Racial disparities in access to medicines increase after implementation of prescription surveillanceBOSTON--Health policies designed to curb inappropriate medication prescribing can have the unintended effect of increasing racial disparities in access to appropriate care, reports a study by the Department of Ambulatory Care and Prevention (of Harvard Medical School and Harvard Pilgrim Health Care). The research, led by Dennis Ross-Degnan, ScD, associate professor in the Department of Ambulatory Care and Prevention, and Sallie-Anne Pearson, PhD, of the University of New South Wales, is reported in the March 13 Archives of Internal Medicine.
"This is the first well-controlled study to show that health policies designed to reduce drug costs and abuse can increase racial disparities in access to effective care for those with chronic illnesses, like schizophrenia," said Pearson.
The authors examined the effects of a prescription-monitoring program on access to benzodiazepines among nearly 125,000 Medicaid enrollees living in neighborhoods of different racial composition. Benzodiazepines are widely prescribed and effective treatments when used appropriately for anxiety, panic, sleep, and seizure disorders. They are also adjunct therapies for people with chronic mental illness, such as bipolar disorder and schizophrenia. However, there is controversy about their risk of dependency and abuse.
The New York program that monitors use of benzodiazepines reduced problematic use and almost completely eliminated benzodiazepine abuse including pharmacy hopping, in the cohort of Medicaid patients followed. Yet larger groups of vulnerable patients also showed reduced access to appropriate use of benzodiazepines as a result of the monitoring program. Blacks had a lower baseline rate of benzodiazepine use as compared to whites and Hispanics, but also had the greatest reduction in use as a result of the monitoring policy.
"These findings suggest that well-intentioned health policies can exacerbate racial disparities," Ross-Degnan said.
Across all practice and pharmacy locations, black enrollees in Medicaid were consistently the most likely, and white enrollees the least likely, to experience reductions in access to benzodiazepines. The authors report that racial disparities in benzodiazepine use after introduction of the monitoring program were maintained six years later and are likely to be a problem in other states that use this regulatory approach. While decreasing abuse of the medications is desirable, these findings indicate that decreasing appropriate prescribing and access to benzodiazepines can have a negative affect on already vulnerable populations.
"The specific ways in which the policy causes these disparities remain unknown, but may include racial differentiation in treatment by medical providers and pharmacies reacting to incorrect beliefs about racial differences in abuse," Ross-Degnan said. "To eliminate disparities, we need a combination of social change, redesign of systems of care, and careful examination of policy impacts."
This work was funded by the National Institute on Drug Abuse (of the National Institutes of Health), the Harvard Medical School Fellowship Program in Pharmaceutical Policy, and the Harvard Pilgrim Health Care Foundation.
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HARVARD PILGRIM HEALTH CARE
Harvard Pilgrim Health Care is a not-for-profit health care plan operating in Massachusetts, New Hampshire, and Maine with a network of more than 22,000 doctors, 135 hospitals, and more than 925,000 members. Harvard Pilgrim was the first New England health plan to establish a non-profit foundation with the sole purpose of serving the community at large. The efforts of the foundation reflect Harvard Pilgrim's mission, which is to improve the health of its members and the health of society. The Department of Ambulatory Care and Prevention is a unique partnership between HPHC and HMS, the nation's only medical school department jointly sponsored by a health plan.
HARVARD MEDICAL SCHOOL
Harvard Medical School has more than 7,000 full-time faculty working in eight academic departments based at the School's Boston quadrangle or in one of 47 academic departments at 18 Harvard teaching hospitals and research institutes. Those Harvard hospitals and research institutions include Beth Israel Deaconess Medical Center, Brigham and Women's Hospital, Cambridge Health Alliance, the CBR Institute for Biomedical Research, Children's Hospital Boston, Dana-Farber Cancer Institute, Forsyth Institute, Harvard Pilgrim Health Care, Joslin Diabetes Center, Judge Baker Children's Center, Massachusetts Eye and Ear Infirmary, Massachusetts General Hospital, Massachusetts Mental Health Center, McLean Hospital, Mount Auburn Hospital, Schepens Eye Research Institute, Spaulding Rehabilitation Hospital, and VA Boston Healthcare System.
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