On September 24, the Health Care Council of Chicago (HC3) hosted a discussion to address challenges to medication compliance, address barriers to medication access, and examine the solutions and opportunities there are to address these inequities through innovation and policy-reform.
Meghan Phillipp, Executive Director, HC3
Nazia S. Babul, PharmD, Clinical Pharmacist, Ambulatory Pharmacy Services and Clinical Assistant Professor, Pharmacy Practice, UIC College of Pharmacy
LaShawn Ford, Illinois State Representative, 8th District
James Lott, PharmD, MPP, CEO, Scripted Health
Dima M. Qato, PharmD, MPH, PhD, Hygeia Centennial Chair and Associate Professor of Pharmacy at University of Southern California
News Coverage PHARMACY DESERTS THREATEN HEALTHCARE ACCESS ACROSS STATE | Health News Illinois, September 24, 2021 | Link to Article
Watch the Recap | Link to Video
Dima M. Qato, PharmD, MPH, PhD - Pharmacy deserts in Chicago
Much of my research focuses on addressing disparities and access to medications. What we have found is that Black and Hispanic minorities are less likely to adhere to medication regiments. Pharmacy deserts are most common in Black neighborhoods in Chicago, and to a lesser extent in Latinx neighborhoods, but overall, there is less access than predominantly white neighborhoods. In 2020, 45 percent of Black neighborhoods in Chicago were pharmacy deserts, compared to 1 percent of white and 14 percent of Latinx neighborhoods. Chicago has some of the worst disparities in the entire nation around pharmacy access. Many of the pharmacies that are available in Black neighborhoods are not contracted with the state and will not get reimbursement through Medicaid or Medicare which creates even larger access issues and gaps.
2021 - slide presented by Dima M. Qato, PharmD, MPH, PhD, Hygeia Centennial Chair and Associate Professor of Pharmacy at University of Southern California
Representative LaShawn Ford: Policies creating barriers
Many of the issues we see around pharmacy access and pharmacy deserts have a direct correlation and linkage to policies. Earlier this year, I was part of the filing of a bill (HB591) that ensures that Medicaid beneficiaries can access prescriptions from any licensed pharmacy, which industry pushed back on. The bill would require The Illinois Department of Healthcare and Family Services (HFS) to allow consumers to go to their pharmacy of choice and initiate an independent study and analysis of the MCOs. HFS approved an amendment that does not allow Medicaid patients to go anywhere but agreed to review studies/findings the support necessary to understand the issues. CVS bought Aetna which is an Illinois MCO has power to control who can go to what pharmacy, excluding their competitors. CVS has denied Medicaid recipients to use their services and also made it more difficult for those with Aetna to access these benefits. Pharmacy deserts and access to medicine is denied across the state.
Nazia S. Babul, PharmD: Pharmacy work in practice within the community
Pharmacists are no longer just providing prescriptions; they are providing a whole-person centered care experience. I spend part of my weeks at a UIC (University of Illinois Chicago) outpatient center which serves a large population of Medicaid and Medicare benefits, albeit some patients still run into accessibility and coverage issues. I also work with CommunityHealth, which is a different practice setting with providing support for those without insurance in a free clinic setting. At CommunityHealth it is a unique pharmacy setting because we can provide all medications for free, without any barriers.
Most of my focus across the board is on counseling patients about the importance of Rx adherence. As I work with patients, many talk about not being able to afford their prescriptions. At UIC there is a medication assistant program, so I can refer them to programmatic support within the hospital system. But not all pharmacies can refer patients to financial program aids like this and really just are not equipped to support them in that way. Transportation barriers exist as well, so there is a mail-order program. Sometimes patients have many prescriptions, so they can be referred to a medication synchronization program. Working within a system is nice, because pharmacists have access to EHR records – they can provide better care when they are brought on as part of the health care team.
James Lott, PharmD, MPP: Pharmacy Innovation
I founded Scripted, as a platform that allows patients to connect with pharmacists. The first transaction was a few months ago by a single mother with a UTI. She was not going to be able to see her rural doctor for three weeks, so she went to her local pharmacy and asked what she could get for temporary relief, the pharmacy told her about Scripted and she was able to scan a QR code and do a quick questionnaire. She was charged $40 and got her medication and the care she needed. Scripted’s goal is to enable this type of interaction at any pharmacy in any zip code across the U.S. Pharmacies can offer several opportunities to close gaps in care. Eighty percent of pharmacists are engaged in their changing role, but there is hesitancy and operational challenges will need to be addressed. At Scripted, we are helping them step into the future with technology tools that can help them reach their fullest potential. Challenges that current pharmacists share include regulatory issues, workflow, marketing, and finding physician partners.
What are some of the ways that the role of the pharmacist is evolving?
NB: There are opportunities to share protocols that allow pharmacists to administer orders for things like the needles required to go with an insulin prescription. Also, allowing pharmacists to enter orders to the medical record for more continuity, but also providing access to medications in a timelier manner. We published a protocol to allow pharmacists to initiate orders for nicotine prescriptions and now with recent legislation they can initiate orders for naloxone, as well as oral contraceptives.
Some of the advocacy you (Representative Ford) are doing is around coverage. How do some of the laws impact delivery of service, especially around Medicare, and what are the policies that can allow more accessibility?
LF: Right now, with my private insurance, I am able to go anywhere with a prescription from my doctor, but if I am insured through Medicaid, I cannot. We need to make sure regardless of color, income, neighborhood, that everyone has access to health care and everything that goes with that, including access to pharmacies. We can’t allow insurers to run health care.
“That has to be our focus: putting people first.”
You have not yet launched in Illinois, what does that say about our market? And why you have chosen to start other places.
JL: The amount of innovation coming from insurance companies is threatening local models of pharmacies. Telehealth might also be a threat to pharmacies, because PharmDs are in a highly regulated industry, creating more issues for them. The way it stands, Illinois law is flawed. We would rank Illinois in the bottom half of states to launch in, because of the restricted nature of prescribing. We have seen some states put into their legislation that state insurance companies must be allowed to bill and be covered as providers. Washington, Tennessee, and Idaho have the best legislation in terms of pharmaceutical legislation.
DQ: Delivery through mail order was proposed as a solution. It became more apparent when COVID-19 hit. To ensure that people stay home, states allowed more flexibility for mail order. Many people don’t realize that Medicaid is restricted when it comes to mail order prescriptions. Home delivery is a short-term solution, but it was not an option for many people, and it does not address the root cause of limited resources. It does not necessarily provide equity. Most people have to go in person to get prescription if they are covered by Medicare and Medicaid. If we promote pharmacies prescribing more, then we create a greater disparity in areas that are experiencing pharmacy deserts and no access to those services.
How does policy play a role in pharmacy deserts?
DQ: When a chain pharmacy opens up, it threatens the independent pharmacies and usually causes them to eventually close. The independent pharmacies lose all of their patients, possibly because of their preferred status (not preferred by Medicaid), because they cannot survive against large chains, plus they are getting paid less. In Illinois, the Aetna Medicaid plan adds CVS as the preferred pharmacy, and independent pharmacies are rarely prioritized like that. Medicaid/Medicare reimbursements are less for prescriptions than private reimbursements which discourages pharmacies from opening up in areas that are predominantly low-income and coincidentally also minority, which makes it tremendously difficult for pharmacies to stay open even if they do set up shop, because they are out-of-network. Open networks would protect pharmacies in minority and low-income neighborhoods.
JL: One additional challenge throughout the pandemic is that Illinois law prevents pharmacies from providing COVID-19 vaccine without contracting with a physician, and they often have to pay the physician to do so.