USPS: An Integral Part of the U.S. Healthcare System

While Congress and the public debate the implications of the Trump Administration’s plan to de-fund the United States Postal Service (USPS) on voting rights and the outcome of the presidential election, we must be acutely aware of the potentially irreparable harm delaying the mail may have on some of our most vulnerable populations. While we, at Atromitos, definitely have an opinion on the issue of absentee ballots and voting rights, our goal today is to simply inform you about the benefits that mail-order prescriptions provide to many populations and the real threat to their health and safety that USPS delays will cause.

According to the U.S. House of Representatives Energy and Commerce Committee, 1.2 billion prescription medications were delivered through the USPS in 2019. Data shared by Drug Channel Institute CEO Adam Fein indicates that this number represents about 4.9 percent of all prescriptions dispensed in 2019. But Politico says those numbers do not include the considerable jump in the use of mail-order prescriptions, which rose by 21 percent over the previous year, due to people staying home in response to the Coronavirus.

It is important that we put a face to this potential problem to understand the depth of the impact a delay in receipt of one’s medications may have on a person’s life. According to an Axios-Ipsos Coronavirus Index poll published August 18, 2020, almost one in five American’s received medication through the mail in the last week. And one in four of these (5% of all Americans) experienced a delay or non-delivery. To further exacerbate the problem, many of those utilizing mail-order medications are vulnerable populations within our communities—veterans, low-income families, and people living with chronic health conditions. And for each of these groups, access to mail-order medications can have a significant impact on their health and quality of life.

VETERANS

The Department of Veterans Affairs (VA) was one of the first organizations to offer mail-order medications to its patients and now represents the largest processor of mail-order prescriptions in the United States. The VA Mail Order Pharmacy processes approximately 80% of all VA outpatient prescriptions. This represented 125.2 million outpatient prescriptions in fiscal year 2019 alone. The daily magnitude is significant with over 470,000 prescriptions mailed via the USPS to over 330,000 Veterans per day.

Connecting Vets, a veteran-run social media and news outlet, has been reporting on the issue of USPS delays since the beginning of August, sharing personal stories of veterans waiting for critical medications to treat conditions such as pain, depression, post-traumatic stress disorder (PTSD), and other serious physical and mental health concerns.

The VA’s online MyHealtheVet tool allows veterans to track their mail-order prescriptions. For some veterans who spoke to Connecting Vets, their medications have been sitting at post office locations for weeks with no movement. With some local VA pharmacy locations closed due to COVID-19, veterans are limited in their ability to obtain emergency doses of medications. The only other alternative is to go to a clinic or a VA hospital where they run the risk of exposure to COVID-19.

Are we willing to allow USPS to fail and compromise the health and wellbeing of those who served our country?

LOW INCOME RURAL AND URBAN COMMUNITIES

An estimated 100 million Americans lack good access to pharmacies and are said to live in a “pharmacy desert.” A “pharmacy desert” is defined as any area with poor access to prescription medications. While you may expect that pharmacy deserts are most prevalent in rural areas, the problem is more than simply a matter of distance. Pharmacy access lags for myriad reasons including low income, insurance status, high prices, poor transportation, long distances, or a combination of those factors.

The term pharmacy desert was coined in 2014 by Dima M. Qato, PharmD, MPH, Ph.D. She built the criteria off the U.S. Department of Agriculture concept of food deserts—areas without adequate access to food. In 2012, while working as an assistant professor of pharmacy and public health at the University of Illinois at Chicago, Dr. Qato noted poor access to a pharmacy in areas of Chicago’s South and West sides that were largely Black or Hispanic. At that time about a million residents of Chicago lived more than a mile from the nearest pharmacy. That was about 37% of the city’s 2.7 million residents. Through her work with patients, she came to find that even a mile could be impossible to travel in the city for a variety of reasons.

Her studies revealed that multiple factors drove disparities in pharmacy access, including income and race. But the key factor she identified was insurance coverage and the resulting pharmacy reimbursement. Communities that had high Medicaid and Medicare coverage could not sustain local pharmacies because the reimbursement was too low. These findings have been echoed in studies in other urban areas of the country. Experts project that more than 99 million of the country’s 268 million urban residents may lack adequate pharmacy access.

Mail-order prescriptions can save families money thereby increasing accessibility to medications. Many mail-order pharmacies contract with an insurance plan’s pharmacy benefit manager (PBM) which enables the pharmacy to purchase and sell drugs in bulk. These high volume and highly automated operations result in lower overhead costs which are often passed onto the mail-order patients in the form of lower per-unit pricing and dispensing costs.

Additionally, many mail-order pharmacies offer a 3-month supply which requires the patient to pay a single copay rather than a monthly copay when obtaining a 30-day supply at a walk-in pharmacy. For example, a family can spend $46 at a local pharmacy for a 30-day supply of their child’s attention deficit hyperactivity disorder (ADHD) medication or receive a 90-day supply via mail order for $45. These lower costs can lead to considerable savings on an annual basis, especially for an individual who takes multiple medications.

When your access to a local pharmacy is limited by distance or social barriers, the best option is to go to mail order. And when mail order is inconsistent or not delivering at all, the risks are high for families in these communities. Many cannot trek across town to find emergency supplies of medication because doing so may put them in jeopardy of missing work or may simply cost too much. And where insurance is involved, often refills are denied when a prescription has already been filled by a mail-order pharmacy, even if it has not arrived to the intended user. In these cases, families must pay for the prescription out-of-pocket or go without.

Are we willing to allow USPS to fail and make parents choose whether to pay for their medication or put food on the table for their children?

INDIVIDUALS WITH CHRONIC CONDITIONS

According to the Centers for Disease Control (CDC), the great majority of adults who have one of five common chronic conditions—diabetes, heart disease, hypertension, arthritis, and cancer—use prescription drugs. For example, 89 percent of people with arthritis and 98 percent of people with diabetes use prescription drugs. People with these conditions fill many prescriptions annually; adults with diabetes fill about 4 times as many prescriptions as the general population.

Now let’s put this in terms of the proportion of the American public impacted. According to a recent RAND study, 60 percent of adults now live with at least one chronic condition and 42 percent have more than one. That is 151 million adults living in the US with at least one chronic condition. And the percentage of older adults (50+) with chronic conditions is significantly higher—80 percent.

Studies have shown that adherence to prescribed medications is associated with improved health outcomes, fewer hospitalizations, and reduced mortality. Conversely, non-adherence puts patients with chronic disease at serious risk with higher rates of hospital admissions and increased morbidity and mortality, not to mention increased health care costs. According to the CDC, direct health care costs associated with non-adherence have grown to approximately $100-$300 billion of U.S. health care dollars spent annually.

Improving medication adherence is a public health priority and can reduce the economic and health burdens of many diseases and chronic conditions. A growing body of research suggests that mail-order pharmacy use is associated with better medication adherence in diabetes and across a wide range of chronic conditions. Mail-order pharmacy use is also linked to better health care outcomes and decreased health care utilization and costs. However, when mail order is not reliable, a missed dose can lead to hospitalization. With their greater susceptibility to COVID-19, this is no time for chronically ill patients to be in a hospital.

Are we willing to let USPS fail and reduce access to medications that are necessary to preventing hospitalizations for adults and elderly Americans with chronic conditions?

A failure of the postal service will have significant impacts on the health and wellbeing of millions of Americans and the unnecessary costs to the healthcare system and, therefore, all Americans has the potential to be in the billions. This isn’t a time for political power plays. The USPS is an integral part of the U.S. healthcare system and it must have the support needed to run efficiently and effectively.