Disparities in Asthma Medication Dispensing Patterns: The Case of Pediatric Asthma in Puerto Rico

Abstract

Background Disparities exist in asthma medication dispensing between children with public insurance and those with private insurance under a Managed Care Medicaid system in Puerto Rico. Objectives Island-wide medical claims data were used to examine the extent to which differences between the private and public health care sectors affect medication dispensing and health care utilization among asthmatic children. Methods Children 3–18 years old with at least one service claim (outpatient, hospitalization, or ED visit) for asthma or reactive airway disease from 2005–06 were selected. Chi-square analyses compared medication dispensing and health care utilization between the public and private sectors. Negative binomial regression identified factors associated with the mean dispensing rate of prescriptions for controller anti-inflammatory medication (CM). Results Private insurance families (n= 28,088) were dispensed significantly more CM (48.3% vs. 12.0%) and quick relief medication (47.4% vs. 44.6%) than public insurance families (n=13,220). The dispensing of inhaled corticosteroids (24.4% vs. 6.7%) and leukotriene modifiers and cromolyn (31.4% vs. 5.7%) was dramatically higher in the private sector. In contrast, ER use was significantly higher among public insurance children (51.7% vs. 13.8%). Multivariate analysis showed that age, number of beta-agonists, and type of insurance was associated with CM dispensing; private insurance showed the greatest effect. Conclusion Asthmatic Puerto Rican children enrolled in public insurance were significantly less likely to be dispensed CM than children with private insurance; suggesting that under- treatment of public insured children may substantially contribute to increased asthma morbidity in this population as evidenced by significantly higher rates of ED visits.

Factors associated with disparities in emergency department use among Latino children with asthma

“…This public health policy was in great part responsible for the fact that only 12.3% of children with asthma that had public insurance versus 48.3% in the private sector were dispensed controller asthma medication within a given year. 25 After controlling for severity, children with public health plans who were not receiving controller medications compared to those that were dispensed the medication, were also significantly more likely to use the ED use and to have their asthma be poorly controlled. 25 Since October of 2010 the public health policy has changed in Puerto Rico and insurance companies instead of providers are directly responsible for medication costs.…”

“…25 After controlling for severity, children with public health plans who were not receiving controller medications compared to those that were dispensed the medication, were also significantly more likely to use the ED use and to have their asthma be poorly controlled. 25 Since October of 2010 the public health policy has changed in Puerto Rico and insurance companies instead of providers are directly responsible for medication costs. Changes in public policy so that reimbursement to providers are increased, or the risk for medication costs and referrals is eliminated, have the potential of eliminating barriers of access to specialists and prescription of controller medications previously associated with public insurance.…”

Effectiveness of a multi-level asthma intervention in increasing controller medication use: a randomized control trial

“…We know that many children with asthma are undertreated, particularly inner city low income children [46] and in Puerto Rico under-treatment is even more dramatic that in other cities of the US [23, 47, 48]. However, it seems that in this sample of children with persistent asthma, more than half of the children at baseline and follow up reported controller medication use (our primary outcome).…”

“…no case management personnel, only one nurse per clinic) to attend this high volume. Low capitation fees assigned by the government to the clinics that attend Medicaid children may be related to the lack of resources available at the clinics [23]. Furthermore, there is evidence that physicians face several barriers to prescribing controller medication particularly inhaled corticosteroids [41-43].…”

“…In our previous research we had addressed the individual and family component of the model, as well as the environmental context (allergens and triggers) with the development of the CALMA-only intervention [11]. We had partly addressed the health care system domain, by providing evidence on how a government reimbursement policy for physicians treating children with persistent asthma and public insurance was related to significantly lower controller medication dispensing among these children as compared to children with private insurance [22, 23]. However, we had not addressed the extent to which the clinic environment and provider training (part of the health system domain) was related to asthma disparities, particularly as it related to controller medication use.…”