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Gastroesophageal Reflux Disease in a Managed Care Setting: Professional, Facility, and Pharmacy Charges

Mary S. Keyser, Joseph A. Crawley, George A. Goldberg, and Michele M. Shaw

ABSTRACT:The objective of this study was to compare the overall health care charges of managed care organization (MCO) patients with gastroesophageal reflux disease (GERD) with comparison groups of MCO members. The study consisted of a retrospective review of eligibility data and claims filed for services dated January 1, 1994 through December 31, 1994 in a private benefit plan including HMOs and preferred provider organizations serving commercial and Medicare markets in the Midwest and South.

Patients were continuously eligible for drug benefits and were not enrolled in a capitated benefit plan. The GERD group (n=5,254) inclusion required a claim with a diagnosis of GERD. Three comparison groups, age- and gender-matched to the GERD group, were randomly selected (n=5,254 in each group). The first comparison group inclusion required membership in the MCO plan in 1994 whether or not claims were submitted. The second group inclusion required that at least one claim had been submitted in 1994. The third required a claim with a diagnosis of low-back pain (LBP). The groups were mutually exclusive.

The measurements used were overall average charge per member per month (PMPM), disease-attributable average charge PMPM overall claim types and for professional, facility, and pharmacy claim types, by age category. Overall charges were derived from any claim; attributable charges were derived from claims with diagnoses or prescriptions consistent with GERD or LBP.

Study results showed that GERD patients had facility, professional, and pharmacy average overall charges PMPM 1.7 to 4.8 times greater than those of the comparison eligible or claims groups. All GERD average charges PMPM were significantly greater than the comparison-eligible or claims group averages (p<.05). GERD facility, professional, and pharmacy average overall charges were from 1.1 to 1.7 times greater than those of the LBP group. The GERD facility and pharmacy charges PMPM were significantly greater than the LBP average charges PMPM (p<.05).

GERD-attributable professional and facility average charges were significantly lower (by 63% and 33%, respectively) than LBP-attributable charges. However, GERD-attributable pharmacy average charges were 2.4 times higher than LBP-attributable charges.

Total charges for MCO patients with GERD were significantly higher than total and component charges for MCO members without GERD and were generally comparable to charges for patients with a comparison condition, LBP. GERD-specific charges were lower than LBP-specific charges, except for pharmacy charges. These results suggest that GERD patients require significantly more MCO resources in general than do typical MCO members. Further analysis of the sources of GERD resource use is necessary to understand how quality of care can be improved and made more efficient.

KEY WORDS: Gastroesophageal reflux, GERD, Cost, Economics, Managed care

J Managed Care Pharm 1998; 4: 64-70

Gastroesophageal reflux disease (GERD) is an acid reflux disorder. Typical symptoms of GERD are heartburn and regurgitation. Additional symptoms may include chest pain, dysphagia, belching, bloating, hoarseness, and hypersalivation.¹ GERD occurs in approximately 5% to 10% of the adult population.² GERD may be associated with up to 50% of patients with noncardiac chest pain, 78% of patients with chronic hoarseness, and 82% of patients with asthma.³ Cost-effective medical management of GERD should consider the range and severity of symptoms.⁴ GERD management includes lifestyle modification and antacid therapy, pharmacological medications (histamine H2 receptor antagonists, proton pump inhibitors, sucralfate, and prokinetics), and surgery for those 5% to 10% of patients with nonresponsive GERD^1,5 resulting in what some consider to be a high rate of health care use.⁶ The cost of managing GERD, especially in a managed care environment, has not received much attention in the literature. Because the prevalence of the disease and the potential morbidity and mortality of its complications and associated conditions may be underestimated, managed care organizations (MCOs) may not have developed appropriate diagnosis and treatment regimens and may not understand the costs of the disease.

The purpose of this study was to compare in a given year the overall health care cost (direct charges) of managed health care patients with GERD with comparison groups of MCO members.

Methods

Data were obtained from the Computerized On-line Medical Pharmaceutical Analysis and Surveillance System (COMPASS), a database composed of professional, facility, and pharmacy claims data from public and private benefit plans. For these analyses, private benefit plan data were used, derived from HMOs and preferred provider organizations (PPOs) serving the commercial and Medicare markets and covering approximately 2.7 million eligible lives. Members resided primarily in the Midwest and Southern U.S.

Study Population

Patients selected for the GERD group were required to have a diagnosis of GERD (International Classification of Diseases, Ninth Revision, Clinical Modification⁷ [ICD-9-CM] codes 530.1, 530.10, 530.11, 530.19, 530.81) in 1994. Patients were excluded if they were not continuously eligible for pharmacy benefits or if they received services under a capitated benefit plan.

Three comparison groups were selected. The first comparison group included 1:1 gender- and age-matched members randomly selected from the eligible population without GERD in 1994. This population included members who may or may not have received services during the year. The second comparison group included 1:1 gender- and age-matched patients randomly selected from the population without GERD who received services of some type during 1994. The third comparison group included 1:1 gender- and age-matched patients randomly selected from the population without GERD who had a diagnosis of low-back pain (LBP) in 1994. This allowed an evaluation of GERD relative to another disease that is common and is perceived to be expensive in terms of resource use.^8-12 The GERD and comparison groups were mutually exclusive. Age categories were 0-19 years, 20-39 years, 40-64 years, and 65+ years old.

Measures

The billed amount on a claim represents charges prior to distribution among payment categories, such as copay or other insurers. Using the billed amounts on the claims, overall and attributable charges were tabulated. Overall charges were derived from any claims, whether or not disease specific, and were tabulated for GERD patients and the three comparison groups. Attributable charges were tabulated for GERD and LBP patients and were derived from only those claims containing diagnoses or prescriptions consistent with GERD or LBP (e.g., a professional or facility claim was attributed to GERD if one of the ICD-9-CM codes on the claim was a GERD code, and a pharmacy claim was attributed to GERD if the National Drug Code was for a GERD drug described below; a similar attribution was made for LBP claims). Attributable charges may be underestimated because some claims, particularly those for laboratory tests, frequently did not identify diagnoses. On those claims for GERD patients listing both GERD and nonGERD diagnoses, attributable charges were apportioned based on the number of diagnoses on the claims. Similarly, for LBP patients, attributable charges were apportioned based on the number of LBP and nonLBP diagnoses on the claims. GERD drug classes included proton pump inhibitors, H₂ receptor antagonists, prokinetic agents, and mucosal protective agents. LBP drug classes include antiinflammatory agents (nonsteroidal and steroidal), analgesics (nonnarcotic and narcotic), muscle relaxants, and antisecretory/antiulcer drugs (correctly and incorrectly used to counteract stomach-related side effects of antiinflammatory agents).

Per member per month (PMPM) overall and attributable charges were calculated for each patient in the GERD and comparison groups by dividing the summed charges by the number of eligible months for overall charges and in the GERD and LBP groups for attributable charges as well. Average charges PMPM were calculated by professional, facility, and pharmacy claim type and total overall claim types by age category. Professional claims were those submitted by providers such as physicians, physical therapists, chiropractors, dentists, and psychologists. Facility claims were those submitted by institutions such as hospitals, outpatient clinics, nursing care facilities, and independent laboratories. Pharmacy claims were those submitted by outpatient pharmacies and did not include pharmaceuticals distributed to hospital inpatients or long-term inpatients such as those in psychiatric, rehabilitation, or chronic disease facilities. An analysis of variance was performed using SAS® statistical software¹³ to compare the GERD group and the comparison groups on average overall and attributable charges PMPM.

Results

In the GERD group, 5,254 patients met the selection criteria. Fifty-nine percent of the GERD group and its comparison groups were female; 53% of the entire MCO's population was female. Each study group mean age (�SD) was 48.7 (�16.7) years, and the median age was 48 years; the MCO population (n=2,672,453) mean age (�SD) was 41.4 (�25.6) years, and the median age was 39 years. The age distribution was as follows: 4% were younger than 20 years, 23% were 20-39, 55% were 40-64, and 18% were 65 years or older. The age distribution of the MCO�s population was as follows: 23% were younger than 20 years, 29% were 20-39, 26% were 40�64, and 22% were 65 years or older. The mean (�SD) months of eligibility for the GERD, eligible, claims, and LBP groups were 10.7 (�2.6), 9.9 (�3.3), 9.4 (�3.8), and 10.6 (�2.8) months, respectively; the mean (�SD) length of eligibility for the MCO group was 9.3 (�3.8) months. The GERD study group accounted for nearly 1% of all 1994 MCO charges, of which 5% were attributable to GERD-related diagnoses and services.

Comparing Overall Charges

The GERD average overall charges PMPM (see Table 1 and Figure 1) were significantly greater (p<.05) than eligible and claims groups' charges PMPM in total (all claims) and for each claim type. The total average overall charges PMPM for the GERD, LBP, claims, and eligible groups were $1,003, $765, $403, and $229, respectively.

Table 1: Average 1994 Overall PMPM: GERD and Comparison Groups

The GERD average charges were significantly greater (p< .05) than the LBP total average charges. The average overall professional charges PMPM were $311, $284, $139, and $78, for the GERD, LBP, claims, and eligible groups, respectively; GERD and LBP professional charges were not significantly different in comparison.

Figure 1: Average 1994 Overall PMPM: GERD and Comparison Groups

The average overall facility charges PMPM were $661, $463, $246, and $139, for the GERD, LBP, claims, and eligible groups, respectively; the GERD charge was significantly greater (p<.05) than the LBP charge.

The average pharmacy charges PMPM were $30, $18, $18, and $12, for the GERD, LBP, claims, and eligible groups, respectively; the GERD charge was significantly greater (p<.05) than the LBP charge.

GERD average total, professional, and facility overall charges PMPM increased as age increased for age groups older than 19; age category 0-19 charges were as great as those for the 40-64 age category. GERD average professional and facility overall charges were lowest for the 20-39 age category, whereas the LBP professional and facility charges were lowest for the 0-19 age category. GERD and LBP average pharmacy overall charges were lowest for the 20-39 age category, and the charges were greatest for the 40-64 age category.

Comparing Attributable Charges

Of the overall GERD charges, 5% were classified as attributable to GERD, whereas 12% of the overall LBP charges were classified as attributable to LBP. Of the GERD professional overall charges, 6% were classified as attributable to GERD, whereas 17% of the LBP professional overall charges were classified as attributable to LBP. Of the GERD facility overall charges, 4% were classified as attributable to GERD, whereas 8% of the LBP facility overall charges were classified as attributable to LBP. Of the GERD pharmacy overall charges, 32% were classified as attributable to GERD, whereas 22% of the LBP pharmacy overall charges were attributable to LBP.

Table 2: Average 1994 Attributable Charges PMPM: GERD and LBP Groups

The GERD-attributable average health care charges PMPM (see Table 2 and Figure 2) were significantly lower (p<.05) than the LBP-attributable charges PMPM in total and for professional and facility claim types; the GERD-attributable average pharmacy charges PMPM were significantly greater (p<.05) than the LBP-attributable average charges PMPM. The GERD-attributable average total charge PMPM ($53) was 42% lower than the LBP-attributable charge ($91); the GERD-attributable average professional charge PMPM ($18) was 63% lower than the LBP-attributable charge ($48); the GERD-attributable average facility charge PMPM ($26) was 33% lower than the LBP-attributable charge ($39); the GERD-attributable average pharmacy charge PMPM ($10) was 2.5 times greater than the LBP-attributable charge ($4). The GERD-attributable average total charges PMPM were generally equivalent among the age categories, whereas the LBP-attributable charges increased as age increased, except that the 65+ category charge was lower than the 20-39 and 40-64 age category charges. These trends were also observed for the professional and facility claim types for both GERD- and LBP-attributable charges. The GERD-attributable average pharmacy charges PMPM were greatest in the 20-39 and 40-64 age categories, whereas the LBP-attributable charges were greatest in the 40-64 and 65+ age categories.

Figure 2: Average 1994 Attribute Charges PMPM: GERD and LBP Groups

Discussion

Overall, GERD patients had from 1.7 to 4.8 times greater average total, professional, and facility claims charges PMPM than the eligible or claims comparison groups, indicating that GERD and LBP patients in general have conditions or comorbidities requiring more expensive resource use than the MCO population without GERD. GERD patients were generally similar to LBP patients with respect to professional resource charges, but GERD total and facility charges were significantly greater than LBP charges by 31% and 43%, respectively. GERD patients had from 1.7 to 2.6 times greater pharmacy average overall charges PMPM than those for the eligible, claims, and LBP groups. This indicates that GERD patients were receiving more expensive or more types of medications overall than the LBP group or the MCO population as a whole. Average overall and facility overall charges increased as age increased from age 20 for GERD and all comparison groups. Average professional overall charges were greatest in GERD and LBP patients after age 40. Average pharmacy overall charges were lowest for the 20-39 age category in GERD patients and all comparison groups.

GERD-attributable average charges PMPM were significantly lower than LBP-attributable charges PMPM by 42% for all claim types, by 63% for professional, and by 33% for facility claim types. A possible explanation for this finding is that because attributable charges required the presence of the specific diagnosis attached to the service line of a claim, GERD claims may have included more diagnoses than LBP claims, so that fewer charges were apportioned to GERD in GERD patients than to LBP in LBP patients. Also, GERD diagnoses were not as specific as LBP diagnoses; that is, a patient may have had a non-GERD diagnosis, such as chest pain, when, in fact, eventually GERD was diagnosed. This means that some of the overall costs may have been attributable to GERD but not captured as attributable. This could partially explain why GERD overall charges were higher than LBP charges and why GERD-attributable charges were lower than LBP-attributable charges. Attributable professional charges may have been lower in GERD patients than in LBP patients because GERD patients may have been less likely than LBP patients to visit the physician, or LBP patients may have received more types of professional charges related to LBP, such as physical therapy, than did GERD patients. Attributable facility charges may have been lower in GERD patients than in LBP patients because GERD patients may have had fewer hospitalizations with GERD diagnoses, fewer emergency room visits, and fewer laboratory/diagnostic or surgical/ therapeutic procedures. In contrast, GERD-attributable pharmacy charges were 2.5 times greater than LBP-attributable charges. In 1994, common GERD prescription medications (cimetidine, nizatidine, famotidine) were not yet available over the counter (OTC), so these charges were reflected in the claims data. Conversely, LBP patients may have used more OTC pain-relief medications than GERD patients used; claims data do not capture OTC use.

Conclusion

Total charges for MCO patients with GERD were significantly higher than total and component charges for MCO members without GERD and were generally comparable to charges for patients with a comparison condition, LBP. GERD-specific charges were lower than LBP-specific charges, except for pharmacy charges. These results suggest that GERD patients require significantly more MCO resources in general than do typical MCO members. Further analysis of the sources of GERD resource use is necessary to understand how quality of care can be improved and made more efficient.

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