The American Journal of Managed Care November 2014
Medical Cost Burdens Among Nonelderly Adults With Asthma
We used the 2003-2009 Medical Expenditure Panel Survey to evaluate average annual total and out-of-pocket expenditures by nonelderly adults with asthma.
We divided patients diagnosed with asthma into 4 groups, based on whether or not they had had an asthma attack in the previous year (a crude marker for disease severity) and whether or not they reported using treatment for their asthma.
For each group we calculated total and out-of-pocket average annual spending for hospital inpatient, hospital outpatient, emergency department, and physician office care, as well as for prescription drugs. These averages were adjusted to account for differences in respondents’ overall health (presence of other co-morbidities, self-reported health status, and self-reported activity limitations), sociodemographic characteristics (age, sex, race/ethnicity, income), and insurance status.
We found that among the 4 groups, those who were receiving treatment but continued to experience asthma attacks had the highest total and out-of-pocket expenditures in all categories, consistent with their likely higher illness severity. However, patients who reported receiving treatment and did not experience attacks also reported relatively high adjusted total and out-of-pocket expenditures—most notably $536 per year out of pocket for prescription medications and $231 per year out of pocket for physician office visits. After adjustment, about the same proportion of patients in these 2 groups (13.5% who did not get treated and had attacks, and 13.8% who did get treated and avoided attacks) reported high financial burden.
Patients may experience financial challenges to appropriate self-management of asthma, even when they are able to avoid exacerbations.
Am J Manag Care. 2014;20(11):925-932
People with asthma face substantial out-of-pocket costs—even when they take medi- cations to manage their illness. However, many choose to continue treatment despite these costs.
- People who use asthma medications are most likely to continue using medications, even if they experience high financial burden.
- Rather than giving up their medications, they may be cutting back in other areas.
- Administrators of programs to reduce the costs of asthma medications may underestimate the programs’ financial impact if they look only at ongoing medication use.
For some “silent” chronic conditions, such as hypertension and diabetes, patients may reduce or decline treatment to avoid high costs without experiencing adverse health effects for years, if ever. However, for chronic conditions such as persistent asthma, patients who forgo treatment are more likely to experience short-term consequences such as asthma attacks, and potentially high out-of-pocket costs associated with ED visits and hospital inpatient stays.
Asthma is a chronic disease that can be controlled with drugs—usually suppressive medications and rescue medications used to ease the symptoms of attacks once they begin; and with self-management techniques such as environmental modification and lifestyle changes aimed at blocking the inflammation that leaves patients vulnerable to asthma attacks. Asthma ranges considerably in severity: some patients may experience only rare, mild symptoms that are easily controlled with common medications, while others may experience frequent, severe, and even life-threatening attacks requiring emergency treatment or hospitalization for advanced interventions.
Thus, asthma patients’ cost burdens depend on both the costs they incur for proactive preventive care and self-treatment with rescue medications, and on the costs of addressing adverse health consequences and potential complications if they fail to manage their disease. Patients with severe asthma may believe that they have little choice but to incur the high cost of treatment, given their greater likelihood of experiencing asthma attacks (and the potentially high out-of-pocket costs of hospital inpatient and/or ED use) without such treatment; some will experience ED visits and hospitalizations even with appropriate management. Other patients, with less severe asthma, may gamble that the risk of exacerbations is lower than the costs of sup- pressive therapy and rescue medications.10 Of critical concern to both clinicians and policy makers is the extent to which high medical cost burdens affect patients’ decisions to continue or discontinue self-management.
This study uses the 2003-2009 Medical Expenditure Panel Survey–Household Component (MEPS HC) to examine healthcare spending and medical cost burdens for patients who reported that they had been diagnosed with asthma. The study is guided by 3 main research questions: 1) To what extent do people with asthma experience high medical cost burdens relative to the general US population? 2) How does the extent of medical cost burden vary depending on patients’ disease severity and on whether they are actively treating their asthma? 3) Do high medical cost burdens associated with the treatment of asthma lead some individuals to discontinue treatment?
We used data from the 2003-2009 MEPS. As described elsewhere,11 the survey is based on a large nationally representative sample of the civilian noninstitutionalized population, and is conducted annually by the federal Agency for Healthcare Research and Quality (2009 was the latest year for which data were publicly available at the time of this study). The survey collects detailed information on healthcare expenditures, use of services, insurance coverage, sources of payment, health status, medical conditions, and other sociodemographic details on individuals and their families. Sample sizes range between 33,000 to 37,000 for each year.
The sample for this survey includes persons aged 18 to 64 years who, in response to a survey question, reported that a physician or other health provider had told them that they had asthma, confirmed that they still had asthma at the time of an in-person interview,12 and completed a supplemental questionnaire related to their asthma care. Annual samples of nonelderly adults with asthma ranged from 1465 in 2003 to 1904 in 2009. To increase the statistical precision of estimates, samples from the 2003-2009 MEPS were pooled, yielding a total sample of 10,374 nonelderly adults with asthma. We excluded children because their healthcare utilization tends to differ substantially from that of adults. Persons 65 years and older were excluded because their higher levels of comorbidity would make it harder to see the effect of a single illness.
Expenditures for each medical visit or event for each sample respondent were collected during 3 rounds of survey interviews during the calendar year. Expenditures were reported separately for office-based medical provider visits; hospital inpatient, outpatient, and ED care; prescribed medicines; home healthcare; dental services; and vision aids. For each visit/event, total expenditures were reported (ie, from all payer sources), as were the amounts paid by third-party payers and out-of-pocket by the patient. To improve the quality and accuracy of expenditure reporting, the MEPS Medical Provider Component collects data from a sample of medical providers and pharmacies used by sample persons, which are used to either supplement or replace patient-reported data on expenditures.
Expenditures across all medical visits/events were aggregated and summarized at the person-level, and reported as averages. Average total expenditures and average out- of-pocket expenditures were reported separately. Spending by type of service was also reported, including hospital inpatient stays, hospital outpatient department visits, hospital ED visits, office-based medical provider visits, prescribed medicines, dental care, vision expenses, home health expenses, and other expenses (mostly relating to medical equipment purchases). Spending for hospital inpatient, outpatient, and ED visits includes both facility and physician charges. All expenditure data are inflated to reflect 2009 dollars, based on the Consumer Price Index.
High medical cost burdens are defined similarly to how they were defined in previous studies using the MEPS, as the ratio of total out-of-pocket spending on health services and health insurance premiums to total family income.13 For this measure, out-of-pocket spending is defined at the family level (ie, summed across all members in the family, typically defined as the nuclear family). Each individual is assigned the family-level burden measure. Individuals who live in families that spend more than 10% of family income on healthcare are defined as individuals with high financial burden.
Classifying Persons With Asthma
To examine differences in spending and medical cost burdens among persons with asthma, we classified the sample of persons with asthma into 4 categories based on 1) whether or not they were receiving treatment for asthma, and 2) whether or not they had an asthma attack in the past year (see Table 1 for details). Dividing respondents in this way allows for an approximation of disease severity, which is not otherwise addressed in the MEPS questionnaire. Respondents who reported experiencing asthma exacerbations despite using treatment would be expected to have more severe disease, and therefore higher expenditures, than would respondents who did not experience exacerbations. Those who did not report exacerbations despite not using therapy would presumably have the lowest severity of all.
For the first part of the analysis, we calculated total and out-of-pocket spending overall and for several sub-categories: spending on physician services, outpatient services, inpatient services, and prescription drugs. Because differences in spending and medical cost burdens among asthma patients may reflect other health and patient characteristics, estimates of spending and medical cost burdens are based on regression-adjusted means that control for differences in other factors that are known to affect healthcare utilization and costs, including the number of comorbidities, self-reported health status, and difficulties with activities of daily living, as well as age, race and ethnicity, education, income, insurance status, and smoking status. Adjusted means and percentages are computed using Ordinary Least Squares regression analyses, with each of the spending variables as depen- dent variables, and a 4-category asthma severity/treatment variable as the primary independent variable (see columns in Table 1 and Table 2 for specification of the 4 categories). Other independent “control” variables include those mentioned above, and are specified based on the categories shown in Table 1. Adjusted estimates of spending for the 4 asthma categories are derived from the regressions based on the coefficients for these categories.