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

项目总结 该项目的目标是评估结构性种族主义在Medicare Part-D政策和药房中的影响 关闭老年人Medicare Part-D受益人在接受慢性药物治疗方面的种族/民族差异。 尽管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上，但老年人 成年黑人/西班牙裔少数群体遇到了社区层面的障碍，包括药店的地理可及性， 在坚持他们的处方药时，由于种族/民族居住，他们的白人同行没有经历过 种族隔离。药房关闭对隔离的少数族裔社区造成不成比例的影响，并加剧了现有的差距 在药店的地理可达性方面。Medicare Part-D政策，包括低药房报销率和 首选药房网络的增长通常不包括位于少数族裔社区的药店，这一点被认为是 这是导致这种关闭的根本原因。尽管有这些见解，关闭对服药依从性差异的影响， 结构性种族主义在D部分药房准入规定中的作用尚不清楚。关闭药房可能是一种 被忽视的结构性种族主义的社区一级机制，加剧了种族隔离对 在药房准入和服药依从性方面存在差异。我们建议利用几个专有和公开的数据 来源，包括联邦医疗保险D部分患者级处方索赔的普查，以汇编纵向、多层次 地理编码数据集，包含有关药房位置和特征的详细信息(例如，首选药房状态)和 推出一系列新的措施，包括在县一级对医疗保险中的结构性种族主义采取多维措施 D部分(例如，参与D部分优先网络的黑人社区与白人社区中药店的比率) 并进行创新分析。该提案旨在：(1)评估关闭药房对种族/民族的影响 联邦医疗保险D部分受益人之前(2014-2019年)和期间(2020-2020)接受慢性药物治疗的差异 2022年)新冠肺炎大流行；(2)确定个人层面(例如，双重资格)和社区-- 级别(例如，种族/民族构成)特征改变了药店关闭对遵守以下标准的差异的影响 在Medicare Part-D受益人中进行慢性药物治疗，并确定不遵守后最有风险的亚群 关闭和需要药房服务；以及(3)调查在医疗保险中暴露于结构性种族主义的影响 D部分关于联邦医疗保险D部分受益人在个人一级按种族/族裔分列的用药依从性 社区层面。我们提议的工作是创新的，因为这将是第一个调查药房影响的研究 关闭老年人服药依从性方面的持续差异。我们对多层次因果路径的分析 负责封闭术后服药依从性的变化也是新奇的。关于预期结果，工作 提议将有助于证据表明，政策制定者需要推进Medicare Part-D支付和交付改革， 减少而不是恶化药房关闭的差距，进而减少服药依从性。这些结果将会有一个 鉴于药房在预防和紧急护理方面发挥越来越重要的作用，将产生积极影响，并将支持NIA 在其为政策决策提供信息和减少健康差距的战略目标中。

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.