstable housing may lead to limited medication and healthcare access. Although pharmacists may not be able to solve these problems directly on their own, screening tools may help identify the problems and help triage or refer patients to other resources in the community, such as Community Health Workers or mental health clinicians, for further assistance. Additional considerations, such as abbreviated public transportation schedules, may make it difficult for patients to get to the pharmacy to pick up medications. Medication synchronization programs or coordination of delivery of medications may help improve access. When applicable, pharmacists should continue to find ways to reduce pill burden and cost, and improve overall access to care. These recommendations may include optimization of medications, recommendations to improve disease control, and monitoring and health maintenance follow-up. Pharmacists have an opportunity, or perhaps rather an obligation, to connect with their patients during this time in order to gain an understanding of their needs and help improve outcomes.
Unfortunately, policy change, including development and implementation of payment models (see our past blog post on the “why” behind provider status), are needed in order to ensure access to these pharmacist’s services for all people, especially our most vulnerable populations. Additionally, funding to support CDC and state and local public health agencies to provide public health infrastructure are crucial to combating the inequities of social determinants of health that impact many of our patients.