Structural Racism, Pharmacy Closures and Disparities in Medication Adherence Among Older Adult Medicare Part-D Beneficiaries

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PROJECT SUMMARY The objective of this project is to evaluate the impact of structural racism within Medicare Part-D policies and pharmacy closures on racial/ethnic disparities in adherence to chronic medications among older adult Medicare Part-D beneficiaries. Although ongoing efforts focus almost exclusively on addressing individual-level barriers to medication adherence, older adult Black/Hispanic minorities encounter community-level barriers, including the geographic accessibility of pharmacies, in adhering to their prescription medications not experienced by their White counterparts due to racial/ethnic residential segregation. Pharmacy closures disproportionately affect segregated minority neighborhoods and worsen existing disparities in the geographic accessibility of pharmacies. Medicare Part-D policies, including low pharmacy reimbursement rates and the growth of preferred pharmacy networks that often exclude pharmacies located in minority neighborhoods, are considered a fundamental cause of such closures. Despite these insights, the impact of closures on disparities in medication adherence, and the role of structural racism within Part-D pharmacy access regulations, is not known. Pharmacy closures may be an overlooked community-level mechanism of structural racism that exacerbates the adverse consequences of segregation on disparities in pharmacy access and medication adherence. We propose to leverage several proprietary and public data sources, including a census of Medicare Part-D patient-level prescription claims, to assemble a longitudinal, multi-level geocoded dataset with detailed information on pharmacy locations and characteristics (e.g., preferred pharmacy status) and derive a series of novel measures, including a multidimensional county-level measure of structural racism within Medicare Part-D (e.g., ratio % of pharmacies located in Black vs. White communities that participate in Part-D preferred networks) and conduct innovative analyses. The proposal aims to: (1) evaluate the effect of pharmacy closures on racial/ethnic disparities in adherence to chronic medications among Medicare Part-D beneficiaries before (2014-2019) and during (2020- 2022) the COVID-19 pandemic; (2) Determine the extent to which individual-level (e.g., dual-eligible) and community- level (e.g., racial/ethnic composition) characteristics modify the effect of pharmacy closures on disparities in adherence to chronic medications among Medicare Part-D beneficiaries and identify subgroups most at-risk for non-adherence post- closure and in need of pharmacy services; and (3) Investigate the impact of exposure to structural racism within Medicare Part-D on medication adherence among Medicare Part-D beneficiaries by race/ethnicity at the individual-level and community-level. Our proposed work is innovative because it will be the first study to investigate the impact of pharmacy closures on persistent disparities in medication adherence at older ages. Our analyses of multi-level causal pathways responsible for changes in medication adherence post-closure is also novel. With respect to expected outcomes, the work proposed will contribute evidence that policymakers need to advance Medicare Part-D payment and delivery reforms that reduce, and not worsen, disparities in pharmacy closures and, in turn, medication adherence. These outcomes will have a positive impact given the increasingly important role of pharmacies in preventive and emergency care and will support NIA in its strategic goals of informing policy decisions and reducing health disparities.