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If We Prescribe It, Will It Come?
Access to Asthma Equipment for Medicaid-Insured Children and Adults in the Bronx, NY
Karen L. Warman, MD;
Amanda M. Jacobs, MD;
Ellen J. Silver, PhD
Arch Pediatr Adolesc Med. 2002;156:673-677.
ABSTRACT
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Context Asthma is a major cause of morbidity in the United States. Self-management
of asthma requires access to appropriate equipment. Clinical experience in
an inner-city practice suggests that families encounter difficulties in filling
prescriptions for spacers/holding chambers, peak flow (PF) meters, and nebulizer
machines.
Objectives To determine whether Bronx, NY, pharmacies (1) carry spacers/holding
chambers, PF meters, and nebulizer machines; (2) accept Medicaid insurance
for them; and (3) perceive barriers to reimbursement by Medicaid for this
equipment.
Design and Setting Structured telephone survey of 100 Bronx pharmacies randomly selected
from the1999 telephone directory.
Participants Ninety-eight pharmacists and 2 pharmacy technicians in 100 different
pharmacies.
Main Outcome Measures Pharmacists' reports of equipment availability, Medicaid acceptance,
and reasons for not carrying equipment or accepting Medicaid.
Results Overall equipment availability was as follows: spacers (68%), spacers
with masks (57%), adult PF meters (40%), child-range PF meters (24%), and
nebulizer machines (56%). For Medicaid recipients, equipment was less available:
spacers (45%), spacers with masks (35%), adult PF meters (27%), child-range
PF meters (17%), and nebulizer machines (33%). Surveyed pharmacists reported
misconceptions about requirements for Medicaid reimbursement, which included
the following: that Durable Medical Equipment permits are required (64% spacers
and 33% PF meters), that special forms are needed (17% PF meters), or that
this equipment is not covered by Medicaid (14% spacers and 8% PF meters).
Of the 100 surveyed pharmacists, 32 reported difficulties with Medicaid reimbursement
and 41 had never tried to receive reimbursement.
Conclusions These results suggest that (1) access to spacers/holding chambers, PF
meters, and nebulizers for Medicaid-insured families is severely limited in
Bronx pharmacies; (2) misunderstandings regarding Medicaid reimbursement policies
are common; and (3) interventions to increase the proportion of pharmacies
that dispense equipment are needed.
INTRODUCTION
ASTHMA IS a complex public health problem that affects 14 to 15 million
people in the United States of whom 5 million are children.1
Self-management of asthma requires access to appropriate equipment that may
include medication delivery devices, such as spacers/holding chambers, peak
flow (PF) meters, and nebulizer machines. In the clinical experience of one
of us (K.L.W.) in practice at several Bronx, NY, primary care sites, patients
often return with prescribed medications but report difficulty in obtaining
prescribed equipment.
This clinical impression was supported by a small study that examined
access to spacer devices and PF meters in Harlem, NY, an adjacent inner-city
area that also serves a preponderantly poor, minority population with a high
asthma prevalence. In 1995, a survey of all 20 Harlem pharmacies revealed
that 51% reported not selling spacer devices and 65% reported not selling
PF meters.2 This study, while valuable, did
not explore why equipment was unavailable or whether Medicaid insurance was
accepted for the equipment.
The importance of equipment for appropriate management of asthma is
outlined in the 1997 National Asthma Education and Prevention Program's Expert Panel Report II: Guidelines for the Diagnosis and Management
of Asthma.3 Recommendations include
use of spacer devices and/or nebulizer machines for the safe and effective
delivery of inhaled medications. Inhalation of asthma medications is the preferred
route because higher concentrations of drugs are delivered more effectively
to the airways and systemic adverse effects are avoided or minimized.4
Spacer devices improve deposition of medication into the lungs,5-6 decrease oropharyngeal deposition and
colonization with Candida species,7
and reduce the need for coordination thereby allowing infants and young children
to effectively receive medication from metered-dose inhalers. Use of spacer
devices is particularly important to minimize potential adverse effects of
inhaled steroids, the first-line preventive medication for moderate and severe
persistent asthma.
Nebulizer machines provide another avenue for delivering inhaled medications.
There are, however, only 2 available preventive medications approved for delivery
by nebulization—cromolyn sodium that has a well-established safety profile,
but is only recommended for mild persistent asthma, and budesonide solution
for inhalation, an inhaled steroid, whose safety and efficacy were tested
using a specific jet nebulizer8-9
and not the standard aerosolized nebulizers issued to patients in the United
States for home use.
The guidelines also recommend that adults and children 5 years and older
with moderate to severe persistent asthma should learn how to monitor their
peak expiratory flow and have a PF meter at home. Peak flow meters are also
recommended for any patient with a history of a severe exacerbation. Interventions
using PF meters in conjunction with a comprehensive asthma program have shown
significant improvements in lung function, symptoms, and medication use.10-11
Young children and infants with asthma may require special equipment.
For example, preschool children usually require spacer devices with masks
that fit over their mouth and nose, instead of inside the mouth, to ensure
proper drug delivery. Similarly, PF meters need to have readable lower numerical
ranges than standard adult ranges to enable proper measurement of children's
smaller lung capacity.
Medicaid, the largest insurer of poor families in New York State, covers
the costs of spacer devices, PF meters, and nebulizer machines.12
New York State Medicaid does not consider spacer devices and PF meters durable
medical equipment (DME). Prescriptions, without any additional paperwork,
are sufficient for pharmacies to dispense spacers and PF meters. Pharmacists
obtain approval online through the Electronic Medicaid Eligibility Verification
System. Nebulizer machines, however, are considered DME and, therefore, pharmacists
must have a DME permit to dispense them and, in addition, must manually apply
for reimbursement from the New York State Medicaid office.
Despite insurance coverage of spacers/holding chambers, PF meters, and
nebulizer machines, the clinical experience of physicians in a Bronx primary
care clinic was that many families encountered difficulties in obtaining prescribed
asthma equipment. We hypothesized that (1) families have difficulty accessing
asthma equipment because many pharmacies do not carry the equipment, and (2)
pharmacies do not carry equipment because they perceive or encounter barriers
to appropriate reimbursement. The objectives of this study were to determine
whether Bronx pharmacies (1) carry spacers/holding chambers, PF meters, and
nebulizer machines; (2) accept Medicaid insurance for them; and (3) perceive
barriers to reimbursement by Medicaid for this equipment.
PARTICIPANTS AND METHODS
PARTICIPANTS
All pharmacies listed in the 1999 Bronx telephone directory (Yellow
Pages; NYNEX Information Resources were stratified by zipcode. This stratification
ensured that the sample selected represented an even geographical distribution
of available Bronx pharmacies. Half of the listed pharmacies were randomly
selected from within each ZIP code using a coin toss. A total of 110 pharmacies
were selected. Of these, 100 pharmacies participated in a 5-minute telephone
survey conducted between August 16, 1999, and November 16, 1999. Ten pharmacies
were not contacted for the following reasons: 5 were disconnected numbers,
2 were incorrect numbers, 2 did not answer repeated calls, and 1 was listed
twice in the directory and already contacted. All of the 100 pharmacies that
were reached participated; respondents consisted of 98 pharmacists and 2 pharmacy
technicians.
MEASURES
Data were obtained by structured telephone interviews conducted by trained
research assistants (A.M.J.). Pharmacists were asked, "Can you tell me if
you carry: spacer devices, spacers with masks, adult peak flow meters, child
peak flow meters, and nebulizer machines?" Pharmacists who did not carry specific
asthma equipment were then asked, "Why is this?" for each specific piece of
equipment. Pharmacists who reported carrying equipment were asked, "Do you
accept Medicaid for spacer devices, spacers with masks, adult peak flow meters,
child peak flow meters, and/or nebulizer machines?" Those who did not accept
Medicaid were asked, "Why is this?" Lastly, all pharmacists were read the
following statement and asked a follow-up question: "We understand some pharmacists
have difficulty getting reimbursed from Medicaid for asthma equipment. Have
you found that this is a problem?" Those who responded yes were asked, "What
difficulties have you encountered concerning Medicaid reimbursement?" Questions
that yielded open-ended responses were coded post hoc by 2 of us (K.L.W. and
A.M.J.) independently.
DATA ANALYSIS
The analyses we report are descriptive and include the percentage of
pharmacies giving each response. The SEs were calculated using the finite
population correction. Data are reported as mean (SE).
RESULTS
Of the 100 surveyed pharmacies, the number of pharmacies that reported
carrying specific asthma equipment were as follows: spacers, 68 (2.3); spacers
with masks, 57 (2.5); adult PF meters, 40 (2.4); child-range PF meters, 24
(2.1); and nebulizer machines, 56 (2.5) (Figure 1). Fewer pharmacies both carried equipment and accepted
Medicaid for reimbursement: spacers, 45 (2.5); spacers with masks, 35 (2.4);
adult PF meters, 27 (2.2); child-range PF meters, 17 (.9); and nebulizer machines,
33 (2.4).
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The reports of 100 Bronx, NY, pharmacists for the availability of
spacers/holding chambers, peak flow (PF) meters, and nebulizer machines and
their acceptance of Medicaid insurance for payment.
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Pharmacists' reasons given as to why specific equipment was not carried
by the pharmacy varied by the type of equipment (Table 1). The most common reasons were equipment was infrequently
requested (34% spacers, 60% PF meters, and 39% nebulizer machines); the pharmacy
did not accept Medicaid for the equipment (31% spacers, 15% PF meters, and
20% nebulizer machines); and that it was "store policy" (28% spacers, 18%
PF meters, and 34% nebulizer machines).
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Table 1. Reasons Pharmacists Gave for Not Stocking Various Types of
Asthma Equipment*
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Reported reasons for not accepting Medicaid for equipment varied by
type of equipment (Table 2) and
revealed misconceptions about procedures for Medicaid reimbursement. For example,
pharmacists reported not accepting Medicaid for spacer devices and PF meters
because they thought that DME permits were required for reimbursement (64%
spacers and 33% PF meters); they thought they needed special forms (17% PF
meters), or they thought that they were not covered by Medicaid (14% spacers
and 8% PF meters). Insufficient reimbursement was also cited as a reason for
not carrying equipment: for spacers (9%), spacers with masks (14%), adult
PF meters (33%), child-range PF meters (38%), and nebulizers (13%).
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Table 2. Reasons Pharmacists Gave for Not Accepting Medicaid by Type
of Asthma Equipment*
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Of the 100 surveyed pharmacists, 32 reported having had difficulties
with Medicaid reimbursement, 27 had had no difficulties, and 41 had never
tried to receive reimbursement. Of the 32 pharmacies that reported having
had difficulties with Medicaid reimbursement, the 3 major reasons given were
too time consuming (25%), insufficient reimbursement (22%), and denial of
previous requests (22%). Other less common responses were denial of online
computer requests (12%), never reimbursed (6%), lacked the proper forms (6%),
denied reimbursement owing to time restraints (6%), and unaware of the need
for a DME permit (3%).
COMMENT
These results suggest that despite the high prevalence of asthma in
the Bronx and the borough's high proportion of Medicaid-insured families,
many Bronx pharmacies do not carry spacers/holding chambers, PF meters, and
nebulizer machines. Fewer than half of all pharmacies surveyed accept Medicaid
for this equipment.
Our survey suggests that a significant barrier to pharmacies accepting
Medicaid for spacer devices is misconceptions by pharmacists about the requirements
for reimbursement. Although spacer devices are not considered DME by Medicaid
and only require a prescription for dispersal, most pharmacists not accepting
Medicaid for spacers erroneously thought that they required a DME permit to
dispense them. Similarly, some pharmacists thought that DME permits or special
forms were required to dispense PF meters.
Most pharmacists reported they did not carry PF meters because they
were infrequently requested. In a prior study, we found that only 30% of children
aged 5 years or older who had been hospitalized for asthma in the prior 2
years had a PF meter at home.13 In contrast,
most families reported having spacers (75%) or nebulizer machines (74%). This
difference most likely reflects the current practice of Bronx hospitals of
dispensing spacers and/or arranging for nebulizer machines prior to hospital
discharge.
Nebulizer machines are considered DME by Medicaid and do require a DME
permit. It seems reasonable that nebulizer machines, which require significant
storage space and maintenance, be dispensed by designated supply stores. Spacers
and PF meters, in contrast are small, inexpensive devices, that do not require
ongoing professional maintenance and may be more readily distributed by pharmacies.
Certain equipment required for young children was less available than
adult equipment. Fewer pharmacies that accepted Medicaid for equipment carried
spacer devices with masks compared with standard mouthpieces (35% vs 45%);
and fewer carried PF meters with child ranges compared with adult ranges (17%
vs 27%). Because young children are disproportionately affected by asthma
and early treatment may help prevent disease progression increasing availability
of appropriate asthma equipment for young children is an important area for
intervention.
One third of the pharmacists surveyed reported difficulties with Medicaid
reimbursement and another third had never tried to receive reimbursement.
In the Bronx, an area with a large population of patients with Medicaid insurance,
it is surprising that pharmacists are not more experienced in obtaining reimbursement
by Medicaid.
Other avenues outside of pharmacy distribution may be taken to distribute
spacer devices and PF meters. Some clinical sites or intervention programs
purchase their own supplies for patients in bulk and distribute them. While
the advantage to this is clear, timely distribution of materials and the ability
to demonstrate proper usage to families, it redistributes the cost of items
to clinical sites or interventions instead of to Medicaid or other insurers.
In April 2000, after this survey was completed, the Commissioner of
the New York City Department of Health sent a mailing to all New York City
pharmacists detailing the procedure for dispensing spacer devices and providing
information from a cost survey of manufacturers and distributors of spacers
and holding chambers. The wholesale costs reported by vendors at this time
for Aerochamber (V), a specific brand of spacer device, ranged from $7.50
to $16.50 for spacers without masks and from $14 to $31.50 for spacer devices
with masks. (These rate quotes were in effect as of February 2000.) In July
2000, Medicaid raised reimbursement rates from $12.50 to $16.50 for spacers
without masks and from $23.75 to $27.75 for spacers with masks. Reimbursement
rates for PF meters were increased to $19.24.12
These adjustments were made in part to account for the costs of purchasing
items individually instead of in bulk. The effect of these interventions on
increasing spacer and/or PF meter availability is not yet known.
Although the participation rate for this survey was high, it was limited
by having a single informant at each pharmacy who may not have been completely
informed about store policies; however, this may well reflect the experience
families have when arriving at pharmacies with prescriptions in hand. Another
limitation of this survey is that it only included Bronx pharmacies. If barriers
exist in obtaining spacers/holding chambers, PF meters, and nebulizer machines
in the Bronx, where the prevalence of asthma is higher than the national average,14 it may be reasonable to suspect that children and
adults in other areas of the country also encounter difficulties obtaining
certain asthma equipment. Further research is necessary to evaluate whether
barriers to accessing asthma equipment exist in other areas of the United
States.
CONCLUSIONS
Families in need of spacers/holding chambers, PF meters, and nebulizer
machines may encounter difficulties in obtaining them in Bronx pharmacies.
Pharmacies reported reasons for not carrying equipment reveal misunderstandings
about Medicaid reimbursement procedures. Interventions are necessary to direct
families to pharmacies that carry prescribed equipment and to increase the
proportion of pharmacies that do. Strategies may include increasing pharmacists'
awareness regarding Medicaid reimbursement procedures and addressing pharmacists'
concerns about reimbursement rates.
| What This Study Adds
The purpose of this study was to investigate the clinical impression
that Bronx families encounter difficulties in obtaining prescribed asthma
equipment, such as spacers/holding chambers, PF meters, and nebulizer machines.
To our knowledge, it is the first study to explore true and/or perceived barriers
reported by pharmacists as to why they do or do not carry specific equipment
and as to whether they accept Medicaid insurance for reimbursement.
This study suggests that clinicians caring for families in the Bronx
must be aware of the limited availability of asthma equipment for Medicaid-insured
families in local pharmacies and direct families to pharmacies that both carry
the equipment and accept Medicaid for it. In addition, targeted interventions
that address pharmacists' reported misconceptions and concerns regarding Medicaid
reimbursement for asthma equipment might help increase the proportion of pharmacies
that both carry the equipment and accept Medicaid for it.
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AUTHOR INFORMATION
Accepted for publication April 4, 2002.
Presented in part at the 40th Annual Meeting of the Ambulatory Pediatric
Association, Boston, Mass, May 13, 2000.
Corresponding author and reprints: Karen L. Warman, MD, Department
of Pediatrics, Children's Hospital at Montefiore/Albert Einstein College of
Medicine, 1621 Eastchester Rd, Bronx, NY 10461 (e-mail: KWarman{at}Montefiore.org).
From the Department of Pediatrics, Children's Hospital at Montefiore,
Albert Einstein College of Medicine, Bronx, NY.
REFERENCES
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1. Adams PF, Hendershot GE, Marano MA. Current estimates from the National Health Interview Survey, 1996. Natl Center Health Stat. 1999;10:200.
2. Ford JG, Findley SE, Nachman SA, Trowers RL, McLean DE. Fatal asthma in perspective: relation between individual and community
risk factors. In: Sheffer A, ed. Fatal Asthma. New York,
NY: Marcel Dekker Inc; 1998:47.
3. National Asthma Education and Prevention Program. Expert Panel Report II: Guidelines for the Diagnosis
and Management of Asthma. Bethesda, Md: National Institutes of Health; 1997.
4. Newhouse MT, Dolovich MB. Control of asthma by aerosols. N Engl J Med. 1986;315:870-874.
ISI
| PUBMED
5. Konig P. Spacer devices used with metered-dose inhalers: breakthrough or gimmick? Chest. 1985;88:276-284.
FREE FULL TEXT
6. Selroos O, Halme M. Effect of a volumatic spacer and mouth rinsing on systemic absorption
of inhaled corticosteroids from a metered dose inhaler and dry powder inhaler. Thorax. 1991;46:891-894.
ABSTRACT
7. Toogood JH, Baskerville J, Jennings B, Lefcoe NM, Johansson SA. Use of spacers to facilitate inhaled corticosterid treatment of asthma. Am Rev Respir Dis. 1984;129:723-729.
ISI
| PUBMED
8. Shapiro G, Mendelson L, Kraemer M, Cruz-Rivera M, Walton-Bowen K, Smith JA. Efficacy and safety of budesonide inhalation suspension (Pulmicort
Respules) in young children with inhaled steroid-dependent, persistent asthma. J Allergy Clin Immunol. 1998;102:789-796.
FULL TEXT
|
ISI
| PUBMED
9. Baker JW, Mellon M, Wald J, Welch M, Cruz-Rivera M, Walton-Bowen KA. A multiple-dosing, placebo-controlled study of budesonide inhalation
suspension given once or twice daily for treatment of persistent asthma in
young children and infants. Pediatrics. 1999;103:414-421.
FREE FULL TEXT
10. Woolcock AJ, Yan K, Salome CM. Effect of therapy on bronchial hyperresponsiveness in the long-term
management of asthma. Clin Allergy. 1988;18:165-176.
FULL TEXT
|
ISI
| PUBMED
11. Beasley R, Cushley M, Holgate ST. A self management plan in the treatment of adult asthma. Thorax. 1989;44:200-204.
ABSTRACT
12. MMIS Pharmacy Provider Manual, Rev. July 2000. Albany: NY State Dept of Medicaid; 2000.
13. Warman KL, Silver EJ, McCourt MP, Stein REK. How does home management of asthma exacerbations by parents of inner-city
children differ from NHLBI guideline recommendations? Pediatrics. 1999;103:422-427.
FREE FULL TEXT
14. Crain EK, Weiss K, Bijur P, Hersh M, Westbrook L, Stein RE. An estimate of the prevalence of wheezing among inner city children. Pediatrics. 1994;94:356-362.
FREE FULL TEXT
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