Priority Considerations to Advance Equity in Formulary and Benefit Design

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Several key principles emerged from the forum discussion as means to mitigate racial health disparities; these are expounded upon throughout this report. One principle is to acknowledge that structural racism exists and that it can impact the provision of health care, including but not limited to formulary development and benefit design. Another is that proactive strategies to improve equity, beginning with education and training, must be integrated into all aspects of health care. A third is that patients must be viewed holistically, with an understanding of the compounding effect of social determinants of health on their personal wellness.

Forum participants emphasized early in the discussion the importance of having an understanding of terminology related to building greater equity—such as those terms used throughout the forum (Table 1)—and historical examples of structural racism, how they persist, and how they affect current health care practice. One striking example was one study’s conclusion that false beliefs about the biological differences between Blacks and Whites among medical students and residents led them to report lower pain ratings for their Black patients, which the authors suggested may contribute to racial disparities in pain treatment.⁸ Participants recognized, however, that an opportunity lies in adopting published frameworks to address and cope with such racial bias in health care settings. Two of those frameworks presented during the forum are CHARGE2 (Table 2) and INTERRUPT (Table 3), which include such tenets as advocate; build trust, empathy, and self-efficacy into provider-patient relationships; learn and teach others; mitigate unconscious or implicit bias; and create nonthreatening strategies to address bias during clinical encounters.⁹

TABLE 1 Glossary of Terms Used During the Forum Discussion

TABLE 2 CHARGE2 Framework for Health Care Workers to Mitigate Bias

TABLE 3 INTERRUPT Framework to Address Bias and Microaggressions

With this foundation in mind, participants highlighted a set of priority considerations to advance equity in formulary and benefit design (Table 4). Among the most important of these is the need to fill existing gaps in data. This need is especially relevant for both clinical trials and real-world evidence, and forum participants called for increased diversity among enrolled study participants, stronger trial designs that better detect possible heterogeneity in patient responses, and expanded subgroup reporting to inform more nuanced formulary evidence reviews. Participants also raised considerations with respect to augmenting the data available within health care delivery systems by, for instance, more thoroughly and efficiently collecting patient demographic information into medical records; they acknowledged, however, that collection and utilization of that data must be balanced with patient privacy concerns and were aware that biases may be unintentionally built into current algorithms and artificial intelligence platforms. Additionally, participants suggested that having available more robust health outcomes data by racial and ethnic group and incorporating those data into drug monograph tools used in formulary development—for example, the AMCP Format or monograph templates—would support diversity and equity. Further suggestions to improve this process included providing annual equity training for pharmacy and therapeutics committee members, having committee representation that reflects an organization’s minority membership, adding a member with expertise in equity, creating a subcommittee to evaluate equity in formulary decisions, and engaging patient voices from disadvantaged groups in order to share their experiences and feedback.

TABLE 4 Priority Considerations Identified by Participants

Participants also saw value in evaluating other existing systems through a lens of increasing equity (or acknowledging patient differences), driving a shift from the standard of equality (or treating all patients the same) that they suggested is primarily in place today. This could include involving partners such as consultants and other stakeholders to update benefit designs and allow benefit flexibility, particularly considering the evolving landscape of higher-cost specialty medications, or populations for whom some medications may provide different outcomes or who might be disproportionately affected by certain conditions. Specific solutions were introduced, including allowing variable cost-sharing and premiums, such as on a sliding scale based on income; offering a preventive medication benefit with a low or $0 copay; and adjusting cost-sharing models for disease states by which minority or other at-risk populations are disproportion-ally affected. A system evaluation could also identify opportunities for new or revised programs around payment incentives or disincentives for health care providers who participate in equity efforts; this could enhance accountability for ensuring that these efforts translate into greater equity.

Participants emphasized one crucial consideration, however: the need for any system evaluation to consider how patients access and interact with the system and to implement strategies to lessen any advantage or disadvantage to any particular group. An example was to encourage the use of automated tools such as real-time benefit checks and electronic prior authorization whenever possible in order to assist those with less time or fewer resources to navigate benefits and utilization management. It could also include expanding access to the care delivery network, such as by relocating clinics or pharmacies along public transportation lines.

Participants recognized that successful efforts to improve equity in the provision of health care must be committed to patient-centered care. Engaging in both broad and local activities to build trust and increase access among minority populations is one timely example, especially, participants noted, as health care professionals seek to increase adoption of COVID-19 vaccinations. Also important was enhancing care coordination through more systematic engagement of pharmacists, community partners, and health navigators, which could further foster trust, be a way to assess accurately patient-specific social determinants of health, and efficiently address persistent barriers to access, whether they be socioeconomic factors, limited access to health care facilities, interpersonal and systemic racism, or others. Additional examples included enhanced diversity and inclusion among the health care workforce, development of patient outreach programs with simplified materials to improve health and health insurance literacy, and the sharing of best practices and case studies in peer-reviewed journals such as JMCP.

As a follow-on to these considerations, participants suggested methods of ongoing evaluation to assess their effectiveness, including research and the addition of quality metrics specific to equity. Quality metrics could include prior authorization approval and denial rates, adherence among various patient subgroups, or other measures that may be influenced by disparities. These could then be shared via a central data warehouse or communicated by the evaluating entity (eg, Centers for Medicare & Medicaid Services star ratings).

Policy, Education, and Training Considerations to Advance Equity

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Several policy areas were identified during the discussion as having the potential to affect equity, including those that address data collection standards, those that require nondiscrimination, and those related to clinical trial design and data access. Data collection standards in administrative records, for instance, should be reviewed to determine whether they contribute to or mask inequities; for example, although race may be captured, other characteristics such as gender identity may not be. Also, laws and regulations that require nondiscrimination may unintentionally hinder equity if they prohibit the implementation of more personalized or subgroup formulary or benefit features. Further, there is an opportunity to advance equity with policies related to clinical trial design and data access by aiming for the most representative racial/ethnic populations affected by the condition being studied and increasing the role of real-world data to allow understanding of and track disparities in medication access.

As these current policies may need to evolve or new policies may need to be developed, participants thought it was important to continue fostering relationships, better communication, and increased understanding between regulators and managed care stakeholders, including patients or advocates who are familiar with racial health disparities. They also suggested that a set of core principles for policy development be established. For participants, policy reform plays a key role in aligning incentives, especially between payers and physicians as they seek to implement innovations to increase equity.

Education and training are also central to addressing equity gaps. Participants indicated the importance both of foundational education for all health care stakeholders about why inequities exist and persist and of updates to health sciences educational curricula. They also noted that patient-related education about, for example, health insurance literacy could provide opportunities to strengthen relationships between health care providers and communities. As with all proposed considerations, it will be important to assess any such education program to determine whether it achieves its intended objectives.

In addition to annual equity training for pharmacy and therapeutics committees, participants considered training to be necessary across all aspects of health care, with an intentional focus on leadership training. Effective equity training would include topics such as related terminology (Table 1), structural racism, implicit bias, and cultural competency, among others. For the managed care industry specifically, training on equity best practices, trust in data and good practices for data utilization, and transparency to outside stakeholders would also be valuable.

Conclusions

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The health disparities derived from racism and social determinants of health that exist in the United States are deeply rooted and complex. To begin mitigating these disparities as they relate to benefit design, this forum’s participants noted that it is critical to acknowledge that systemic racism exists, to integrate proactive strategies to improve equity, and to view patients holistically.

Participants also proposed considerations in priority areas such as mitigating existing gaps in clinical trial and health care delivery system data, increasing diversity and equity in formulary development and benefit offerings, and improving access for patients in disadvantaged groups. Additionally, education and training on topics such as equity-related terminology, systemic racism, implicit bias, and cultural competency were highlighted as vital to effective equity efforts. Evolving current policies and developing new policies are opportunities to positively impact equity.