番茄社区

In this video, 番茄社区's editor-in-chief, Jeremy Faust, MD, of Brigham and Women's Hospital in Boston, and Utibe Essien, MD, MPH, of the University of Pittsburgh, discuss racial disparities in healthcare amid the COVID-19 pandemic and how we can achieve pharmacoequity.

The following is a transcript of their remarks:

Faust: Hello, it's Jeremy Faust, editor-in-chief of 番茄社区. I'm very pleased to be joined today by my friend and colleague Dr. Utibe Essien, who is an assistant professor of medicine at the University of Pittsburgh, where he studies health disparities. In addition, I've been really interested by some pieces that he led work on in , as well as – really excellent pieces. And he's almost convinced me to do Bow Tie Friday, but not quite yet. Dr. Essien, thank you so much for joining us.

Essien: Hey, thanks so much for having me, Dr. Faust.

Faust: So tell us what "pharmacoequity" is and how that term came about.

Essien: Yeah, you know, for the last – I guess now almost a decade or so – I've really been passionate about trying to understand why there are health disparities in our society. All throughout medical school, even before then as a pre-med student volunteering in emergency departments in New York City where I trained and grew up, I would see care being provided in different spaces for different people -- especially those who look like me and my family.

I came out of med school thinking I was going to be this social justice warrior and help save the day one patient at a time, but really realized just how challenging that was to do on a day-to-day basis. With so many other things, the social determinants of health playing a role, but specifically making sure that patients had access to the care that they need to be able to have the highest quality of life came up so often time and time again.

And now in a research career, I've had a chance to really study that and really try and understand what are the drivers, the factors, that make it so patients who are from poor socioeconomic statuses, from racial and ethnic minority backgrounds, residing in rural neighborhoods just don't have access to the highest quality of care that they need.

Faust: Before the pandemic you were focused a lot on cardiovascular therapeutics. What's the situation there, and did the Affordable Care Act represent progress there? Where are we in terms of that?

Essien: Yes, exactly. My work focuses on the cardiovascular space -- specifically around atrial fibrillation, which is, you know, the most common heart rhythm disorder in the world. But whether you're looking at Afib or you're thinking about heart attacks, thinking about heart failure, with some of the new, exciting drugs that are out in that space, we have seen that racial and ethnic minorities have poor access to those treatments. As new or more expensive treatments become available, individuals from low socioeconomic means have poor access to those therapies.

And so, yes, the Affordable Care Act [ACA] was phenomenal in insuring about 20 million new patients so that they have better access to these medications. But sadly, we still have 30 million individuals who are uninsured. And we have so many patients who even with insurance have extremely high co-payments, either for generic drugs or non-generic drugs, that they're really having a tough time affording.

So we definitely saw some gains and improvements with the ACA. Unfortunately, those are still lagging behind where I think we can achieve pharmacoequity.

Faust: I've spent a lot of time reading your work. And in doing that, I kind of came to this idea that there's at least three things that feed into pharmacoequity: places, provisions, and practices.

Places being these pharmacy deserts, so you don't actually have a place to go. Provisions being that there's not coverage, so even if you do have a place to go, you may not be able to afford that medication. And then the last thing is Practices, which is that even if a systemic issue is addressed, a doc like me has to prescribe the right medication. And in a way I feel like the last one's the easiest one [to solve], because once the system is set up to encourage us to do the right thing, the last step is easier. Is that fair?

Essien: Yeah, it's a great point. And I love that alliteration. I'm all about it. I have my ABCs, but I may steal that for my next talk.

But I think I've always been of the mind that if we make the right choice, the easy choice, we will start to eliminate some of these disparities. And so, for example, what if we put in the EHR [electronic health record] whenever you see a new patient with atrial fibrillation, it shoots out what their risk of stroke is, and doesn't give you the chance to order the less novel therapy – warfarin. If they are qualified, it just says, "Hey, this is the new therapy available. This is what you should be prescribing for your patient."

There's none of this guessing game, subjective decision-making that goes on when we're rushed, when we're busy, when we're tired, that so often happens in the clinical space, and unfortunately so often disadvantages communities of color and poor communities.

So yes, it's all about making the right choice the easy choice, about fixing that "practices" part of the algorithm. And the other two I think are challenging, but we still have opportunities there as well.

Faust: Just in terms of making the system work better, I also think about – you mentioned the EHR being a place where that sort of ground zero for decision-making. That makes a lot of sense, but I also think a lot about governments, and particularly the federal government with Medicare/Medicaid services, really holding a purse string to so much.

I remember this paper from a couple of years ago which showed that hospitals serving underrepresented racial and ethnic minorities, poor areas, were getting dinged more on quality metrics, and then they'd get less financial reward. So round and round we go. Now I read that CMS [Centers for Medicare & Medicaid Services] is trying to actually address this. Is there progress? What do you think can be done?

Essien: Yeah, so those are really important points. My colleagues and I wrote a paper last year in the about colorblind policies. So policies like the one that you just described that, you know, we just want to improve quality and improve payment across the board. But unfortunately because of centuries of poor access to care, segregated neighborhoods and communities, etc., hospitals that serve patients of color tend to be poor-quality hospitals, tend to reside in certain neighborhoods that have less tax dollars, and that kind of cycle continues.

So we have seen some commitment, especially with the current administration, to addressing health equity as a core to a lot of these quality metrics. I think time's still out to tell us whether it's actually been an improvement. Those data that you highlighted really just came in over the last couple of years or so to make us realize this isn't actually as color blind as we maybe hoped it would be. So I believe putting equity at the core of whatever it might be – if it's a policy decision or a system made within our healthcare administrations or our insurance policy – is really going to help us stamp out some of these inequities.

Faust: Let's talk about COVID for a little while here -- where are we in terms of equity? In terms of vaccine uptake and monoclonals?

Essien: Good point and question. You know, here we are, what is it, 22 months into the pandemic? 23 or so, and we're still seeing some of the same early disparities that we saw with differential access to vaccines when they first came out, all the way to monoclonal antibodies.

And so, unfortunately the fact that we didn't have equity as kind of a goal post when we were starting to build out these incredible therapies that are now saving lives every day, we've made it so that racial and ethnic minorities – Black, Hispanic, some Asian subgroups, Native Americans – have really been undertreated with poor access to vaccines.

Recent data from the CDC showed that some of the newer monoclonal antibodies and even some of the antiviral therapies like remdesivir have been unequally distributed across the board for new infections of COVID. And so sadly we're seeing similar disparities to what I was studying around cardiovascular before the pandemic really playing out here.

The point that I often make around pharmacoequity is a reminder that this is not a new problem. There was a paper my colleague sent me a few weeks ago that showed that when the HIV epidemic started back in the early '90s and antiretroviral therapy was available for these individuals, Black individuals were the least likely to be treated with these medications. And here we are 30 years from that epidemic facing a new global pandemic and we're seeing the same story play out.

So again, being really intentional about actually addressing equity is what we wrote about in our pharmacoequity piece. And I'm hopeful we'll be able to see that down the line.

Faust: And your Health Affairs piece in particular, you really took head on this idea of race-conscious guidelines and as a way to really address these disparities. For example, the monoclonal piece that you mentioned – you point out that some of the guidelines that try to find the higher-risk individuals do bake in some of the disparities, because if you have certain conditions, you're more likely to qualify, but it's not enough.

And so you've talked about race-conscious guidelines and it has sparked from criticism. So tell us about that and how that can play out.

Essien: Yeah, it's been such an interesting conversation. Again, we've had an administration that really is committed to equity. And I do think that some of the leaders who are helping support their policies care about these issues, but that's, you know, few and far between. We have to really have equity at the CDC, at the FDA, at the HHS – across the board. If we do not, I think we see something like the conversation we're having.

A couple of months ago, the FDA put out that people at high risk, including lots of chronic comorbidities, certain age groups, might consider other factors such as race and ethnicity when considering giving monoclonal antibodies. That was all they said -- they said they'd consider it. And I think the pushback politically has been that we shouldn't be thinking about race. Now, we're going to discriminate against non-minority people, and is the FDA racist – basically, was kind of the argument that's coming from some sides of the country.

And then you fast forward away from some of those reports, we see that Minnesota, which initially had pretty race-conscious policies, took a step back because of the backlash that they were getting from that. So the commitments -- again, that we're trying to make as a country to actually stamp out disparities and be focused on equity -- are being kind of viewed as racist against groups who have for centuries had the most privileged opportunity in our healthcare systems.

So we wrote about this in our piece. We said that A, clearly it's not true. As we talked about, the data are unfortunately showing that racial and ethnic minorities are not actually getting the highest rates of these treatments. And secondly, we really do have to be race-conscious about the groups that have been most affected by the pandemic, and conscious about the fact that they've unfortunately had differential access to care regardless of a pandemic or not.

The only way to really fix this is by being race conscious in our policy and in our practice. So, I'm hopeful that folks get a chance to read that piece littered with lots of references around how we can actually achieve this goal, and I think it will be a really important step as we move forward.

Faust: I think it's really important to say this: is there any shred of data to suggest that the approach that you advocate for will take therapies out of one person's hands and put it into another?

Essien: There are no data, as far as I can tell, that actually supports that. You know, I like to say that health equity is not a zero sum game, that we do have the opportunity to improve the health of millions of Americans every single day by focusing on equity as our goal, and not continuing to maintain the current practice as it is that unfortunately has been unequal.

Faust: You've given us a lot to think about, and I hope that this brings more awareness to the issues, because I feel like when people are aware of them and they're conscious of them, they begin to look for solutions and become part of the process as opposed to being separated from it. So thanks for the scholarship you're doing and for the advocacy and really helping us understand this issue better so that we can make progress.

Essien: Absolutely. Thanks for the opportunity. You know, the three words I always leave folks with are: listen, learn, and lead. Kind of playing on your alliteration, Jeremy. And so I think you're listening to us now. You can learn, do some of the homework on the references we share, and lead in whatever spaces you are in to achieve pharmacoequity and health equity overall. I appreciate the conversation.

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