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

项目摘要 该项目的目的是评估医疗保险D部分政策和药房中结构性种族主义的影响 关闭老年人医疗保险D部分受益人在坚持慢性药物治疗方面的种族/民族差异。 虽然正在进行的努力几乎完全集中在解决个人层面的药物依从性障碍， 成年黑人/西班牙裔少数民族遇到社区一级的障碍，包括药店的地理可及性， 在坚持他们的处方药没有经历过他们的白色同行由于种族/民族居住 种族隔离药店关闭不成比例地影响了隔离的少数民族社区，并加剧了现有的差距 药店的地理可及性。医疗保险D部分政策，包括低药房报销率， 首选药店网络的增长，往往排除药店位于少数民族社区，被认为是 这是造成这种封闭的根本原因。尽管有这些见解，关闭对药物依从性差异的影响， 以及D部分药房准入法规中结构性种族主义的作用，尚不清楚。关闭药房可能是一个 被忽视的社区一级的结构性种族主义机制，加剧了隔离对 在获得药房和坚持服药方面的差距。我们建议利用几个专有和公共数据 来源，包括医疗保险D部分患者水平处方索赔的普查，以组装纵向，多层次 具有关于药房位置和特征的详细信息的地理编码数据集（例如，首选药房状态）和 得出一系列新的措施，包括医疗保险内的结构性种族主义的多维县级措施 D部分（例如，参与Part-D首选网络的黑人社区与白色社区的药房比例%） 进行创新分析。该提案旨在：（1）评估药房关闭对种族/民族的影响 在2014-2019年之前和2020- 2021年期间，医疗保险D部分受益人对慢性药物依从性的差异 （2）确定个人层面（例如，双重资格）和社区- 水平（例如，种族/民族组成）特征改变了药房关闭对依从性差异的影响， 医疗保险D部分受益人中的慢性药物，并确定最有风险的亚组， 关闭和需要药房服务;和（3）调查暴露于医疗保险内的结构性种族主义的影响 按种族/民族划分的医疗保险D部分受益人的药物依从性， 社区一级。我们提出的工作是创新的，因为它将是第一个研究药物的影响， 关闭老年人服药依从性的持续差异。我们对多层次因果通路的分析 导致闭合后药物依从性变化的原因也是新颖的。关于预期成果， 建议将提供证据，表明政策制定者需要推进医疗保险D部分支付和交付改革， 减少而不是恶化药房关闭的差异，从而减少药物依从性。这些结果将有一个 鉴于药房在预防和紧急护理中发挥越来越重要的作用， 在为决策提供信息和减少健康差距的战略目标方面，

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.