These services are frequently hosted on digital platforms which can be inaccessible to disabled people, the consequences of which can be life-altering.

Blind people, for example, have reported being unable to book vaccinations during the pandemic due to websites that block screen readers. Wheelchair users report having to give their secure card details to strangers when they cannot reach a payment kiosk.

Disabled voters may face challenges accessing online voter registration systems or digital voting platforms that are not designed with accessibility in mind, effectively excluding them from participating in democratic processes.

The new book Digital Accessibility Ethics: Disability Inclusion in all Things Tech, with contributions from a global coalition of experts and advocates, calls for urgent action.

“Digital accessibility is not a luxury, it’s a civil and human right,” the editors Lainey Feingold, Reginé Gilbert and Chancey Fleet argue. “Without it, disabled people are excluded from participating in society, and the digital world cannot be ethical.”

Inequity in the digital age

The team of 39 expert authors demonstrate how the digital accessibility gap, a component of the digital divide, harms disabled people, who make up over 1 billion of the global population according to the World Health Organisation.

The experts argue that inaccessibility is pervasive and a daily challenge. As more services move online and technology continues to advance, without digital accessibility the digital divide will continue to widen.

“Increasingly, everything is digital,” the editors explain. “Our devices help us find our next job, our next love, our community gathering places. Learning and teaching happen online – in and out of the classroom, the workplace, the library. We depend on computers for work, entertainment, shopping, civic participation, and connection. Digital tools allow us to withdraw our own money, listen to music, play games, follow our favourite teams, and participate in local government.

“Legal problems are increasingly handled online. Daily, we look to our phones to find our way. In an emergency, the digital devices in our pockets offer critical safety information and unite us with loved ones.

“None of this is possible for people with disabilities when digital tools and content are not accessible.”

Inaccessibility has economic and social consequences for disabled people, who are more likely to live in poverty, face higher unemployment rates and lack access to critical services due to systemic barriers. Employers also miss out on the skills and creativity of a large section of society when disabled people are blocked from leadership potential by inaccessible workplace tools.

Systemic exclusion

One example where the stakes could not be higher is in emergencies and crises. According to the United Nations, only 20% of disabled individuals can evacuate without support, but less than 40% of emergency plans mention disability at all.

“These statistics are not coincidences,” explains Erin E. Brown, a Bahamian Disability Inclusion Consultant. “They are symptoms of structural ableism, where emergency preparedness frameworks fail to incorporate basic accessibility, digital or otherwise. And in a world increasingly reliant on technology to issue warnings, give directions, and provide services, the absence of digital accessibility is more than a design flaw. It’s an ethical breach.”

Emergency alerts and news updates often fail to include captions, sign language interpretation or screen-reader-friendly formats, leaving deaf, blind and neurodivergent individuals without critical emergency information.

A roadmap for change

The authors introduce a Digital Accessibility Ethics Framework, a tool designed to guide governments, corporations and people in creating inclusive digital environments.

The authors call for immediate action in several key areas, including introducing the Ethics Framework into organisational decision-making before exclusion happens, calling for more government accountability and enforcing compliance with the growing number of digital accessibility legal requirements across the globe.

The authors also suggest organisations should focus on creating digital tools and content that disabled people can use just as easily and independently as everyone else. This means adopting policies to ensure all technologies, whether purchased, licensed, or free, provide equal access to everyone.

They also suggest organisations should provide accurate and current accessibility information about their products and services, including a clear roadmap for addressing accessibility gaps. A robust feedback loop should be established to capture, remediate, and report on issues identified by disabled individuals, ensuring their voices are heard and acted upon, they advise.

“While technology and law are rapidly changing, one thing remains constant: the continued growth of the digital world. In the coming years, more decisions will be made about digital tools and content that impact ever-increasing aspects of our lives. Digital accessibility ethics must be part of that decision‑making,” the editors conclude.

DOI: 10.1201/9781003616702 

Study Approach: Researchers conducted a retrospective, mixed-methods study one year after deploying five primary care pharmacy technicians across 11 clinics in a large urban safety-net network. They analyzed electronic health records (EHR) from June 2023 to May 2024 to track the number and type of medication tasks the technicians handled. Clinic staff were surveyed. The survey included a 0 to 10 “pain point” rating of medication access work before and after technician deployment; estimated hours saved per month; perceived impact on work experience, quality of care and patient access, and open-ended responses.

Main Results:

• In 12 months, five pharmacy technicians handled 43,782 medication items (65% refills, 18% medication problems, 17% prior authorizations).
• Average ratings of “medication access work as a pain point” (0 to 10 scale) decreased from 8.3 before to 3.6 after pharmacy technician deployment.
• Themes from open-ended questions described pharmacy technicians dealing with prior authorizations, communicating with pharmacies, timely medication access for patients, expertise of pharmacy technicians, and reduced task burden/ greater efficiency.

Why It Matters: The findings from this study suggest pharmacy technicians can be an asset for team- based primary care, bringing expertise in efficiently managing medication access processes that benefits clinician and nurse work experience and patient access to medications.

Permanent link: Impact of Pharmacy Technicians on Clinician and Nurse Work Experience in Primary Care I

Anusha McNamara, Pharm D, et al

San Francisco Department of Public Health, San Francisco, California

The study, published Dec. 3 in the journal Health Affairs, analyzes local and market characteristics of pharmacy closures between 2010 and 2021. With thousands of more pharmacy closures expected in the coming years, researchers said their findings offer a roadmap for identifying which communities are most at risk of losing drugstores and for crafting policies that may help them survive.

“At the same time many states are making efforts to expand the scope of pharmacy services beyond dispensing drugs to include the provision of preventive and emergency care, we found that there are—for the first time for at least a decade—fewer pharmacies available to provide them,” said senior author Dima Mazen Qato, a senior scholar at the USC Schaeffer Center for Health Policy & Economics and the Hygeia Centennial Chair and associate professor at the USC Mann School of Pharmacy and Pharmaceutical Sciences.

Accelerating closures have led to net loss in pharmacies for the first time since at least 2010

For most of the 2010s, pharmacy openings in the U.S. outpaced closures. And in previous work, the researchers found that pharmacies closed at a much slower rate during the first half of the decade, with 1 in 8 drugstores shuttered between 2009 and 2015.

Their new study finds an unprecedented decline in the number of pharmacies began in 2018, primarily driven by closures of chain pharmacies during an active period for industry consolidation. This included the merging of large pharmacy chains with dominant pharmacy benefit managers (PBMs), which negotiate prescription drug benefits and steer patients to preferred pharmacies.

Researchers identified pharmacies using a registry maintained by a national nonprofit and linked the data to county- and neighborhood-level data from the U.S. Census Bureau and the National Center for Health Statistics. Among their findings:

• Between 2018 and 2021, the number of pharmacies declined in 41 states. During the entire study period (2010-2021), nearly one-third of counties experienced a net decline in pharmacies, affecting 91.6 million people.
• In seven states, more than half of counties experienced a net decline in pharmacies: Illinois, Maine, Mississippi, New York, Pennsylvania, Rhode Island and Vermont.
• At the community level, pharmacy closure rates were higher in predominately Black and Latino neighborhoods—37.5% and 35.6%, respectively—than predominately white ones (27.7%).

The last finding is partly explained by the struggles of independent pharmacies, which were more than twice as likely to close as chain stores. They were also much more likely to be in Black, Latino and low-income neighborhoods, as well as those with disproportionate rates of people with Medicare or Medicaid coverage.

“Our findings suggest that closures may widen health disparities in access to prescription and other essential pharmacy services, such as vaccinations and pharmacist-prescribed regimens, including contraceptives, medications for HIV prevention, and treatments for opioid use disorder,” said first author Jenny Guadamuz, an Assistant Professor at the UC Berkeley School of Public Health and the Health Equity Program Director for the UC-Berkeley Center for Health Management & Policy Research.

“Without safeguarding pharmacies in marginalized neighborhoods, expanding health care services at pharmacies may enhance convenience for more affluent populations while failing to address the health needs of communities disproportionately affected by pharmacy closures, particularly Black and Brown populations in low-income urban areas,” added Guadamuz.

Preventing Future Closures

“As highlighted in a recent FTC report, a key factor contributing to the higher risk of closure for independent pharmacies may be their frequent exclusion from preferred pharmacy networks,” said Guadamuz. PBMs use preferred pharmacy networks to encourage patients to visit certain locations by offering lower cost-sharing or out-of-pocket costs. The recent mergers of large pharmacy chains and PBMs also likely contributed to low reimbursements from PBMs at these combined companies to independent pharmacies and rival chain pharmacies, the researchers added.

The researchers said federal and state policymakers should consider policies that would increase participation of independent pharmacies in preferred networks. This could include mandating Medicare and Medicaid plans to give preferred status to pharmacies at heightened risk of closure or those serving “pharmacy deserts” with reduced access to pharmacy services.

In the commercial market, federal and state regulators should also consider requiring that PBMs’ preferred networks do not disproportionately favor pharmacy chains, including those part of the same company, the researchers said.

“Federal, state and local policies and programs should consider targeted strategies, including increases in Medicare Part D and Medicaid pharmacy reimbursement rates, to protect critical access pharmacies most at-risk for closure, particularly those serving neighborhoods that are or are at risk of becoming pharmacy deserts,” Qato said.

“As pharmacies close, more and more Americans are left without easy access to medications, with disproportionate consequences on certain communities. We found that patients in counties with higher social vulnerabilities and fewer primary care providers were up to 40% more likely to reside in a region with a pharmacy desert,” said Timothy Pawlik, MD, senior author of the study and holder of the Urban Meyer III and Shelley Meyer Chair for Cancer Research at the OSUCCC – James. Pawlik also serves as surgeon-in-chief at The Ohio State University Wexner Medical Center and as chair of the Department of Surgery in the Ohio State College of Medicine.

The U.S. Centers for Disease Control (CDC) defines social vulnerability as “potential negative effects on communities caused by external stresses on human health.”

“These findings highlight how disparities compound the lack of access to basic health care and how it can lead to many people not taking their prescribed medications and having worse health outcomes, especially for chronic conditions like diabetes and hypertension,” Pawlik added.

Study results were published today in JAMA Network Open.

Methods and Results
Researchers reviewed data on communities located less than 10 miles from the nearest retail pharmacy from the publicly available TelePharm Map. Counties were noted as having a high pharmacy desert density if the number of pharmacy deserts per 1,000 residents was in the 75th percentile. Social vulnerability index (SVI) and healthcare provider data were obtained from the CDC’s Agency for Toxic Substances and Disease Registry and the Area Health Resource File databases, respectively. The researchers used statistical methods to analyze the relationships between these factors.

The study found almost 46% of the 3,143 counties had at least one pharmacy desert. Counties with a high density of pharmacy deserts had higher social vulnerability and fewer primary care providers. People in these high-density pharmacy desert areas were more likely to face difficulties accessing medications and healthcare services.

Collaborators in this study include Giovanni Catalano, MD, Muhammad Muntazir Mehdi Khan, MBBS, and Odysseas P. Chatzipanagiotou, MD.

They found that 1 in 8 caregivers had difficulty accessing mental health services for their children between 2016 and 2019. But those who lived in states with the most comprehensive mental and behavioral health coverage laws were about 20% less likely to report trouble accessing care than those who lived in states with the least comprehensive laws.

Caregivers of Black and Asian children were more likely to report poor access to mental and behavioral health care, as were caregivers of children who experienced more adverse childhood events (ACEs).

“Unfortunately, in my own practice, I regularly see children who are unable to access needed mental health care, and their symptoms continue to worsen until they reach a crisis point,” said first author Ashley Foster, MD, a pediatric emergency care physician at UCSF Benioff Children’s Hospital San Francisco. “That inspired me to study whether more comprehensive laws about mental health insurance coverage can influence whether kids can get the care they need, and that is exactly what we found.”

The study appears Aug. 12 in JAMA Network Open.

While legislation appears to influence access, it also matters how well states enforce their laws.

“Even when families have insurance, mental and behavioral health providers may refuse to accept certain insurance types – or insurance altogether,” Foster said. “For those who do access care, there may be high co-pays or deductibles, which can affect perceptions of access.”

To counter this, the authors wrote, states should invest in community-based mental health services, develop a workforce that better reflects the state’s cultural diversity and support reimbursement for tele-mental health care. States also should define the disorders that must be covered by insurance, such as autism and attention-deficit hyperactivity disorder.

Authors: Additional co-authors include Jennifer A. Hoffmann, MD, MS, of Ann & Robert H. Lurie Children’s Hospital of Chicago; Megan Douglas, JD, of Morehouse School of Medicine; Michael C. Monuteaux, ScD, Kathrine E. Douglas, MD, and Joel D. Hudgins, MD, MPH, of Boston Children’s Hospital; Teal W. Benevides, PhD, MS, OTR/L, of Augusta University; and Amanda M. Stewart, MD, MPH, of Children’s National Hospital.

Funding: None.
Disclosures: None.

Being able to get an appointment at GP surgeries and to see the same doctor improves patient health, is a more cost-effective use of healthcare resources, and is popular.

A new study, led by the University of Leicester, analysed data across 6,010 English practices between 2018 and 2022, using continuity data from the General Practice Patient Survey which showed that fewer patients both had and were able to see a preferred doctor in their practices.

The national average dropped from 29.3 per cent to 19 per cent of patients in just four years, with the decline steepening following the COVID-19 lockdown. Although the decline occurred across all types of practices, differences between practices widened over this period.

The study examined a range of factors related to both patients and their practices in order to determine whether any were linked to the rate at which continuity was declining. These included the percentage of patients with White ethnicity, the numbers of GPs and nurses per 10,000 patients, and the percentage of patients reporting being able to get a same day appointment, as well as the practice’s deprivation score and region in England.

Dr Steven Levene from the Department of Population Health Sciences at the University, who led the study, said: “Our study showed slower declines in continuity in practices with more doctors and with higher percentages of patients seen on the same day as booking. However, continuity declined more quickly in practices where continuity had previously been better, where there were higher percentages of patients of White ethnicity, or practices located in many areas outside of London.”

The rate of declining continuity was not associated with deprivation, whether the practice was urban or rural, practice size, nurse numbers, NHS contract type or NHS practice funding.

The study has now been published in the journal Annals of Family Medicine.

Dr Levene said: “Patients who can regularly see the same doctor usually have increased satisfaction with their care, while avoiding having to repeat their medical history leads to a more efficient use of time and resources.

“The surge in demand following lockdown and the backlog of work have resulted in higher workloads in already overstretched practices: not only are patients finding it harder to get an appointment, but this is less likely to be with their regular practitioner. Not surprisingly, public satisfaction with the NHS is at a record low and improving access to a GP appointment is the top reported priority for patients (British Social Attitudes survey).

“The number of qualified GPs has remained relatively static whilst the population continues to grow. Despite more GPs being trained, a recent poll of GPs revealed many are struggling to find an NHS GP post; yet an established NHS scheme to support practices financially to expand their workforce excludes doctors.

“The disappearance of continuity of care should not be inevitable. By prompt effective nationwide action to help practices provide enough appointments and prioritise continuity more within appointment systems, and to remedy shortages of GPs in many practices, the NHS might be able to halt and then reverse this worrying trend. Continuity of care matters – to patients, to the better delivery of healthcare, and to the health of the country.”

Nearly identical percentages believe mental health is handled either “much” (38%) or “somewhat” worse (37%) than physical health ailments, while 15% say they are dealt with “about the same.” Just 5% think mental health is treated “somewhat” (4%) or “much” better (1%). This negative assessment of mental healthcare comes as 4 in 5 Americans perceive an increase in conditions such as depression or anxiety over the past five years, including 42% who think they have increased a lot.

These latest findings may explain why 57% of Americans give poor to failing grades to the nation’s healthcare system for its handling of mental health conditions — 32% give it a “D” and 25% give it an “F.” Only 1% awarded the top grade of “A”, with 8% giving it a “B” and 27% a “C.”

“Many Americans struggle with mental and behavioral health conditions that often go unaddressed in the context of treating and managing other medical conditions,” said Timothy Lash, President, West Health, a nonprofit focused on aging and healthcare in America. “Health systems, providers, caregivers and patients themselves need to pay just as much attention to mental health as they grow older as they do their physical health. The two are inextricably linked and critical to overall health, aging successfully and quality of life.”

According to the CDC, depression is more common in people who have other illnesses. About 80% of older adults have at least one chronic health condition, and 50% have two or more. Notably, the West Health-Gallup survey finds a higher percentage of older adults than the general population (82% vs. 75%) feel mental health issues are not treated as they should. This is a particularly important finding in that come 2030, people 65 and older will outnumber children for the first time in the U.S. and increase the demand for mental health services.

The survey finds 51% of Americans say they have experienced depression, anxiety or some other mental or emotional condition in the past 12 months. This group includes 22% who say their condition was so significant that it disrupted their normal activities, such as going to work or taking care of their household.

Over half of Americans see psychological counseling (53%) as an effective treatment and 35% say the same of prescription medication. But two potential barriers including lack of affordability (52%) and difficulty in accessing a provider (42%) may be preventing people from seeking care. Other barriers or reasons include a belief that the individual can deal with their condition on their own (28%), shame or embarrassment (27%) or not thinking treatment would help (24%).

Seven in 10 Americans report societal stigma around mental illness, which also played a role in keeping people from getting professional help. The belief is strongest among those who say they have dealt with a mental health condition in the past year (74%) and older adults (75%).

“Effectively meeting the behavioral health needs of Americans and their families throughout the different stages of life requires providers, caregivers, policymakers, payers and patients themselves work together to reduce barriers to care,” said Lash. “There are still sizable numbers of people not getting the treatment they need – a situation that may only worsen as the population ages. Effective approaches, including integrated and person-centered models of behavioral health that deliver services through clinics or community-based organizations, should be more fully leveraged to ensure people are able to get the care they need when and where they need it.”

Since 2008, the Mental Health Parity and Addiction Equity Act (MHPAEA) called for health plans to cover mental health benefits to the same level they cover general healthcare. But according to the White House, “too many Americans still struggle to find and afford the care they need.” In 2020, the government reported less than half of those with a mental illness received care for it.

Last year, the Biden administration highlighted mental health as a priority with a “comprehensive national strategy to transform how mental health is understood, accessed, treated, and integrated in and out of health care settings,” which includes expanding access to mental health services from Medicare.

Methodology
Results for this Gallup poll are based on self-administered web surveys conducted Feb. 2-14, 2024 with a random sample of 2,266 adults, aged 18 and older, and are members of the Gallup Panel. Gallup uses probability-based, random sampling methods to recruit its Panel members. For results based on the sample of U.S. adults, the margin of sampling error is ±3 percentage points at the 95% confidence level.

About Gallup
Gallup delivers analytics and advice to help leaders and organizations solve their most pressing problems. Combining more than 80 years of experience with its global reach, Gallup knows more about the attitudes and behaviors of employees, customers, students and citizens than any other organization in the world.

About West Health
Solely funded by philanthropists Gary and Mary West, West Health is a family of nonprofit and nonpartisan organizations that include the Gary and Mary West Foundation and West Health Institute in San Diego, and the West Health Policy Center in Washington, D.C. West Health is dedicated to lowering healthcare costs to enable seniors to successfully age in place with access to high-quality, affordable health and support services that preserve and protect their dignity, quality of life and independence. Learn more at westhealth.org and follow @westhealth.

IMAGE: OVER HALF OF AMERICANS SEE PSYCHOLOGICAL COUNSELING (53%) AS AN EFFECTIVE TREATMENT AND 35% SAY THE SAME OF PRESCRIPTION MEDICATION. BUT TWO POTENTIAL BARRIERS INCLUDING LACK OF AFFORDABILITY (52%) AND DIFFICULTY IN ACCESSING A PROVIDER (42%) MAY BE PREVENTING PEOPLE FROM SEEKING CARE. OTHER BARRIERS OR REASONS INCLUDE A BELIEF THAT THE INDIVIDUAL CAN DEAL WITH THEIR CONDITION ON THEIR OWN (28%), SHAME OR EMBARRASSMENT (27%) OR NOT THINKING TREATMENT WOULD HELP (24%). view more CREDIT: WEST HEALTH-GALLUP

It is well known in Canada that there is a crisis in primary care, with about 17% of people reporting that they were without a regular primary care clinician before the COVID-19 pandemic. The pandemic made the situation worse, with some family physicians retiring early, a situation common in other countries also.

The authors looked at 9 countries where more than 95% of people have a family doctor, primary care clinician or place of care, including France, Germany, New Zealand, United Kingdom, Denmark, Netherlands, Finland, Italy and Norway, and consider lessons for Canada.

Canada’s health spending was in the middle of the pack, although the percentage of health spending that was public was the lowest at 70%, a figure unchanged since the 1990s. Canada had similar numbers of family physicians per capita but the lowest number of total physicians per capita and spent less of the total health budget on primary care.

“Other countries have designed their system so that everyone has access to primary care. We need to do the same,” says Dr. Tara Kiran, a family physician at St. Michael’s Hospital, Unity Health Toronto and the Fidani Chair of Improvement and Innovation at the University of Toronto. “At the core, we need to guarantee access to primary care and increase how much we spend on it.”

Historical factors, such as physicians negotiating to remain autonomous at introduction of Medicare, have also affected Canada’s health system.

Key lessons for Canada:

• Accountability — In countries with high rates of primary care attachment, family doctors have stronger contractual agreements and accountability to government, insurers or both, whereas in Canada, they are private contractors with little system accountability. These countries also have more family doctors, or general practitioners, working in office-based, generalist practices compared with Canada, where many family doctors work in other parts of the system (e.g., providing emergency or hospital care) or in focused practice (e.g., sports medicine).
• Funding — A higher proportion of the total health budget should be spent on primary care. Medicare coverage in Canada could be extended to prescription medications, dental care and expanded mental health care to reduce the burden on physicians to provide care in these areas. Canada also needs more physicians per capita.
• System organization — Canada should move to a model where residents are guaranteed access to a primary care practice near their home and ensure that these practices are funded appropriately.
• Information systems — Practice efficiency can be improved and patient communications can be streamlined with online booking, secure messaging and a single patient health record accessible across Canada by patients and clinicians.
• Practice organization and physician payment — Governments and medical associations should shift primary care physicians to capitation or salary payments and away from fee for service, which is how most family physicians currently are paid in Canada. More organized after-hours care, fewer walk-in clinics and expanded roles for other health professionals can enable our primary care resources to be used more efficiently.

“These international examples can inform bold policy reform in Canada to advance a vision of primary care for all,” the authors conclude.