Sander guesses that the huge increase in expenditures for children’s asthma medications is largely the result of three factors: the CFC to HFA transition beginning in 2006 that resulted in an increase in the cost of MDIs; greater acceptance of inhaled corticosteroid use by parents; and a more casual attitude toward treating the underlying disease because symptoms are better controlled.
The phase-out of CFC inhalers is likely responsible for much of the increase in out-of-pocket expenditures, Sanders suspects, because most insurance companies require significantly higher co-pays for brand name medications than for generics. She also faults the government for failing to consider the effect of the mandated transition on patients, asserting that patients should have been provided with vouchers to cover the cost increase.
The increased acceptance of inhaled corticosteroids, which cost significantly more than oral corticosteroids, is another factor; expenditures for ICS in 07-08 were approximately 260 times higher than for the oral form. “Prednisone is only pennies per pill; however the detriment to the body is horrific,“ Sanders notes, “so you definitely don’t want to be taking that for any length of time.”
Fifteen years ago, she says, her organization got lots of calls from parents who were afraid to give steroids to their children, even as an inhaled medication, but those calls have largely stopped. According to the AHRQ research, the percentage of children using reliever medications without any controller medication fell from almost 44% to about 30%. Over the same period, the percentage of asthmatic children using oral corticosteroids dropped from ~17% to ~9%, and expenditures on oral corticosteroids fell by nearly 70%; however, because they cost very little, the total reduction amounted only to $17 million.
The increase in controller use should ideally lead to a decrease in rescue inhaler use; however, the researchers found no statistically significant change in the number of children using reliever medications (mostly short-acting beta agonists) except among some disadvantaged populations where the use of relievers increased. Annual total expenditures on reliever medications actually rose by almost 60%, to $352 million.
Successful symptom control, Sanders points out, is far from the same thing as successful control of the disease. At a recent AANMA summit, she says, participants concluded that even some medical professionals are failing to take asthma seriously in the era of ICS therapy: “They often say, ‘Oh, morbidity and mortality rates are going down so we have this asthma thing fixed,’ and every child gets an inhaled corticosteroid, and people move on.”
“What happens,” Sander explains, “is that the children continue to be exposed to the allergens because their parents don’t know what to be looking for; our concern is that their medication use is going to be higher as long as they are surrounded by the things that are making them sick.”
AHRQ Statistical Brief #332
AHRQ Statistical Brief #341
Research Findings #31
