Racial and ethnic disparities in prescription coverage and medication use

Health Care Financing Review, Winter, 2003 by Becky Briesacher, Rhona Limcangco, Darrell Gaskin

INTRODUCTION

This study examines the access that black and Hispanic Medicare beneficiaries have to prescribed drugs for chronic conditions. We know little about how race and ethnicity influences medication use despite substantial research showing that, for most health care services, minority beneficiaries use fewer services compared with white persons (Gornick, 1999, 2000, 2003; Gornick et al., 1996; Gornick, Eggers, and Riley, 2001; Murray, 2000). One exception to this pattern--and a possible indicator of medication underuse--is a higher than average need for procedures used to treat the complications of chronic illnesses. For instance, elderly black beneficiaries are three to four times more likely than white beneficiaries to undergo amputations of lower limbs or implantations of shunts for renal dialysis due to uncontrolled diabetes (Gornick, 1999, 2000; Gornick et al., 1996). Such differences have been generally interpreted as evidence of widespread insensitivity in the acute care setting (Mayberry, Mili, and Ofili, 2000). An alternative explanation is that minority beneficiaries may be facing persistent problems in getting necessary medications that eventually lead to the most debilitating effects of unmanaged chronic illness.

Black and Hispanic Medicare beneficiaries may be particularly susceptible to medication underuse for economic reasons because outpatient prescription drugs will not be included under the traditional Medicare benefit until 2006. Until then, beneficiaries must negotiate some form of drug benefits or else pay out-of-pocket for their medication expenses. Options for gaining drug coverage include earning comprehensive retiree health benefits, buying personal insurance, enrolling into M C plans with a drug coverage option, or qualifying for public assistance (e.g., Medicaid or State pharmaceutical assistance programs). Some of these avenues may be less accessible to minority populations, while other types place considerable demands on personal income and savings. For example, private drug plans often require substantial cost sharing in the form of copayments for each prescription fill, deductibles, and monthly premiums. Access to employer-sponsored drug coverage depends on consistent employment opportunities in industries offering retiree benefits. Enrollment into M C plans with drug coverage has becoming increasingly limited for residents of Southern States where many minorities live. Similarly, only three States offer substantial drug assistance programs for Medicare beneficiaries, and they are all in the Northeast (New Jersey, New York, and Pennsylvania). For chronically-ill black and Hispanic beneficiaries with regular medical needs and scarce personal resources, inadequate drug coverage may translate to disparities in medication use.

Few studies have compared racial disparities in medication use by drug insurance status despite the intuitive relationship between affording drug therapies and managing disease (Espino et al., 1998; Fillenbaum et al., 1993; Fillenbaum et al., 1996; Nelson, Norris, and Mangione, 2002; Svetkey et al., 1996; White-Means, 2000). We used the wide variation in prescription drug coverage among Medicare beneficiaries to study prescription spending and use by race and Hispanic ethnicity for three groups with persistent medication needs--those with diabetes, hypertension, or heart disease. Cardiovascular disease and diabetes are two of three chronic conditions (the third is HIV/AIDS) identified as targets for Federal initiatives to eliminate racial/ethnic disparities in health (U.S. Department of Health and Human Services, 1999). We also examined beneficiaries with hypertension as a condition commonly identified as sensitive to race and ethnicity, in terms of disease prevalence, treatment selection, and health care use (Sung et al., 1997). All three conditions are commonly treated with drug therapy to minimize the debilitating effects of progressive disease. Our main objective was to distinguish whether drug coverage lessens or eliminates racial and ethnic differences in the use of medications for chronic conditions, and whether certain types of coverage are more effective at improving access.

METHODS

Data

We used data from the 1999 MCBS Cost and Use File to study prescription drug coverage, expenditures, and use across different race and ethnic groups. The MCBS is a longitudinal panel survey of a representative national sample of the Medicare population conducted under the auspices of CMS. Beginning in fall 1991, more than 12,000 Medicare beneficiaries have been interviewed three times a year using computer-assisted personal interviewing. Each respondent is followed for up to 4 years. MCBS interviewers collect extensive information on individuals' use and expenditures for health services including source of payment, as well as information on health insurance, access to care, health and functional status, socioeconomic status, and demographic characteristics. Prescription drug utilization data in the MCBS are based on self-reports of each prescription filled and refilled during the year. To assure accurate recall, respondents are asked to keep bill records and prescription containers to show interviewers during the three yearly interviews.