Attacking Asthma’s Costs

By Pamela Babcock Jun 1, 2007
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HR Magazine, June 2007 By upgrading the asthma care provisions in their health plans, employers could avoid high costs later for treatment and lost productivity.

Kirk Sullivan wasn’t in it for the free air cleaner. But it turned out to be a welcome health benefit for the longtime asthma and allergy sufferer—and it’s just one facet of his employer’s effort to contain the costs of asthma.

After Sullivan took a job in the Santa Fe Springs, Calif., office of IQAir, a Swiss-based producer of medical filtration systems, he learned it was company policy to give employees with asthma or allergies a free $795 room air cleaner to use at home. And because Sullivan’s asthma is so severe, his employer is giving him a free whole-house system that usually costs up to $7,500 installed.

The air cleaner is part of the asthma-management program that Sullivan’s employer offers employees who have the potentially life-threatening condition. The program reflects the widening belief that employers can restrain their health costs over the long term by dealing with employees’ serious health issues at early stages rather than only when conditions turn more serious—and more expensive.

Sullivan, public relations director for IQAir North America, says the major benefit of his current employer’s approach is that now he can see a number of specialists and aggressively address his asthma with the support of his health plan. “Good or enhanced coverage is a real key to improving asthma treatment,” he says. “I never would have pursued treatment this effectively without my medical coverage.”

Sullivan’s plan allows him to see a specialist regularly for a $20 co-payment, to try different treatment protocols and to get the brand-name drugs that have worked best for him with a low co-payment. It’s vastly better, he says, than the treatment he received “periodically, and poorly, for many years,” during which he contracted pneumonia three times.

Part of the Program

The proactive health-management approach that Sullivan’s employer sponsors for its employees with asthma is similar to programs offered by some other employers for a variety of serious and chronic conditions. Programs range from piecemeal health-risk screenings to employee outreach and comprehensive health-management initiatives, and asthma is among the conditions getting substantial attention.

The 2006 Mercer Health & Benefits National Survey of Employer-Sponsored Health Plans found that 50 percent of large employers (more than 500 employees) offer disease-management programs for asthma and allergies, while 65 percent of jumbo employers (more than 20,000 employees) offer such programs.

In the survey, asthma ranked third in prevalence, behind diabetes and heart disease, among illnesses addressed in disease-management programs; it was followed by cancer and depression.

While asthma gets disease-management attention and generally receives basic coverage in health plans, it should be more visible and get upgraded coverage, some asthma organizations contend, so that its treatment can be more effective and ultimately less costly.

The American College of Allergy, Asthma and Immunology (ACAAI), based in Arlington Heights, Ill., maintains that when employers offer asthma and allergy coverage that the group would deem inadequate, they unwittingly discourage employees and dependents from seeking necessary treatment, which can result in higher costs when conditions are treated at acute stages.

Consider, for example, sinusitis—inflamation of the nasal sinuses. Dr. Stanley Fineman, ACAAI treasurer and a physician with the Atlanta Allergy & Asthma Clinic in Marietta, Ga., says untreated or inadequately treated chronic sinusitis can lead to recurrent respiratory infections in people regardless of age, and to recurrent ear infections in children. When children are sick, of course, working parents may have to stay home to care for them.

“People with asthma and allergies really have a reduction in their quality of life, so they’re not functioning to their full capacity when they’re having symptoms,” Fineman says. “The patient might go to work and tough it out when they shouldn’t be there,” he says, “or when they should be getting better treatment. And in that regard, it can definitely affect the employer in terms of the employee’s efficiency and productivity at work.”

A Bit Below the Radar

For many people, including some HR professionals who help shape and implement their employers’ health coverage plans, asthma is almost an invisible condition, says Mike Tringale, a spokesman for the Asthma and Allergy Foundation of America in Washington, D.C. Many asthma and allergy sufferers’ symptoms occur away from the job—outdoors and at certain times of the year, perhaps, or only at night.

“When it comes to asthma,” Tringale explains, “people still tend to be a little insecure about it as a disease you talk about. It’s still considered a weakness. In popular culture or movies, it’s the kid who is picked last in gym class, or the adult who isn’t physically fit.”

In fact, asthma and allergies affect more than 60 million Americans, including many in the workforce. The conditions and the medical problems they cause account for an estimated $18 billion in health care costs each year, according to the ACAAI.

Asthma alone affects about 20 million Americans, almost one-third of them under 18. The condition causes about 478,000 hospitalizations in the United States each year, the organization says, and leads to about 4,500 deaths.

Dr. Bradley E. Chipps, the lead physician at Capital Allergy & Respiratory Disease Center in Sacramento, Calif., says the shift to more-restrictive health maintenance organization (HMO) arrangements has had an effect on asthma and allergy management. He says HMOs that require a gatekeeper have left most plans with shortcomings in obtaining specialist referrals, diagnostic testing and access to the latest drugs.

Chipps says HR professionals must decide whether to make asthma and allergy coverage a priority, and that in turn may depend partly on their personal experience with those conditions. Although it’s more serious than “a runny nose and a little coughing,” he says, it takes a back seat in health plan designers’ views to “things like cancer, heart disease, obesity and diabetes. If they have no personal experience with [asthma], I can see how they might think that’s a pretty nice target when they’re trying to cut costs.”

Getting Down to Specifics

Two years ago, the ACAAI launched “Connections to Care,” a campaign aimed at helping purchasers and beneficiaries of group health plans make better-informed decisions when evaluating various health plans’ asthma provisions—access to specialists and particular drugs, for example. Chipps is co-chair of the ACAAI campaign. The effort focuses on employers and HR professionals who select, negotiate or purchase group health plans, and on employees who periodically choose among employer-sponsored health plans.

The ACAAI’s campaign includes a checklist of the minimum levels of asthma coverage it recommends that employer-sponsored plans offer, and it also addresses treatment for allergies. The checklist recommends that plans:

  • Allow patients to see a specialist for asthma, allergic rhinitis (hay fever), eczema and other skin allergies, as well as for food and drug allergies, insect stings and recurring infections caused by immune system deficiencies.

  • Provide the option of diagnosis and ongoing disease management by a specialist, and don’t limit the number or frequency of visits.

  • Reimburse for special diagnostic tests, such as antigen testing and “challenge” tests to determine the cause of allergies; pulmonary function tests to evaluate lungs in asthma patients; rhinoscopy to examine nasal passages; and nitric oxide monitoring to measure lung inflammation.

    Fineman says in his view the biggest roadblock is limiting the number of allergy tests a patient can receive, which is a problem in areas where a wide variety of pollens and other allergens can affect patients. “You really want to be able to point to the precise trigger,” he says. “When your hands are tied, that presents a problem.”

  • Provide affordable specialty treatments such as immunotherapy (allergy shots) and anti-IgE therapy, a relatively new treatment option that blocks the antibodies that cause allergic reactions.

  • Do not require excessive co-payments or other out-of-pocket costs for specialty diagnoses and treatments for allergies.

Many health plans, Tringale explains, require a “fail first” approach to allergy care that requires doctors to tell patients to try over-the-counter—and thus not reimbursable—medications before they can receive prescription drugs. “It’s a disturbing trend,” he says, “ because not only does it pass the cost on to the patient, but it also requires a second visit to the physician.”

Is It Worth It?

Employers looking for the return on investment in disease-management programs may see more measurable results—bigger dollar savings—from diabetes or heart disease programs than from efforts centering on asthma, says Bonnie Sechrist, a principal consultant with Mercer in Richmond, Va. The reason, essentially, is that other diseases have far greater costs to be addressed. For serious conditions other than asthma, she explains, “the treatment, diagnostic activities [and] follow-up care tend to be more utilization-intensive and for a longer period of time.” ›

An asthma attack, on the other hand, can mean an emergency room visit and some medications to relieve stress and the asthma symptoms, Sechrist says, “with a small percentage of individuals requiring admission for additional or prolonged treatment. Following the attack, the follow-up care is typically an office visit to the MD with little or no additional diagnostic testing or utilization of other health care resources.”

Best-practice disease-management programs for asthma, Sechrist says, should include health coaching or lifestyle management to help participants understand triggers in the home; efforts to encourage asthmatics to take necessary medications, either by reducing co-pays or providing asthma drugs for free; and education focused on how to recognize an impending asthma attack.

“It really gets to the heart of preventative care,” Tringale says. “There’s no cure for asthma or allergies, and we’re not on the cusp of any breakthrough for a cure. There’s no lack of effort, but until there’s a cure, there should be a lot of good preventative strategies and a lot of good treatment for those who are suffering.”

Pharmaceuticals in the Mix

A significant issue for asthma and allergy sufferers, as for people who have other chronic conditions, stems from limits in drug formularies. Some health plans will not reimburse the costs of newer drugs if comparable medications are available at lower prices. In effect, limits on coverage of particular drugs force patients who want those drugs to pay full price for them.

To eliminate financial disincentives that might prompt employees with certain chronic conditions to avoid particular drugs for managing their conditions, a number of companies have begun providing such drugs free or with reduced co-pays.

One such employer is Marriott International, based in Washington, D.C. In January 2005, Marriott eliminated co-pays for generic drugs and cut co-pays in half for brand-name drugs that are used in treating three specific conditions. “We wanted to increase compliance with drugs related to heart disease, asthma and diabetes,” says Jill A. Berger, vice president of health and welfare at Marriott. “This is so we can reduce complications—including emergency room and hospital admissions—related to these conditions and increase health and productivity.”

The University of Michigan and Harvard University are studying the effects of Marriott’s approach. Preliminary data show an increase in compliance, Berger says, and “the preliminary numbers look good.”

Asthma also is becoming a focus of the American Pharmacists Association Foundation. The organization, based in Washington, D.C., is expanding its employer-based offerings and hopes to offer an asthma program later this year, says William M. Ellis, executive director and CEO.

Under the foundation’s program for diabetes, employer groups have set up a voluntary health benefit for employees and their dependents. Using incentives such as waived co-pays, employers encourage people to manage their diabetes with the help of pharmacist coaches, physicians and community health resources. (See “Challenging Diabetes” in the June 2006 issue of HR Magazine.)

Long-Term Outlook

Whether the success of the ACAAI’s program to increase the attention paid to asthma and allergies will be measurable is uncertain. “It is difficult to quantify the impact of the campaign, but we do feel that we’ve been successful in helping to build awareness in each person who has been touched by it,” says Alan K. Leahigh, associate executive director for the group.

Sullivan of IQAir says he hopes to continue building education and consumer awareness about the problem of asthma and its effects. His employer is an educational partner with the American Lung Association. “I have the good fortune of being a person with asthma who gets to actively try to work to make the world a better place for other people with the condition,” he says. “It definitely makes the job motivation more personal.”

Pamela Babcock is a freelance writer in the New York City area.

Web Extras

Online sidebar:
Taking a Toll at Work

Article:
Connections to Allergy and Asthma Care 
(Public Communications Inc.)

Web sites:
Asthma and Allergy Foundation of America

American College of Allergy, Asthma and Immunology

SHRM article:
Challenging Diabetes 
(HR Magazine)

Report:
The Business Case for Asthma Management 
(National Business Group on Health)

SHRM toolkit:
Health Care

What Causes Asthma

Asthma is a lung disease in which the airways become blocked or narrowed, causing difficulty breathing, according to the Asthma and Allergy Foundation of America. Symptoms include coughing, wheezing, breathing problems and chest tightness. The skin, eyes and nose may become inflamed.

The chronic disease is commonly divided into two types: allergic (extrinsic) asthma and nonallergic (intrinsic) asthma.

Allergic asthma, the more common form, is triggered by an allergic reaction. It is brought on by inhaling allergens such as dust mites, pollen, mold, pet dander and other substances.

Nonallergic asthma is triggered by factors such as anxiety, stress, exercise, cold or dry air, hyperventilation, smoke, viruses, or other irritants.

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