Finding Relief: A Fresh Look at Asthma Treatments for Medicaid

Sep 15, 2013
A new report on the overreliance on rescue medications for Medicaid asthma patients.
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  • Medicaid
  • Asthma
  • Children

The Overreliance on Rescue Medications for Medicaid Asthma Patients

Two general types of medications are used to treat asthma. Some are classified as controller medications, which aid in preventing asthma exacerbations (worsening of symptoms). Controller medications should be taken daily on a long-term basis to reduce airway inflammation, decrease mucus production and desensitize the lungs to environmental triggers.1,2 The second main type of asthma medications is rescue medications, which are used on an as-needed basis for acute symptom relief. Rescue medications work by helping to relax airways.3 In general, rescue medications should be used judiciously, and using rescue medications to treat acute asthma symptoms more than two days per week likely indicates the need for controller medications.2

Asthma and Medicaid

Among Medicaid beneficiaries for whom Express Scripts manages pharmacy benefits, asthma is the most prevalent and costly condition at the per-member-per-year (PMPY) level. In 2012, 15.1% of Medicaid beneficiaries used asthma medications at a PMPY cost of $59.47, which represented a 6.2% increase in PMPY spend between 2011 and 2012. Spend in the class increased despite the patent expiration of the blockbuster drug Singulair® (montelukast), which prior to losing patent protection on August 3, 2012, held more than 10% of the Medicaid asthma therapy class market share.4

In addition to being expensive, asthma and its treatments are especially important for Medicaid because of the complex relationship between asthma and income — further confounded by a possible contribution of urban environments to asthma exacerbations. Asthma disproportionately impacts populations with low annual household incomes,5 and may be more prevalent in urban environments. Both groups include many receiving healthcare benefits through Medicaid. Some studies suggest that Medicaid patients with asthma have more attacks and use more healthcare resources than similar patients with private insurance or even no insurance.6,7

A recent Express Scripts examination of asthma medication utilization among Medicaid beneficiaries sheds light on some of the utilization drivers in the class. Specifically, Express Scripts researchers compared utilization of rescue and controller medications over time and across different subpopulations of gender, urbanicity and age. Our goals were to determine what kinds of medications were used by Medicaid beneficiaries and whether utilization patterns changed between 2011 and 2012.

Utilization of Controller and Rescue Medications

Among 315,600 Medicaid beneficiaries age 0 to 64 who were using any type of asthma medication in 2012, a greater proportion of beneficiaries were using rescue medications than controller medications. In our study, 90% of beneficiaries filled at least one prescription for a rescue medication, only 42.4% filled a prescription for a controller medication and about one-third used both rescue medications and controller medications. Notably, 55.7% were using only rescue medications, implying inadequate asthma control, which often leads to increased medical resource utilization8 (data not shown).

Patterns of controller and rescue medication use by gender and urbanicity are shown in the table below. Little difference was seen between males and females using rescue medications (89.8% vs. 90.2%, respectively), but a slightly higher percentage of males used controller medications (43.9% vs. 41.2%). A higher percentage of nonurban than urban patients had claims for controller medications (45.8% vs. 42.3%), but a greater percentage of urban patients than nonurban patients filled prescriptions for rescue medications (90.2% vs. 84.7%).

Asthma Medicaid Utilization of Controller and Rescue Medications 

Utilization of controller and rescue medications by age is shown in the figure below. With regard to age, controller medication use was higher for children age 5 to 9, and for 10 to 14 year olds, and then declined in young adults before increasing again among older beneficiaries. At the same time, rescue medication use experienced only a slight increase among older teenagers and young adults before declining for beneficiaries older than age 30. The increase among older beneficiaries partially reflects the increased prevalence of chronic obstructive pulmonary disease (COPD), as many asthma controller medications are also used to treat COPD, a progressive condition that generally does not produce symptoms in patients younger than age 40.

Asthma Medicaid Utilization of Controller and Rescue Medications 

The study also examined utilization trend — the year-to-year change in the total days’ supply of medication. (See table below.) Between 2011 and 2012, the amount of rescue medications being used increased at a faster rate (2.0%) than did the amount of controller medications (0.8%). Male beneficiaries had larger increases in utilization than females. There was also a slight gap in rescue utilization trend between urban and nonurban populations.

Asthma Medicaid Utilization Trend for Controller and Rescue Medications

Breaking down utilization by age, rescue medication utilization increased the most (6.2%) among beneficiaries age 25 to 29. (See figure below.) Utilization of rescue medications increased 5.7% in patients age 50 to 54. The change in controller medication utilization was also high in beneficiaries age 50 to 54 (5.6%), topped only by a 6.3% increase for those age 55 to 59. Increases in asthma drug utilization among older Medicaid beneficiaries may reflect increased COPD diagnoses in older patients.8 Utilization of controller medications decreased the most (-4.9%) among beneficiaries age 20 to 24, whereas rescue medication utilization decreased the most (-9.3%) among the youngest Medicaid beneficiaries, those age 0 to 4.

Asthma Medicaid Utilization Trend for Controller and Rescue Medications

Summary

Across all Medicaid subpopulations in our study, the most commonly used asthma medications were rescue medications, as opposed to controller medications. Additionally, utilization trend increased at a faster rate for rescue medications than for controller medications. Both findings are counter to asthma treatment guidelines, which recommend daily, long-term use of controller medications to prevent asthma exacerbations. Frequent use of rescue medications suggests poor asthma management, resulting in avoidable asthma exacerbations and potentially increasing overall healthcare expense.

Understanding basic utilization patterns among Medicaid beneficiaries with asthma is an important step in identifying additional opportunities for further education and intervention. More comprehensive explorations of utilization patterns are needed to reveal more detailed information about the true extent of controller medication underutilization and rescue medication overutilization. Just as important, determining and addressing the reasons for poor utilization help Express Scripts and Medicaid plan sponsors enable patients to make better decisions that ultimately lead to healthier outcomes.

Footnotes

1 Jonas DE, Wines RCM, DelMonte M, et al. Drug class review: controller medications for asthma: final update 1 report [Internet]. Portland, Ore.: Oregon Health & Science University; 2011. Available at: http://www.ncbi.nlm.nih.gov/books/NBK56695/. Accessed July 5, 2013.

2 National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (EPR-3). Bethesda, Md.: National Institutes of Health. 2007. Available at: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm. Accessed July 5, 2013.

3 U.S. National Library of Medicine. Asthma: quick-relief drugs. March 22, 2013. Available at: http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000008.htm. Accessed July 5, 2013.

4 Express Scripts. 2011 Drug Trend Report. April 2012. Available at: http://digital.turn-page.com/i/70797. Accessed July 5, 2013.

5 Aligne CA, Auinger P, Byrd RS, Weitzman M. Risk factors for pediatric asthma: contributions of poverty, race, and urban residence. Am J Respir Crit Care Med. 2000;162(3 Pt 1):873–877.

6 Finkelstein JA, Barton MB, Donahue JG, et al. Comparing asthma care for Medicaid and non-Medicaid children in a health maintenance organization. Arch Pediatr Adolesc Med. 2000;154(6):563–568.

7 Apter AJ, Reisine ST, Kennedy DG, Cromley EK, Keener J, ZuWallack RL. Demographic predictors of asthma treatment site: outpatient, inpatient or emergency department. Ann Allergy Asthma Immunol. 1997;79(4):353–361.

8 Gershon AS, Wang C, Wilton AS, Raut R, To T. Trends in chronic obstructive pulmonary disease prevalence, incidence and mortality in Ontario, Canada, 1996 to 2007: a population based study. Arch Intern Med. 2010;170(6):560–565.

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