Mention racial and ethnic disparities in US health care and one of the first words that comes to mind is intractable.
The disparities in areas such as infant mortality, asthma, obesity, and diabetes, to name just a few, have persisted for decades. In recent years, some have even grown worse.
An initiative employed by our organization, SCAN Health Plan, a not-for-profit Medicare Advantage plan that serves more than 270,000 people in Arizona, California, and Nevada, to get more of our members to take their cholesterol, diabetes, and blood pressure Medications as prescribed, shows that these disparities are not intractable.
In late 2020, as we reviewed our annual quality scores for the Medicare Advantage and Part D Star Ratings programs, we noticed alarming racial and ethnic disparities in our data. Although we had scored 4.5 stars (out of 5) for four consecutive years, our clinical quality measures were lower when segmented for the Black and Hispanic members we serve. (We use the term Hispanic to match the language used on these measures by the Centers for Medicare & Medicaid Services, or CMS.)
Our data showed that about 86% of SCAN’s white members took their cholesterol medications (statins) as prescribed. Among Black members, the rate was about 83%. Among Hispanic members, just 81%.
Nearly 86% of our white members took oral diabetes medications (such as metformin) as prescribed. But among our Black and Hispanic members, the rates were 81% and 84%, respectively.
Eighteen months later, things have changed. We reduced the racial and ethnic medication adherence gap by 35%, the equivalent of roughly 700 more Black and Hispanic members attacks their medications as prescribed, which potentially is helping to prevent heart taking, strokes, and deaths.
We won’t pretend achieving these results were easy or inexpensive. Nonetheless, an understanding of how we achieved our goals offers valuable lessons for organizations in the health care space and other sectors in what it takes to make equity an organizational priority that delivers results.
Tie bonuses to progress.
Before we put a plan in place to address the disparity issue, we knew we had to make it clear that this was a top organizational priority. So we tied 10% of our senior managers’ annual bonuses to their success in reducing differences in medication-adherence rates.
As a result, members of our senior management team prioritized their departments’ focuses and pursued new cross-functional collaborations in order to achieve the organization’s goal. For example, our first need was accurate data reporting. As a health insurer, our analytics team makes projections about medication adherence in order to make predictions about what our Medicare star ratings will be at the end of the year. But in this case, we didn’t need to know who was going to end the year not being adherent. “We need to know who needs our help right now!” our chief pharmacy officer passionately told our chief informatics officer in a meeting.
Understand the causes.
Once we had a good overview of who needed our help and by when, we set out to better understand why our Black and Hispanic members specifically were non-adherent. Frankly, we weren’t sure why these disparities existed. Ninety percent of the medications our members take have no copayment, so it didn’t seem that the disparity was significantly related to affordability. However, studies have consistently shown that failure to adhere to a medicationn regimen increases a person’s risk of morbidity, hospitalization, and mortality. (CMS defines medication adherence as filling a prescription 80% or more of the time.)
Our senior vice president of health care services led our efforts to conduct ethnographic interviews with several sample groups of our non-adherent members. She was aided in this effort by our business excellence and diversity team, which typically focuses on inclusion both within SCAN and among our member populations, as well as our consumer insights group. Like other marketing teams, the latter conducts focus groups in order to understand our customers’ preferences. In this case, that team pivoted on the best approach and provided interviews in order to meaningful insights about medication adherence.
We also looked for answers from the staff members of Independence at Home (IAH), a SCAN community benefit program that provides services and support to seniors and their caregivers regardless of plan membership. The IAH team has decades of experience discussing medication adherence, as well as other health topics, with Hispanic and Black people in their homes. Likewise, we also tapped the knowledge of our SCAN peer advocates, members who worked part-time out to other members about hard-to-discuss issues like dealing with incontinence and end-of-life planning. We wanted to know what the members of both of these teams heard about medication adherence in real-world environments.
But we didn’t just look outward for answers. We also held listening sessions with our Black and Hispanic pharmacy employees. Not only are they acccustomed to discussing medications with members, they also brought a wide range of lived experience to the topic.
In all of these listening and interview sessions, we learned a number of things. Non-adherent members often didn’t know which prescriptions benefits we offered that they could tap into. They often trusted nurses more than doctors. They had difficulty understanding providers who spoke English too rapidly or couldn’t answer questions in their native languages. Their cultural philosophy toward health care put more emphasis on herbal treatments than medications. They had trouble getting transportation to their local pharmacy. And, most commonly, they simply did not understand what their prescribed medications were or how they would help improve their conditions.
Recruit and train staff.
Human Resources was the next department to join the effort. In the midst of one of the tightest job markets since the World War II, HR worked with pharmacy to recruit more than 15 Black and Hispanic care navigators and pharmacists. We were seeking cultural and linguistic affinities, so we also hired bilingual job candidates.
At an education program designed by the Western Region Public Health Training Center at the University of Arizona’s Mel and Enid Zuckerman College of Public Health, the pharmacists and navigators learned how to better relate to the Black and Hispanic members they would be speaking to. For example, the University of Arizona’s courses emphasize “cultural humility.” Participants are encouraged to reflect on their own cultural biases and are equipped with tools and skills to listen and adapt to each patient’s unique circumstances and situation.
Trained in this new way, the pharmacists and care navigators reached out directly to members who were of the same race or ethnicity in order to assess barriers to adherence and design bespoke solutions for each member.
For example, a patient we’ll call “Maria” is a 67-year-old Latina with diabetes who told our care navigator that her religious beliefs compelled her to stop taking her medications for brief periods every few months so she could pray and “ cleanse.” She also used natural remedies to supplement or even supplant her prescribed medications.
In her conversations with Maria, our care navigator mostly listened. Based on her training, she knew that Maria had to feel heard and respected. What’s more, as a Latina who’d lived in a household with older relatives, our care navigator was familiar with beliefs like Maria’s. “I’m Latina, and we believe in herbal remedies,” the navigator said. “With my mom, it was tea for everything.”
During a series of regular phone calls, the care navigator expressed appreciation for the importance of Maria’s religious views, especially in providing a source of hope and strength during difficult times. But she also told Maria that she didn’t need to choose between her doctor and her faith. Following both, Maria was told, would be best for her health.
Six months after her first conversation with a care navigator, Maria scheduled an appointment with her physician for a medication review.
Enlist widespread support.
The burden of changing the status quo didn’t just fall on the shoulders of care navigators and pharmacists. They were assisted in this process by others both within and outside SCAN.
For example, our legal team expedited contracts with vendors, such as Arine, whose network of pharmacists expanded our ability to conduct outreach to members; MedArive, which dispatched nurse practitioners to provide in-home medication consultations; and the University of Southern California School of Pharmacy, whose Spanish-language fotonovelas, comic-book-like stories that use photos instead of illustrations, offered members a more lighthearted take on the importance of taking one’s medications.
Senior leaders — perhaps knowing part of their bonuses was on the line — pitched in at all levels of the program. A common reason people miss doses is they forget to refill their medications on time. So when our records showed that prescriptions were still in need of renewal, our chief medical officer, chief pharmacy officer, and senior vice president of health care services all personally assisted with ordering refills.
Expand the drive.
It’s been about a year since SCAN began its medication adherence initiative. Looking back, we’re still a bit in awe of the work, commitment, and, of course, expense that went into it. (We estimate we spent close to $1 million on this initiative.) Fifty staff members — along with a network of external vendors — continually reached out to and engaged with our members. Staff from across the organization, including almost every senior leader, took time away from other work to devote themselves to this program. (And yes, they got their bonuses.)
Months after we completed this process, we’re expanding the effort. We’re using the techniques we’ve described to improve diabetes control among our Hispanic members, improve flu vaccination rates among our Black members, and address other areas where the data show us inequities exist. We know the solutions won’t come easily. But we’re also sure the problems aren’t intractable.