Experts Warn DTC Models Could Worsen Health Equity for the "Working Poor" Amid Convenience Gains

In interviews with The American Journal of Managed Care®, Jennifer Graff, PharmD, of Innov8 Health Policy; Joey Mattingly, PharmD, MBA, PhD, of the University of Utah College of Pharmacy; and Brian Reid, MS, of Reid Strategic, discussed the major health equity concerns associated with direct-to-consumer (DTC) pharmacy models.

The experts noted that while DTC models can enhance convenience and engagement, they may also exacerbate health equity challenges for low- to middle-income individuals who face high out-of-pocket costs and limited guidance. They also cautioned that overreliance on DTC platforms and technology could weaken relationships with pharmacists, potentially creating barriers for those with lower health or digital literacy.

Learn more about the impact of DTC models here.

This transcript has been lightly edited for clarity; captions were auto-generated.

Transcript

What are the major health equity concerns associated with DTC pharmacy models?

Graff: DTC is a benefit in some ways and a challenge in others as we think about health equity. For those who are self-pay, you're going to have engaged, higher socioeconomic class, more activated patients who are willing to participate in these programs. However, having a streamlined program actually could help keep patients engaged in that program.

What do I mean by that? Earlier this year, I had hip pain, and rather than going through a traditional practice, I went through a digital offering to work on building PT [physical therapy] skills and reinforcing certain muscle groups. It was much easier for me to do that at home, and they sent me a Kindle, etc, at home to make it very easy and accessible for me to use.

That's the type of model that could work in a similar program, where, for those with low income and high costs, we could use a direct-to-consumer approach, but it would require others to solve the payment issue. Perhaps that's what we're seeing, as we're seeing some of the politically backed approaches around Medicaid and the TrumpRx deals moving towards direct-to-consumer or offering the lowest price to those Medicaid individuals.

Mattingly: My biggest concern is going to be for individuals who do not qualify for something like Medicaid. Often, when we think about low income, you might meet the criteria to qualify for Medicaid, but there's that group right above Medicaid eligibility. They are low-ish income but not low enough to meet the threshold.

It's kind of like my family growing up. Sometimes you'll hear the phrase "working poor," meaning that you work, you make just enough money that you can't qualify for Medicaid, but you don't make enough money to have good insurance, so you're paying a lot out of pocket. For those individuals, my concern is that their out-of-pocket costs, even going through direct-to-consumer, if they get put on a medication that, even through this platform, is still $500 a month, is that going to be feasible? Is that going to be reasonable for what they make financially?

When you think about it as a percentage of one's income, I'm really blessed now to have a good income and a dual-income family, and my wife and I do well that we have some expendable discretionary income, and if one of us were to get sick, maybe we could afford the $500 a month. But that's not the case for a lot of individuals, and it certainly wasn't the case for my family when I was growing up.

Again, it's going to be different for different individuals. The lower-income individuals, again, I want to specify, I'm not saying the lowest income, because the lowest income might actually be part of the safety net with Medicaid. Again, I know the initiative, too, is supposed to lower prices for Medicaid, so that's yet to be determined, but that's one of the goals.

If you're asking people to do things online and you're asking people to use technology, there is certainly a concern to make sure that the technology literacy is high for everyone. I don't think that's necessarily an age thing. It feels like it sometimes, but I think it just depends on what you're exposed to and what you're used to doing. I think part of it's like, what family around you do you have, or friends around you, that can help educate you about something? Then, my concern is going to be individuals who maybe don't have family support, maybe don't have people who could help educate them, and just how they might find that out.

Often, with health literacy, you might have a PhD in an area but have no idea how the health care system works. You may be incredibly smart, but our health care system can be really complicated, and you just have to have experience with it. My fear with the DTC models, if you aren't going to—again, I'm biased, I'm a pharmacist, so I am biased towards traditional pharmacies—if you don't have a relationship with a pharmacist and pharmacy technicians that you get to see once a month or a couple times a year, they're good resources to go talk to about your medications and whether you should order this or double up on this dose if you miss a dose.

They're just really good sources of information, and I'm not convinced yet that online or answers through AI [artificial intelligence] and all that are a complete replacement at this stage in time. My concern is if we have an overreliance on direct-to-consumer and an overreliance on technology, and we lose the relationships, could that have an unintended consequence?

Reid: I don't think anyone is under any illusion as to the extent to which the United States has a health equity problem, and it almost certainly does; that's not the problem we're solving here. Even products that appear to have relatively low direct-to-consumer prices, kind of relative to their list price, even products that may be on a branded basis, are competitive with what a patient might pay when you factor in cost-sharing, premiums, and things like that.

We're still talking about folks who are willing and able to write a check for $50, $100, $500 a month, and that just does not represent the majority of Americans. That's really not the solution to that particular problem, but I don't think that's the problem that this is being engineered to solve in the first place.