The COVID-19 pandemic encouraged a surge in healthcare innovation as well as a return to traditional strategies of care, namely using the home as a site of care. However, as the pandemic’s restrictions fade away, some have begun to question whether these interventions will remain in place. Our answer: they must.
- The home as a site of care was, historically, an important element of American healthcare. While house calls waned from 40% in the 1930s to less than 1% in 1980s, in-home healthcare has experienced a resurgence since the beginning of the COVID-19 pandemic. 1
- Home healthcare and hospital-at-home programs have become popular in part due to expanded reimbursement during the COVID-19 public health emergency. Several pieces of legislation are in motion to retain these levels of reimbursement.
- Allowing the home to be a site of care benefits many patients who are struggling against social determinants of health (SDOHs) that restrict their ability to access health services. 30-35% of health outcomes are directly connected to social determinants of health. 2
- Many patients also suffer immense health stigma, which can further reduce the likelihood that they will seek or receive the care they need.
- In-home care can make a difference by shifting the power dynamic between doctor and patient. This is key for people who have been historically mistreated or undertreated by American healthcare.
- SDOHs and stigma also contribute to low medication adherence. Even when the price of a medication is low, it may be abandoned. In 2021, approximately 81 million new prescriptions were abandoned at the pharmacy, and 48% of those were low-cost, between $0-$10. 3
- Prescription delivery is key to improving adherence, but delivery solutions need to meet patients’ needs. Ground shipping is good for maintenance medications but is inadequate for acute medications and urgent refills.
- Prescription access solutions can be divided into two categories: business-to-consumer or business-to-business. There is a great deal of variety available within each category.
- Ultimately, every entity with power in the healthcare industry must choose to put patients first and invest in flexible interventions like in-home care and prescription delivery that can overcome the obstacles patients face. Otherwise, we will have failed in our collective mission.
Welcome to the 2022 ScriptDrop industry status report.
Everything old is new again.
We don’t expect cyclical trends in healthcare. Perhaps in fashion, architecture, or consumer goods, but not in healthcare. Yet even as we push forward into an increasingly technological future, the industry is returning to one of the oldest strategies in care: providing healthcare in the patient’s home.
House calls. Hand-delivered medications. Customized therapies. These aren’t new concepts, but they did fall away for the majority of the last century as American healthcare and insurance became more complex. It was easier to keep healthcare providers and their equipment in one place and ask patients to come to them.
Then COVID-19 spurred the healthcare industry to acknowledge that different people have different needs. The hospital isn’t always the best place for every patient who needs acute care. People struggle with medication adherence not out of laziness, but out of a lack of time, transportation, or trust in their healthcare providers.
COVID-19 has also been a “disabling event.” As of February 2022, it is estimated that between 7.7 and 23 million Americans have “long COVID,” a post-viral syndrome whose symptoms interfere with daily life and can leave patients homebound. 4 These patients require care that takes their needs into account.
But even without the extenuating circumstances of COVID-19, the odds are simply stacked against many Americans when it comes to having good healthcare experiences and positive outcomes. One-size-fits-all solutions simply aren’t enough.
That’s why we’re excited that options like in-home care are experiencing a renaissance. Let’s take a look at the home as a site of care.
Home as a Site of Care
There’s a reason that American children grow up playing with toy stethoscopes packaged in little doctor’s bags: for generations, American doctors made house calls. Less than a hundred years ago, 40% of healthcare interactions happened in the patient’s home. But by 1980, less than 1% of patient-provider encounters were house calls. 1
There were multiple reasons for this shift away from the home and into the office setting. 1
- Increasingly complex technology and equipment
- Fear of liability
- Poor reimbursement by Medicare, Medicaid, and other payors
- No consistent means of real-time communication between patient and provider
By the early 2000s, the industry was beginning to acknowledge that some patients required in-home care. Medicare Part B increased the reimbursements for house calls, encouraging providers to pack up their doctor bags again for their elderly patients.
Then, in 2020, the COVID-19 pandemic disrupted everything. Suddenly, everyone understood how it felt to be homebound. Every provider needed a telehealth solution. Pharmacies and health systems scrambled to line up home delivery or curbside pickup solutions. Major employers like Amazon rolled out on-demand, in-home acute care as an employee benefit. 5 Even the Centers for Medicare and Medicaid Services sprang into action to help hospitals organize hospital-at-home care programs. 6
Since then, patient needs have shifted somewhat. As case numbers dropped, more patients have felt comfortable returning to in-person appointments. Telehealth usage has fallen across most specialties as a result, except in the area of mental health. By the end of 2021, telehealth visits only represented 1-2% of all appointments for most diagnoses. Mental health conditions like depression and ADHD were the exception, with over 20% of all appointments conducted virtually. 3
Americans who have been concerned about their own mental health or that of family or friends in the past two years 7
Americans 18-34 years old who have been concerned about their own mental health or that of family or friends in the past two years 7
Telehealth, of course, is just one aspect of the in-home renaissance. Home healthcare and hospital-at-home programs have continued to grow in popularity. However, Medicare and Medicaid reimbursement for these services is set to expire once the COVID-19 public health emergency expires. As of this writing, the emergency declaration has been extended until mid-July. Since Health & Human Services has stated they will give 60 days notice of its expiration and they have not done so by mid-May, we can assume the declaration will be extended for at least another 90 days. 8 In the meantime, patient advocates, industry organizations, and legislators in many states are working furiously to ensure patients can continue to receive care at home.
While much of the current push towards home care was inspired by the pandemic, COVID-19 isn’t the only reason why patients need more diverse care options. To understand why home healthcare has taken off, we need to take a look at social determinants of health and disease stigma.
Delivery: Overcoming Obstacles
Naturally, there are limits to home health services and prescription delivery. You can’t get an MRI at home. Many states have strict rules around home delivery of Schedule II drugs. But offering some care in the home is better than none. Delivering care at home for at least some patients can give healthcare professionals more time, resources, and hospital beds for the patients who really need them.
However, the growth of the home as a site of care will be limited if it is not partnered with supportive solutions and services.
An Over-Reliance on Shipping
Regardless of where patients receive their care, adherence to prescription regimens is still a major issue. 20 to 30% of prescriptions are never filled to begin with, and 50% of medications for chronic health conditions are not taken as prescribed. 23
We cannot assume that patients who receive care in their own homes are also receiving their medications at home. Providers may administer some medications during a home visit, but those will be billed under a patient’s medical benefit. Any prescriptions written by a doctor will need to be filled by a pharmacy and billed under the pharmacy benefit. While we like to imagine a world in which pharmacists can also make house calls, that isn’t our current reality.
And as we’ve learned, patients – regardless of where they receive healthcare – struggle to obtain their medications and take them consistently.
Cost is a major obstacle to adherence, but it’s not the only factor. In 2021, approximately 81 million new prescriptions were abandoned at the pharmacy, and 48% of those were low-cost, between $0-$10. 3 Clearly, there are other reasons patients don’t take their medications. We’ve seen how those obstacles are created by social determinants of health and stigma. But many of those obstacles boil down to one truth.
It’s difficult for many patients to get to the pharmacy.
Digital pharmacies have tried to fill the gap between patients and their medications. These companies, which often have few (if any) brick-and-mortar locations, generally can fill any prescription that a neighborhood pharmacy could. But while some digital pharmacies do offer local, same-day delivery, they can only serve a small geographic area. Patients outside of the service area must depend on shipping by ground carriers to get their prescriptions.
Generally, shipping is an excellent choice for maintenance medications. It can also reach patients in areas where couriers might struggle to reach. But it also has a lot of drawbacks.
- Can be slow, especially at high-volume times of year
- Refrigerated medications may spend days in detrimental conditions
- Lengthy chain of custody adds risk
Recent changes to USPS policy are set to slow down the mail even further. Small first-class packages, like prescriptions, will shift from 2-3 day shipping to 4-5 day shipping. 24
The slower the delivery, the less useful it becomes. It’s certainly not ideal for acute medications; nobody wants to wait a day for an antibiotic, let alone four days (or even two weeks, for new prescriptions from some digital pharmacies). It’s not great for temperature-sensitive medications; their ice packs may be melted by the time the package arrives at the patient’s home. Many digital pharmacies even counsel patients to fill their urgently-needed medications at a local pharmacy instead, which negates all the benefits of having delivery.
Pharmacy benefit managers like OptumRx, Caremark, and Express Scripts offer delivery via ground carriers as well, but patients don’t appreciate the lack of transparency into which prescriptions they will receive, what they will be charged, or when their medications will arrive. 25 Perhaps that contributes to the fact that IQVIA found prescriptions delivered by mail have declined by 4% in the past five years. 3
Clearly, patients need more than one option for delivery.
Same-Day and On-Demand
Luckily, there is a good chance that a patient’s local pharmacy offers some form of delivery. Smaller community pharmacies may employ their own driver, or have a pharmacy tech do the occasional delivery.
In the past few years, retail pharmacy chains, health systems, hospitals, pharmaceutical manufacturers, and even some insurance payors have started partnering with delivery solutions that can handle the logistics of same-day delivery and flex with demand. However, these solutions are not created equal.
Some prescription access solutions are limited in their geographic range. Others focus on courier services but don’t offer software to ease the delivery process for pharmacists. Some have begun to specialize to optimize profits and ensure a steady revenue flow. By working with pharmaceutical companies to serve patients who take specific medications, these access solutions may excel at helping patients obtain and remain adherent to one of their prescriptions, but don’t offer an option for others.
In the next section, we’ll break prescription delivery providers into categories to better understand how they operate, what they offer to pharmacies and other healthcare entities, and how they might impact adherence.
Major Players in Prescription Access
This year we’ve divided delivery providers by who they see as their customers.
- Business-to-consumer (B2C) providers allow patients to request delivery directly. These are commonly pharmacies but could be third-party entities that mediate between the patient and pharmacy.
- Business-to-business (B2B) providers work with other healthcare entities, like pharmacies, health systems, hospitals, insurance payors, and pharmaceutical manufacturers. B2B solutions usually do not advertise themselves to patients. They act as the mechanism for delivery, but their customers’ patients may not be aware that the B2B delivery provider even exists.
Many pharmacies and health systems can and do develop their own solutions by hiring their own drivers or setting up their own accounts with ground and air carriers like UPS and FedEx. These will not appear in the following chart, simply because there are too many to track.
We chose the companies mentioned here based on perceived market share and activity within the industry, as well as on what information was publicly available 26.
Please note that the following chart is meant to be a snapshot of the prescription delivery landscape during a specific timeframe and is subject to change.
PBM Mail Order
|Alto||Amazon Pharmacy||Blink Health / Blink Health Plus||Capsule||Genius Rx||Medly||NowRx||PillPack||Ro Pharmacy|
|Delivery fee||Free||Prime members receive free 2-day delivery. All customers receive free 4-5 day delivery; can upgrade to 2-day for $5.99 per shipment||Free||Free||Free shipping option or $4.99 priority shipping||Free||Free||Free||Free|
|Membership fee||None||Amazon Prime membership ($139/annual) required for out-of-pocket prescription discounts and free 2-day shipping||None||None||None||None||None||None||None|
|Accepts insurance||Yes||Yes||Only through Blink Health Plus||Yes||No||Yes||Yes, except Kaiser Permanente||Yes||No|
|Accepts HSA/FSA||Yes||Yes||Yes||Yes||Yes, only over phone||Unknown||Yes||Yes||No|
|Means of payment||Credit or debit||Credit or debit||Credit or debit||Credit or debit||Credit or debit||Credit or debit||Credit or debit||Credit or debit, bank account||Credit or debit|
|Speed of delivery|
|Service levels available||Same-day||Shipping||Shipping||Same-day||Shipping||Same-day||On-demand/Same-day||Shipping||Shipping|
|Average turnaround time||Within hours||2-5 days||3-5 business days||Within hours||Free shipping: 2-5 business days. Priority shipping: 1-3 business days.||On-demand is available for urgent needs||Within 3-4 hours of receiving prescription, during business hours||2-4 weeks for first shipment; following shipments on regular monthly schedule||Processed and shipped within 1-2 of receiving prescription. 2-day shipping, although expedited shipping available|
|Means of delivery|
|Couriers||Ground/air carriers||UPS and USPS||Couriers||Ground/air carriers||Couriers||Couriers||UPS or USPS||Ground/air carriers|
|Service areas||Austin, Dallas-Fort Worth, Denver/Boulder, Houston, NYC, Las Vegas, Los Angeles/Orange County, San Diego, San Francisco, Seattle||Nationwide||Nationwide||Atlanta, Austin, Boston, Chicago, Denver, Houston, Los Angeles, Nashville, NYC, Philadelphia, Tampa, Twin Cities, Washington DC||Nationwide, except Alabama||Colorado, Connecticut, Florida, Georgia, Maryland, New Jersey, New Mexico, New York, North Carolina, Pennsylvania, Texas, Washington||Arizona (Mesa) and California (Burlingame, Hayward, Irvine, Mountain View, Pleasanton, San Jose, Van Nuys).||Nationwide, except Hawaii||Nationwide, except Arkansas, Connecticut, Indiana, Iowa, Louisiana, Michigan, Montana, Nebraska, New Jersey, North Carolina, Tennessee, and Virginia|
|Schedule II meds||No||No||No||Yes||Unknown||Yes||Yes||No||No|
|Over the counter meds||Yes||Yes||Yes, with prescription||No||Unknown||Unknown||Yes||Yes||No|
|Customer service email address||Yes||No||No||Yes||Yes||Yes||Yes||Yes||Yes|
Customer service phone number
|Mobile app/texting service||Yes||No||No||Yes||No||Yes||Yes||No||Yes|
|Pharmacist available||Yes, chat or text||Yes||Yes||Yes, chat or text||Unknown||Yes||Yes||Yes||Yes, call or text|
Conclusion: The Future of Care
It hurts to say it, but not much has changed in terms of what the industry needs to do to improve healthcare.
In June 2020, Deloitte published an article titled, “Is the hospital of the future here today?” 27 The answer was, essentially, no.
- Hospitals are not yet “focused factories catering to procedures for critical care.” 27
- While hospital-at-home programs have expanded, they could evaporate once the public health emergency ends if legislation does not support continued reimbursement.
- Hospitals in some areas may already be considered “health hubs” in their communities, but we have not seen widespread efforts to improve patients’ social determinants of health by improving “food security, housing, employment, utility access, and other needs that impact health.” 27
The healthcare of the future is still on the horizon, but right now too many Americans struggle to receive basic healthcare and access their medications. They struggle against the social determinants of health that reduce their chances of good outcomes and long, healthy lives. Delivery is available, but patients aren’t made aware of it. Accessible, affordable care is still a rarity for most. Care is still episodic in nature – perhaps even more so than before, with the increasingly siloed ways that patients access care.
Too many people have no access to healthcare at all. Too many people don’t have Internet access, don’t get mail delivered directly to their homes, or don’t have homes. The problems we collectively face as an industry and as a nation are immense.
But these problems do have solutions. To start with, the Healthy People 2030 initiative by the Office of Disease Prevention and Health Promotion within the HHS has identified ways to improve social determinants of health. 28 We believe that prescription delivery and other access solutions can make many of these objectives a reality.
But as we’ve said again and again, nothing can be achieved by one company, one hospital, one state, one payor, one pharmaceutical manufacturer, or one federal department. The entire industry needs to invest in interventions like in-home care and prescription delivery now. The patients are already here and already in need. COVID-19 added even more need, with millions suffering from post-viral syndrome. More will follow as the population ages.
We must always return to the reason for the healthcare industry to exist: patients. If we aren’t listening to them and meeting their needs, then we are failing in our collective mission. If care is too expensive or inaccessible, we are failing. If patients don’t feel safe and cared for in healthcare settings, whether they are in a hospital, at a pharmacy, or at home, then we are failing. If patients are too burdened by their life circumstances to seek care or obtain it, then we are failing.
And because healthcare doesn’t work without healthcare professionals, if doctors, nurses, and pharmacists feel unsafe, burned out, or taken for granted, then we are failing.
There is a way forward. But we have to choose it.
Rear Admiral Pamela Schweitzer
Rear Admiral Pamela Schweitzer served as Assistant Surgeon General and Chief Professional Officer of Pharmacy for the United States Public Health Service. While she has retired from these positions, previous assignments include the Indian Health Service, Veterans’ Administration, and the Centers for Medicare and Medicaid Services. A well-known leader in the pharmacy field, Pamela remains active in all things healthcare.
Lee Ann Stember
Lee Ann Stember is President & CEO of the National Council for Prescription Drug Programs (NCPDP) and has led the organization for 40 years. Her work with NCPDP continues to push the pharmacy industry to embrace technology and standards that will improve patient health and safety.
Sloane Salzburg, MS
Sloane Salzburg is Vice President of Horizon Government Affairs, Executive Director of the Campaign for Transformative Therapies, and Vice President of the Council for Affordable Health Coverage. A constant presence on Capitol Hill, Sloane is passionate about using legislation to help patients get their medications easily and affordably.
George Lazenby is the CEO and co-founder of OrderInsite, a pharmacy inventory software company. George is laser-focused on innovation that removes barriers to medication access and on delivering valuable, effective pharmacy solutions.
- When a patient takes a medication exactly as prescribed (i.e. correct dose, correct administration, correct duration of therapy).
- Physical pharmacy stores. These may also use a website, patient portal, phone line, or app to conduct business, but largely depend on customers coming into the store.
- Chronic condition/illness
- A long-term disease or condition, variously defined as lasting at least 3-12 months, and requiring ongoing care or therapy.
- Maintenance medications
- Prescriptions taken at regular intervals (usually daily) to treat chronic conditions.
- Delivery that is completed shortly after being requested by a patient or pharmacist; this could be within one hour or within several hours.
- Over-the-counter, that is, not prescribed.
- Pharmacy benefit manager. Third-party companies that manage patients' prescription drug benefits on behalf of an insurer.
- Payments made to a pharmacy after a prescription is billed to the patient's PBM and the PBM accepts the claim.
- Delivery that is completed the same day that it is requested by a patient or pharmacist.
- Service levels
- In regards to delivery, the turnaround time from delivery request to completion. Service levels could include on-demand, same-day, next-day, shipping, expedited shipping, etc.
- Return to stock (RTS)
- When prescriptions are dispensed but not picked up by the patient, the medication must be put back into stock containers. Some states have strict guidelines on returning to stock to ensure labels are appropriately destroyed and batches of medication are not mixed.
- Delivery completed by the USPS or other package carriers and transported by ground or air.
- Healthcare and health consultations delivered via telephone, online portal, or other telecommunications means.
- Schuchman, M., Fain, M., Cornwell, T. (2018, July). The Resurgence of Home-Based Primary Care Models in the United States. Geriatrics 2018, 3(3), 41. Retrieved from https://www.mdpi.com/2308-3417/3/3/41/htm
- Social determinants of health. World Health Organization. Retrieved from https://www.who.int/health-topics/social-determinants-of-health
- Aitken, M., Kleinrock, M., Pritchett, J. The Use of Medicines in the U.S. 2022: Usage and Spending Trends and Outlook to 2026. (2022, April). IQVIA Institute for Human Data Science. Retrieved from https://www.iqvia.com/-/media/iqvia/pdfs/institute-reports/the-use-of-medicines-in-the-us-2022/iqvia-institute-the-use-of-medicines-in-the-us-2022.pdf
- Science & Tech Spotlight: Long COVID. (2022, March). U.S. Government Accountability Office. Retrieved from https://www.gao.gov/products/gao-22-105666
- Amazon Care to launch across U.S. this summer, offering millions of individuals and families immediate access to high-quality medical care and advice–24 hours a day, 365 days a year. (2021, March). Amazon. Retrieved from https://www.aboutamazon.com/news/workplace/amazon-care-to-launch-across-u-s-this-summer-offering-millions-of-individuals-and-families-immediate-access-to-high-quality-medical-care-and-advice-24-hours-a-day-365-days-a-year
- CMS Announces Comprehensive Strategy to Enhance Hospital Capacity Amid COVID-19 Surge. (2020, November). CMS. Retrieved from https://www.cms.gov/newsroom/press-releases/cms-announces-comprehensive-strategy-enhance-hospital-capacity-amid-covid-19-surge
- Levy, S. (2022, May). CVS Health, Morning Consult survey shares increasing mental health concerns amongst individuals. Drug Store News. Retrieved from https://drugstorenews.com/cvs-health-morning-consult-survey-shares-increasing-mental-health-concerns-amongst-individuals
- Aboulenein, A. (2022, April). U.S. renews COVID-19 public health emergency. Reuters. Retrieved from https://www.reuters.com/business/healthcare-pharmaceuticals/us-renews-covid-19-public-health-emergency-2022-04-13/
- H.R. 7676 - Home Modification for Accessibility Act of 2022. (2022, May). Congress.gov. Retrieved from https://www.congress.gov/bill/117th-congress/house-bill/7676
- H.R. 7053 - Hospital Inpatient Services Modernization Act. (2022, March). Congress.gov. Retrieved from https://www.congress.gov/bill/117th-congress/house-bill/7053
- H.R. 5514 - Choose Home Care Act of 2021. (2021, October). Congress.gov. Retrieved from https://www.congress.gov/bill/117th-congress/house-bill/5514
- Commercial determinants of health. (2021, November). World Health Organization. Retrieved from https://www.who.int/news-room/fact-sheets/detail/commercial-determinants-of-health
- Social Determinants of Health. Healthy People 2030. Office of Disease Prevention and Health Promotion. Retrieved from https://health.gov/healthypeople/priority-areas/social-determinants-health
- Heath, S. (2020, July). Multiple Social Determinants of Health Compound Stroke Risk. Patient Engagement HIT. Retrieved from https://patientengagementhit.com/news/multiple-social-determinants-of-health-compound-stroke-risk
- Kane, J., et al. (2019, February). A scoping review of health-related stigma outcomes for high-burden diseases in low- and middle-income countries. BMC Medicine 17, 2019. Retrieved from https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-019-1250-8
- Mueller, A., et al. (2012, July). Stigma in attention deficit hyperactivity disorder. Attention Deficit and Hyperactivity Disorders 4, 101-114. Retrieved from https://link.springer.com/article/10.1007/s12402-012-0085-3
- Sartorius, N. (2007, June). Stigmatized Illnesses and Health Care. Croatian Medical Journal, 48(3), 396-397. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2080544/
- Young, W., et al. (2013, January). The Stigma of Migraine. PLoS One, 8(1). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3546922/
- Unwin, B., and Tatum, P. (2011, April). House Calls. American Family Physician, 83(8), 925-931. Retrieved from https://www.aafp.org/afp/2011/0415/p925.html#afp20110415p925-b3
- Adherence to Long-Term Therapies: Evidence for Action. (2003). World Health Organization. Retrieved from http://apps.who.int/iris/bitstream/handle/10665/42682/9241545992.pdf
- Yu, A. P., et al. (2008). Delay in Filling the Initial Prescription for a Statin: A Potential Early Indicator of Medication Nonpersistence. Clinical Therapeutics, 30(4), 761-774.
- New Research Shows Patient Proximity to Primary Care, Pharmacies Linked with Mental and Overall Health Satisfaction. (2022, May). Business Wire. Retrieved from https://www.businesswire.com/news/home/20220513005006/en/New-Research-Shows-Patient-Proximity-to-Primary-Care-Pharmacies-Linked-With-Mental-and-Overall-Health-Satisfaction
- Viswanathan, M., et al. (2012, December). Interventions to Improve Adherence to Self-administered Medications for Chronic Disease in the United States. Annals of Internal Medicine, 157(11), 785-795. Retrieved from https://www.acpjournals.org/doi/full/10.7326/0003-4819-157-11-201212040-00538
- Chappell, B. (2022, April). Why your USPS mail package delivery is about to get slower. NPR. Retrieved from https://www.npr.org/2022/04/21/1094011233/mail-usps-slower-packages
- Sample of Beneficiary Complaints Related to Mail Order. (2013). CMS.gov. Retrieved from https://www.cms.gov/medicare/prescription-drug-coverage/prescriptiondrugcovcontra/downloads/sampleofbeneficiarycomplaintsmailorder.pdf
- Fein, A. (2022, March). The Top 15 U.S. Pharmacies of 2021: Market Shares and Revenues at the Biggest Companies. Drug Channels. Retrieved from https://www.drugchannels.net/2022/03/the-top-15-us-pharmacies-of-2021-market.html
- Gebreyes, K., et al. (2020, June). Is the hospital of the future here today?: Transforming the hospital business model. Deloitte Insights. Retrieved from https://www2.deloitte.com/us/en/insights/industry/health-care/hospital-business-models-of-the-future.html
- Healthy People 2030: Building a healthier future for all. Office of Disease Prevention and Health Promotion. Retrieved from https://health.gov/healthypeople
Social Determinants of Health and Stigma
In the past, the healthcare industry tended to assume patients weren’t following their doctors’ orders or not taking their medications due to some personal failing. After all, if it were the patient’s fault, then insurance payors, health systems, pharmacy chains, or pharmaceutical manufacturers didn’t need to change. The patient bore the burden of changing their behaviors and attitudes. Is a patient struggling to take their meds regularly? They just need to try harder!
But it isn’t that simple. It never has been. As we’ve been discussing since 2020, the COVID-19 pandemic has shown that no individual has full control over every single thing that affects their health. Two powerful reasons are social determinants of health and health stigma.
What Are Social Determinants of Health?
Social determinants of health (SDOHs) are non-medical factors that impact a person’s health. They determine what a person can do to support their own health, but they can also predict a person’s long-term healthcare outcomes. It is estimated that 30-35% of health outcomes are directly connected to social determinants of health. 2
Most of these determinants are rooted in the places and communities where people live, learn, and work. Many are influenced by the decisions of corporations. 12 For that reason, individuals do not have much control over them.
Example: If a highly influential, multi-national company is dumping industrial waste into your local waterways and polluting your tap water, your health will be affected. As an individual, if you cannot afford to move away, your options for fixing this problem are limited.
The U.S. Department of Health and Human Services has divided these factors into five categories.
Economic stability: Can this person afford what they need to live comfortably? Are they paid fairly for their labor?
Education access and quality: Does this person have access to school facilities and educational services that are high-quality, safe, and affordable?
Healthcare access and quality: Are there high-quality healthcare facilities close to where this person lives? Can they find healthcare professionals who understand their needs? Can they afford their medications?
Built environment: Is the place where this person lives, learns, and works safe or are they at risk of injury? Is the environment polluted? Can they access the resources that they need?
Social and community context: Does this person feel supported for being who they are?
Think of each category as a spectrum instead of a checkbox. For example, when it comes to economic stability, a person could come from a wealthy family, have a reliable and well-paying job, and have savings and investments. That patient will not struggle to afford their medications. They won’t have to create a crowdfunding campaign to pay for cancer treatment.
Or a person could live in poverty, like 10% of Americans. 13 In that case, they will likely only get medical care when they are critically ill and will not receive preventative care. Or they could fall anywhere in between those two extremes. Regardless, their economic stability will define their health outcomes to some extent.
However, it’s important to recognize that social determinants of health intersect. Even if a person has a high-paying job, they might live in a rural area where the nearest pharmacy is 25 miles away. Or even if they live in a community with the best doctors and hospitals in the country, they might be homebound and unable to get to their doctor’s appointments. The more negative SDOHs that a person experiences, the more likely they are to suffer severe health events, like a stroke. 14
Social determinants of health compound over time. A lifetime of no health insurance or little social support will worsen a person’s health outlook. But regardless of how long a person has struggled with the negative impact of a given determinant, interventions can shift a person’s situation towards the positive end of any category.
What Is Health Stigma?
Stigma could be considered an element of the Social and Community Context SDOH, but it’s worth exploring on its own. Health stigma has been defined in many different ways, but essentially it is:
Stigma begins as external to the person who is suffering from the illness. A community develops negative ideas about an illness and then devalues anyone with that illness. As a result, people with the given illness are discriminated against. They may be blamed for their illness, left out of social gatherings because they do not fit the social “norm,” turned down for jobs or housing, or even denied the healthcare they need to function. This is considered experienced stigma. [15, 16]
Over time, people with stigmatized conditions will anticipate and internalize those negative perceptions. Anticipated stigma could keep a person from seeking testing, picking up their medication, or asking for help, because they assume others hold negative perceptions of their illness. Internalized stigma causes a person to believe the negative perceptions about their condition, which can harm their self-image and self-esteem and lead them to stop seeking care. 15
Stigma can happen to people of any age and background. It can harm not only the affected person, but also anyone who associates with them.
But other diseases and conditions can be stigmatized in certain situations. For example, a study of primarily white Americans with chronic migraines found high rates of stigma because the frequent migraines affected the patients’ ability to work. 18
The damage of disease stigma cannot be overstated. Stigma can affect a person’s relationships, self-image, self-esteem, employment, government assistance, housing, healthcare experiences, and even their treatment after death. That is, it could potentially shift a person towards the negative end of every social determinant of health.
Stigma puts people at risk for depression, anxiety, social hostility, discrimination, and physical attacks. It makes people less likely to seek or receive care for their illness, ultimately increasing their utilization of healthcare services and a community’s disease burden.
Stigma is particularly harmful to groups who have been historically oppressed and discriminated against. People of color – especially women, LGTBQ+, impoverished, undocumented, and elder people of color – struggle to be heard and are all too aware of how American healthcare has historically used, abused, or simply ignored them. A stigmatizing disease only worsens the situation. Patients may not have the energy to spare to ask for what they need – a more private place for medication consultation, a doctor who understands the patient’s lived experience, etc. – and simply give up.
The obstacles to good health are serious for patients with health stigma. Healthcare solutions must acknowledge that.
*The patient depicted is fictional. Any resemblance to actual persons (living or deceased), places, incidents, organizations, or products is purely coincidental.
How In-Home Care and Delivery Can Overcome SDOHs and Stigma
In-home healthcare represents an opportunity for patients and providers alike. Whether it’s for preventative care like a vaccination, an acute concern, or chronic care, an in-home appointment shifts the power balance in the patient-provider interaction. The provider becomes a guest in the patient’s home, which may help patients be more assertive.
Providers are also given the opportunity to observe the patient’s living situation. While not all house calls will have the same goals, the mnemonic INHOMESSS stands for the different components for which a provider may check. 19
It’s important to note that doctors should not bear the burden of trying to fix everything for every patient – that’s an impossible task. But their awareness of patients’ social determinants of health informs their actions, those of their employers, and those of other healthcare entities. Health insurance payors, large hospital systems, pharmaceutical manufacturers, state governments, and the federal government all have a hand in the factors that predict health outcomes. They have the power to adjust reimbursements, alter health coverage, and promote certain services.
One of those services is prescription delivery.
Since social determinants of health encapsulate a wide set of factors, can intersect, and can compound over time, each person’s health experience is different. Nevertheless, we believe prescription delivery can benefit all patients, especially those negatively impacted by their social determinants of health or stigma.
Granted, delivery is only one strategy to improve long-term health. But delivery helps patients stay adherent to their prescription therapies and, as the World Health Organization has stated, medication adherence is key to keeping patients well and reducing our global disease burden. 20
An impoverished or fixed-income patient may not own a car or have access to other means of transportation. Delivery – if it is free or very low-cost – helps them overcome that barrier.
Education access and quality
A patient with low health literacy may not understand the importance of starting their prescription right away. The longer they wait, the less likely they are to remain adherent long-term. 21 Delivery can make sure they have their medications in-hand ASAP.
Healthcare access and quality
According to a recent study, patients who live 20 miles or more from a pharmacy are more likely to be dissatisfied with their care, perhaps because going to a pharmacy is a burden. 22 Delivery provides a connection to their pharmacist.
Delivery can overcome the obstacles of gridlock traffic, unreliable public transportation, and unwalkable cities that keep patients from the pharmacy.
Social and community context
Many patients struggle with little social support, especially if they have a stigmatized condition. Delivery can remove at least one barrier to care.
As in the case of social determinants of health, delivery is just one strategy to overcome the problem of health stigma. There are many other things that need to happen: focused training for doctors and pharmacists on specific diseases, their treatments, and counseling stigmatized patients; more funding and support for research on stigmatized diseases; and a shift in the social and cultural perspective on these conditions. But these interventions will take a lifetime. Patients need solutions that meet their needs now.
In-home care and delivery can bridge the gap. Patients who have – or suspect they have – a stigmatized condition may have internalized stigma, or anticipate the impact of stigma. As a result, they may be uncomfortable going into a doctor’s office, discussing their symptoms with a nurse and a doctor, and standing in line at the pharmacy to receive their prescription. Just the thought of this process may cause very real anxiety for a patient.
Many companies have been started to address this very situation. Direct-to-customer (DTC) platforms that combine telehealth and pharmacy services allow patients to see a doctor for potentially stigmatizing conditions in the privacy of their own home, receive a prescription, order their medication online, and receive it in the mail without ever having to meet with a healthcare professional in person.
*Many of these companies will diagnose and prescribe treatment for other conditions.
There are some significant drawbacks to this method of care, however. Since most of these companies do not accept insurance and have no way to communicate with the patient’s primary care provider or the pharmacy they usually use, a patient’s care can quickly become fractured. Online providers rely on the patient to tell them what other medications they are taking. In-person providers may never think to ask the patient if they’re receiving care online, and the patient might not think to mention it. This can lead to duplication of care, dangerous drug-drug interactions, and confusion on the part of the patient.
House calls can be a good alternative to DTC platforms if they are available, for the reasons outlined above. But even the addition of home delivery can make a difference in the life of a patient struggling with multiple negative SDOHs or a stigmatized condition. Patients might still have to go to the doctor in person, but they can at least avoid the potentially stressful step of going to the pharmacy and picking up their medications.