Guidelines for Collaboration Among Physicians, Pharmacists, and Managed Care Organizations to Improve Asthma Outcomes

New ideas, new tools, and new collaborations among managed care, physicians, and pharmacy to optimize value in asthma management.
Published Online: February 19, 2014
Gary C. Steven, MD, PhD; Don A. Bukstein, MD; and Allan Luskin, MD

Optimum asthma control in the future will rely on managed care organization pharmacy benefit managers working with primary care physicians using new technology to strengthen patient/physician/pharmacist relationships, maximize the group practice model, and improve asthma diagnosis, treatment, and monitoring in accordance with current National Asthma Education and Prevention Program (NAEPP) guidelines.1

Gary C. Steven, MD, PhD

President Allergy, Asthma & Sinus Center

Milwaukee, WI

Don A. Bukstein, MD

Clinical Professor, Family Practice

University of Wisconsin

Madison, WI Allergist

Allergy, Asthma & Sinus Center

Milwaukee, WI

Allan Luskin, MD

Clinical Associate Professor

Internal Medicine

University of Wisconsin

Madison, WI


Center for Respiratory Health

Dean Medical Center

Sun Prairie, WI

This activity is supported by an educational grant from Boehringer Ingelheim Pharmaceuticals, Inc.

Release date: February 18, 2014

Expiration date: February 18, 2016

Estimated time to complete activity: 1.0 hour

Intended Audience

The intended audience for this activity consists of medical directors, pharmacy directors, pharmacy benefit managers, and other managed care professionals who are involved with the treatment of patients with asthma.

Educational Objectives

After completing this article, participants should be able to:

• Discuss the current management of asthma, including guideline recommendations and emerging treatments

• Explore current asthma control rates and the importance of monitoring asthma severity and control

• Examine managed care implications of asthma treatment, including medical costs and resource utilization

• Identify disease management opportunities to improve the clinical and economic outcomes of asthma

• Describe how medicine and pharmacy can collaborate to improve healthcare delivery and asthma treatment

Type of Activity: Knowledge

Fee: There is no fee for this activity.

How to Obtain Credit

To receive credit, all participants must read the CE lesson in its entirety and complete the posttest and evaluation form online. Each participant achieving a passing grade of 70% or better will receive a statement of credit giving the number of CE credits earned. If you do not achieve a score of 70% or better on the online posttest, you will have the opportunity to take the posttest one more time at no cost.

Please visit, where you will be provided with a link to the online lesson, posttest, and evaluation form. You will have the opportunity to print the posttest questions and evaluation and manually complete them ahead of time and then submit answers online at your convenience.

Please retain a copy of the certificate for your records. For questions, please e-mail

Pharmacy Times Office of Continuing Professional Education is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education. This activity is approved for 1.0 contact hour (0.10 CEU) under the ACPE universal activity number 0290-0000-14-009-H01-P. The activity is available for CE credit through February 18, 2016.

Gary C. Steven, MD, PhD, has no relevant financial relationships with commercial interests to disclose related to this activity.

Don A. Bukstein, MD, received honoraria/lecture fees from AstraZeneca, Genentech Inc, Merck, Novartis, and Teva Pharmaceuticals.

Allan Luskin, MD, received honoraria/lecture fees from Genentech and Merck. He also acts as a consultant and board member for Genentech and Mylan.

American Journal of Pharmacy Benefits

Planning staff – Jeff D. Prescott, PharmD, RPh, and Ida Delmendo, have no relevant financial relationships with commercial interests to disclose related to this activity.

Pharmacy Times Office of Continuing Professional Education

Planning staff – Dave Heckard, Maryjo Dixon, RPh, Steve Lin, PharmD, RPh, and Donna Fausak, have no relevant financial relationships with commercial interests to disclose related to this activity.

The overall prevalence of asthma in adults and children in the United States has increased from 20.3 million people in 2001 to 25.7 million in 2010.2 Asthma prevalence increased among all subgroups, with significant increases occurring among black and Hispanic populations from 2001 to 2010 (from 3.2% to 11.9% and 3.2% to 7.2%, respectively).2 Underserved populations also had a significant increase in the prevalence of asthma at a rate of 11.2% among persons with family income below 100% of the federal poverty level.2

One recent study found that an estimated 5% to 10% of Americans with asthma experience severe disease, half of whom have severe disease that remains uncontrolled.3 Much of the incurred costs of asthma care in the United States are derived from patients with severe and uncontrolled disease (these patients are characterized by frequent exacerbations, emergency department [ED] and hospital visits, and reliance on multiple medications). Patients with severe uncontrolled asthma represent 2.5% to 5% of all patients with asthma, yet patients with severe uncontrolled asthma account for $21 billion, or 37.5%, of the $56 billion of total asthma-related direct costs.3

Retrospective claims research indicates that approximately half of asthma-related direct costs are incurred by patients with severe asthma. The estimated annual per patient direct costs of severe, uncontrolled asthma are $16,154 to $32,308.3

Three common obstacles to optimal control of asthma in relationship to pharmacy benefit managers (PBMs) and the point of access to medications are:

• Failure to use evidence-based guidelines to direct therapy

• Inadequate use of controller therapy due to cost, low health literacy, and lack of an understandable asthma action plan

• Lack of understanding of the seriousness and level of control of the disease

We present case studies of these obstacles and discuss how cooperative implementation of the National Ashtma Education and Prevention Program (NAEPP) 2007 guidelines and practical solutions to the obstacles described above will help patients achieve better control.1 We describe ways to identify and overcome these barriers to good asthma care, use patient examples to demonstrate cooperative efforts that optimize asthma management in a managed care setting, and explain the need to expand these efforts.

Programs that cooperatively incentivize physicians, patients, pharmacists, and managed care organizations (MCOs) will achieve the level of care that is needed to improve the quality of care and decrease the cost of management in difficult-to-control asthma. These programs should be based on the NAEPP 2007 Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (EPR-3),1 address health literacy related to asthma management,4 focus on patient adherence to medication regimens,5 and establish an asthma report card for the patient and physician that includes a measurement of the patient’s asthma impairment and risk domains.6 Furthermore, prescription data can be used by the community pharmacist to promote appropriate prescribing, facilitate adherence, and perhaps uncover undiagnosed asthma. Improved communication among patients, providers, PBMs, and community pharmacists will drive better asthma outcomes and reduce direct and indirect healthcare costs.7 Advances in our understanding of difficult-to-control asthma phenotypes8,9 and their pathophysiology have fueled the development of therapies that control asthma symptoms and prevent exacerbations. The prevalence and economic burden of asthma continue to rise, whichunderscores the need to fully utilize available tools in innovative ways to maximize the control of this difficult, yet utterly manageable, disease state.

Overcoming Obstacles to Asthma Management

Obstacle #1: Lack of identification of the seriousness and level of asthma control.

Case Study:

JA I recently went to the pediatrics clinic to evaluate JA, a young woman aged 17 years. She was 13 weeks pregnant and a high-risk asthmatic with previous ED visits and hospitalizations. Her asthma had been well controlled throughout the previous year when she received care at the University of Wisconsin, across from my medical center. She had been under the care of an outstanding university physician, and he and she were working well together. She had been virtually asymptomatic; yet here she was 2 breaths away from an ED visit. She was refusing corticosteroids because of a conversation with her community pharmacist about the dangers of corticosteroid medication and their effects on the fetus.

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