Racial and ethnic disparities in prescription coverage and medication use

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

DISCUSSION

The Medicare Program has dramatically improved the health of older and disabled persons by removing many financial barriers, yet we know that some populations have fared better than others by most measures of medical care use and outcomes. Differences in the care of minority Medicare beneficiaries have been puzzling to understand as a problem of economic barrier given the near-universal enrollment into the program and uniformity of the benefit (Mayberry, Milli, and Ofili, 2000). Recent evidence in younger adult populations has confirmed the view that health insurance alone does not eliminate racial/ethnic disparities and in fact may play a rather modest role in ameliorating the differences. Investigations into the primary drivers of unequal use of medical services have found that insurance influences access, but much about racial/ethnic differences remains unexplained (Weinick, Zuvekas, and Cohen, 2000; Zuvekas, 1999; Zuvekas, and Taliaferro, 2003). Nevertheless, drug coverage status is far from uniform in the Medicare population and we know type of insurance strongly influences medication use (Stuart, Shea, and Briesacher, 2000). That black and Hispanic Medicare beneficiaries use fewer or less expensive medications than white beneficiaries may still be a problem grounded in socioeconomic causes with far-reaching consequences. Not being able to afford necessary medications may explain, at least in part, why black and Hispanic persons more often than white persons experience some of the worst effects of chronic illnesses. One study that has linked drug coverage to racial/ethnic differences in use of other medical care services comes from an analysis of patients who gained Medicare coverage through the ESRD program (Daumit et al., 1999). Medicare beneficiaries with ESRD entitlement are among the few to receive Medicare reimbursement for critical outpatient medications--erythropoietin for anemia and immunosuppressants. Daumit et al. (1999) found that a three-fold differences in the use of clinical procedures by patient ethnicity nearly disappeared following the acquisition of the special ESRD Medicare coverage. The researchers attributed the decline largely to the Medicare benefit and concluded that equity in care may be attainable for all Medicare beneficiaries if coverage is truly comprehensive, including for necessary prescription drugs.

Our study also detected statistically significant and sometimes large differences in the drug use and spending patterns of chronically-ill Medicare beneficiaries by race and ethnicity. These findings showed wide variation that persisted even among individuals with the same disease and same type of prescription coverage. As with studies of other medical services, we found that minority beneficiaries tend to get less of chronic medications compared with the majority of beneficiaries who are white. Drug coverage from M C plans was the most successful in eliminating the differences although some remained, particularly use of any diabetic agents by black beneficiaries. What might explain the improved equity in drug use associated with M C drug coverage? Speculations include the mandatory assignment of a primary care doctor and disease management programs, although the research is mixed. Hargraves, Cunningham, and Hughes (2001) did not find that managed care policies such as gatekeeper requirements reduced racial/ethnic disparities in having a usual source of care or visiting a physician in the last year. Haas et al. (2002) found some improvements in preventive care services for Hispanic persons in managed care plans relative to FFS enrollees, but not for black persons. Lastly, Schneider, Zaslavsky, and Epstein (2002) noted more equitable use of [beta]-blockers by race with M C enrollment, but only in plans with better overall quality standards.