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The American Journal of Managed Care November 2014
The Correlation of Family Physician Work With Submitted Codes and Fees
Richard Young, MD, and Tiffany L. Overton, MPH
Population Targeting and Durability of Multimorbidity Collaborative Care Management
Elizabeth H.B. Lin, MD, MPH; Michael Von Korff, ScD; Do Peterson, MS; Evette J. Ludman, PhD; Paul Ciechanowski, MD, MPH; and Wayne Katon, MD
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Jared Lane K. Maeda, PhD, MPH; Rachel Mosher Henke, PhD; William D. Marder, PhD; Zeynal Karaca, PhD; Bernard S. Friedman, PhD; and Herbert S. Wong, PhD
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Medical Cost Burdens Among Nonelderly Adults With Asthma
Emily Carrier, MD, and Peter Cunningham, PhD
Care Coordination Measures of a Family Medicine Residency as a Model for Hospital Readmission Reduction
Wayne A. Mathews, MS, PA-C
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Yuting Zhang, PhD; Cameron M. Kaplan, PhD; Seo Hyon Baik, PhD; Chung-Chou H. Chang, PhD; and Judith R. Lave, PhD
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Medical Cost Burdens Among Nonelderly Adults With Asthma

Emily Carrier, MD, and Peter Cunningham, PhD
People with asthma face substantial out-of-pocket costs-even when they take medications to manage their illness. However, many choose to continue treatment despite these costs.
For the second part of the analysis, we examined the percent of asthma patients receiving treatment who discontinued this treatment, and the association between medical cost burdens and the subsequent decision to discontinue treatment. For this part of the analysis, we used the MEPS 2-year panel sample. The MEPS uses a rotating panel design that permits representative estimates for a 2-year period.14-16 A new cohort of households is initiated each year and interviewed 5 times to collect 2 calendar years of data.17 Thus, this part of the analysis combines the 2-year panel samples for the years 2003-2004, 2004-2005, 2005-2006, 2006-2007, 2007-2008, and 2008-2009. For asthma patients receiving treatment in Year 1 of the panel sample, we computed the percentage that continued or discontinued treatment in Year 2. For asthma patients not receiving treatment in Year 1, we computed the percentage that started using treatment in Year 2.

A logistic regression analysis was conducted to examine whether medical cost burdens and other factors present in Year 1 influenced patient decisions to continue or start treatment for asthma in Year 2. The sample for the regression analysis included all non-elderly adult patients with asthma included in the panel samples between 2003 and 2009. The dependent variable is whether the patient received treatment in Year 2. The main independent variable is a measure of medical cost burdens in Year 1 (included as a categorical variable to capture any nonlinear effects). Because treatment and asthma severity in Year 1 will be correlated with both Year 1 medical cost burdens and Year 2 treatment, controls for Year 1 treatment and Year 1 asthma attack are included. Year 2 asthma attack is also included as a control because it is likely to be correlated with treatment in both Year 1 and Year 2. Baseline measures (Year 1) of patient health, demographic, economic, and insurance coverage variables that are likely to be correlated with both Year 1 spending and Year 2 treatment are also added as controls.


Characteristics of Persons With Asthma

Based on the MEPS, 7% of adults aged 18 to 64 years reported that they have persistent asthma. More than two-thirds of these were taking suppressive or rescue medications to control their asthma (see Table 1). Most of those taking medications (or 40.6% of all persons with asthma) had experienced an asthma attack in the prior year. Most of those receiving treatment had used a rescue inhaler in the past 3 months, while less than one-third were taking steroids to prevent flare-ups. About one-third reported that they had asthma but were not receiving asthma treatment, and most of these had not had an asthma attack in the past year. Overall, about 29% used treatment and were successfully avoiding asthma attacks, and about 8% were forgoing treatment and experiencing attacks.

In general, those receiving treatment for asthma had worse overall health, more comorbidities, and greater activity limitations compared with those not receiving treatment, and those receiving treatment who had an asthma attack had the worst health among all persons with asthma.

Persons receiving treatment and who had an asthma attack were somewhat more likely to be poor (18.4%) compared with other persons with asthma, but persons receiving treatment were less likely to be uninsured compared with those not receiving treatment, largely because they were more likely to have public coverage.

Spending for Persons With Asthma

Both total spending and out-of-pocket spending were higher for the 2 groups receiving treatment compared with those not receiving treatment. Among persons receiving treatment, those who had an asthma attack had slightly higher total annual spending ($9155) compared with those with no asthma attack ($8514). Overall, about 16% of persons with asthma report a high medical cost burden, defined as paying more than 10% of their income for out-of-pocket expenses associated with health insurance premiums and health services. Not surprisingly, the proportion with high medical cost burdens is highest among those receiving treatment, especially among those who received treatment and had an asthma attack (20.6%). Those not receiving treatment had lower medical cost burdens compared with those receiving treatment, even if they had an asthma attack in the past year. Of note, medical cost burdens are higher among those receiving treatment who do not experience an asthma attack (17.6%) than among those not receiving treatment who do experi- ence an asthma attack, which suggests that there are no downstream savings for individuals who are more proactive with their treatment. Out-of-pocket costs for prescription drugs, inpatient hospital care, and outpatient care are also higher for those receiving treatment compared with those not receiving treatment. While out-of-pocket spending on ED care is significantly higher for respondents who did not use treatment and did experience attacks, the absolute amount is small ($25, compared with $23 for those who reported using treatment and avoiding attacks).

Continuity of Treatment

About 80% of those receiving asthma treatment in Year 1 of the MEPS panel continued with treatment in Year 2 (Table 3). Most who received treatment and had an attack in Year 1 had similar experiences in Year 2 (60%). About one-third of those not receiving treatment in Year 1 started receiving treatment in Year 2, regardless of whether they experienced an attack in Year 1.

Table 4 shows the results of a multivariate regression describing the association between medical cost burdens in Year 1 and the likelihood of being treated for asthma in Year 2, after controlling for differences in Year 1 treatment, severity, and other characteristics of patients. In general, the results show that issues related to health are much more important than economic factors in determin- ing whether asthma patients continued or started receiving treatment in Year 2. The effects of high medical cost burdens in Year 1 on treatment in Year 2 are inconclusive. Compared with those with low medical cost burdens those who spend between 5% and 10% of their income on healthcare in Year 1 are less likely to have treatment in Year 2. However, those whose spending exceeds 10% of income in Year 1 are no more or less likely to be treated in Year 2 compared with those with lower spending levels. Other economic variables, such as insurance coverage and family income relative to poverty, also did not have statistically significant associations with receiving treatment for asthma in Year 2. Whether people received treatment for asthma in Year 2 was much more strongly associated with age (older rather than younger), having multiple comorbidities, and having an asthma attack in Year 2. People who smoked were less likely to receive treatment in Year 2.


Our study has several limitations. First, MEPS relies on respondents’ self-report of their illness. This limitation is mitigated to some extent by the use of standard questions on asthma and other medical conditions used in surveys by the CDC.18 MEPS also uses a short recall period (typically, 3 to 6 months) to augment reliability of utilization and expenditure data,17 and MEPS findings on healthcare utilization and prescription use have been validated in prior studies.17,19 Also, follow-up surveys to medical providers (including pharmacists) are used by the MEPS to verify and edit medical expenditure information reported by survey respondents. A study of Medicare beneficiaries who responded to the MEPS suggest that these respondents tend to report hospitalizations accurately, but underreport ED and outpatient visits across all respondent groups.20 However, Medicare beneficiaries might be expected to have more outpatient and ED visits compared with the younger respondents in our study, making individual visits less likely to stand out in their recollection.

Because MEPS only asks whether a respondent uses particular medications, rather than how often, we cannot assess whether respondents were taking all doses of all recommended medications, or were only partially adherent. Patients who adhere only partly to medication regimens may experience most of the costs but few of the benefits. Finally, it is difficult to fully adjust for differences in severity of asthma and overall health status.


Respondents who reported using treatment had higher out-of-pocket spending than respondents who did not use treatment—even respondents who, without treatment, experienced asthma attacks. Furthermore, individuals do not appear to discontinue their treatment if they incur very high financial burdens. These findings persist even after adjustment for the presence of comorbidities and disability. While it is difficult to control fully for the severity of respondents’ illness, these results suggest that respondents who engage in appropriate self-management may still incur substantial out-of-pocket costs, and are not necessarily saving on potentially higher out-of-pocket spending by reducing complications and asthma attacks.


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