Providing Asthma Care During an Insurance Crisis

Vol. 14 •Issue 3 • Page 26
Doing Business

Providing Asthma Care During an Insurance Crisis

Providing care out of the goodness of your heart may be the right thing to do when patients can’t pay, but it’s also lousy for business.

Unfortunately, your patients may be facing health insurance troubles for a variety of reasons. Maybe they lost their coverage because they were laid off or because their employer decided it was just too expensive to offer insurance anymore.

Even insured patients may no longer be able to afford high drug co-pays, or even worse, the co-pays for their office visits. That leaves doctors in the tough spot of trying to provide care to patients in serious financial straights.

But doctors are facing their own insurance problems with inadequate reimbursement, not to mention rising liability premiums. The result is a monetary squeeze, with cash-strapped patients on the one side, and cash-deprived offices on the other.

You can be as kind and nice as you want, treating patients despite these harsh fiscal realities, but doctors can’t lose sight of one hard fact: “You need to make enough to stay in business,” said Linda Ford, MD, AE-C, president of the Asthma & Allergy Center, a solo practice in Papillion, Neb.

To do that, asthma doctors in private practice need to navigate insurance requirements, be creative in prescribing meds, and run a tight ship, all the while striving not to compromise the care they’re giving. It’s not easy.


If you suspect that patients may not be able to pay for their medications, you must find that out, just as you would find out if they had pets in the home or any other barrier that would get in the way of optimally controlled asthma, said Andrew W. Green, MD, FAAAAI, FACP, of Green and Sloan LLP Adult and Pediatric Allergy, a two-physician practice in Buffalo, N.Y.

“It’s important to be upfront with them,” Dr. Green said. “Ask them if there is any barrier. If you don’t, they won’t volunteer it.”

These discussions can prove particularly difficult for patients who feel they must choose between paying for their asthma drugs and filling prescriptions for several other conditions as well.

Because of all this, patients are asking more and more about buying drugs from Canada, a tricky question for clinicians, given that the quality of these drugs isn’t guaranteed and that doctors can’t legally advise patients to buy them.

“I don’t recommend it,” said Stanley Fineman, MD, MBA, with Atlanta Allergy & Asthma Clinic, an 18-physician practice in Marietta, Ga. “I discourage it. It’s a potential problem.”


Doctors can work with patients to find solutions closer to home. To begin with, they can hook these patients up with pharmaceutical companies, several of whom have programs that offer drugs for free or reduced cost to financially struggling patients, said Kenneth Chinsky, MD, FCCP, of Chest Diseases of Northwestern Pennsylvania, a five-physician practice in Erie.

Dr. Chinsky’s practice performs clinical research projects, and they try to sign needy patients up for these. Patients receive free care and medicine for participating, and they’re also reimbursed for their time.

Another option is to look at exactly what you’re prescribing. Three or four drugs may exist in the same category, Dr. Green said, so try to determine which one will last the longest for the cheapest amount of money. Try to give the lowest possible effective dose.

This stretching of medication can work well for patients with mild to moderate asthma, though for moderate to severe patients, it may be insufficient. “Doctors have to be creative,” Dr. Green said, “but you don’t want to compromise your principles of care.”

Then there’s the dispensing of free drug samples, a popular solution for people unable to pay. The number of his patients asking for samples has increased, Dr. Green said, and those asking the most aren’t those without insurance, but those stuck with high pharmaceutical co-pays.

To obtain samples from drug representatives, doctors should adopt the mindset of the Temptations: “Ain’t too proud to beg.” Some practices say they won’t see drug reps, but that’s doing a disservice to your patients who can’t afford meds, Dr. Green said.

The best approach is to see the reps and directly ask for samples. “Look at this as another way to help your patients,” he said.

And if none of these approaches is enough to assist patients unable to pay, and if doctors still are determined to give great care, then they ultimately may be required to rely on the kindness of their hearts. Many seem resigned to do just that.

For patients struggling with medical bills, Dr. Fineman will lower the charge as much as he can, asking for enough to cover only expenses.

Dr. Chinsky will work out a payment schedule with patients. “Our policy is, especially for long-standing patients, if the patient says I can give $5 a month, I say, ‘Fine.’ It’s something we feel we should do to give back to the community.”

For patients who can’t afford the office visit co-pays, Dr. Ford charges $10, and the only reason she charges anything is because the patients wouldn’t come if it was free.

“You have to give care,” she said. “You can’t turn them away.”


However, you don’t want to offer so much care at deep discount that you turn yourself into a Dollar Store for asthma treatment. Your budget will be tough enough to balance as it is.

Remember the inadequate reimbursement you’re most likely receiving. For an omalizumab injection, for instance, Dr. Ford is reimbursed $514 from a third-party payer. The price of the drug itself, though, is $475, and that doesn’t include all the other costs that go into giving the shot such as the 30 minutes needed to mix it up in the office. In the end, that doesn’t leave much profit, if any at all.

Under these circumstances, private practices have to run a tight ship. “If you’re getting pushed by the economics of your practice, don’t waste,” said Michael J. Tronolone, MD, MMM, medical director of the Polyclinic in Seattle, a physician owned and operated multispecialty group with 94 physicians. “Take a hard look at yourself.”

Stay on top of changes in the various insurance plans. At Dr. Fineman’s practice, every two months a staff member reviews the many drug formularies the practice deals with. The most common dozen or so plans are placed on an easy-to-read grid so the doctors can see what meds are covered.

It’s never easy to prescribe a medication that isn’t covered, Dr. Ford said. “It takes up a lot of time, more than ever before.” And no matter how much time and effort is put into paperwork justifying to insurers why a particular drug is warranted, there’s no guarantee that they will agree to reimburse the drug.


As if the current state of affairs isn’t uncertain enough, private practice doctors will need to consider an insurance trend that may grow much more popular in the near future: consumer-directed health care plans. “Fundamentally, it’s a really big change,” Dr. Tronolone said. “This is the next big thing.”

Depending on your point of view, the plans, which typically combine health savings accounts with a large deductible, potentially can be either a good or bad development. On the plus side, the plans allow patients to decide for themselves how they want to spend their health care dollars.

But the problem is that patients may choose to spend their money on different health issues, rather than their asthma care.

“Everyone is going to establish their own priorities,” Dr. Green said. So physicians will need to educate patients and convince them that their asthma care is worth their money and is just as important as their other health needs.

“The new plan puts a lot of onus on patients to understand the care they’re getting.” Dr. Tronolone said. “They need information about quality choices.”


Confronted by all these insurance and financial pressures, some doctors have given up running their own practices. “I think a lot of physicians aren’t independent anymore,” Dr. Ford said.

Figuring that their practices were no longer worth the trouble, they went to work for hospitals instead. That sort of arrangement certainly means fewer worries, but something gets lost, too. “You’re marching to the beat of someone else’s drummer,” Dr. Ford said.

For private practice doctors not wanting to meet the same fate, Dr. Ford encourages them to let their senators and congressmen know how the insurance crisis is affecting their patients.

“Let your voice be heard,” she said. “That’s the only way things will change.”

John Crawford is associate editor of ADVANCE. He can be reached at [email protected].


Medicare caused worry in the home care ranks last year when it proposed an 89-percent reimbursement reduction for two nebulized drugs used to treat chronic obstructive pulmonary disease: albuterol sulfate and ipratropium bromide.

“I think what’s happening is Medicare is looking at nebulized medications very closely,” said Philip Marcus, MD, MPH, chief of the division of pulmonary medicine, St. Francis Hospital, Roslyn, N.Y.

The cuts were mandated by law, as Medicare was required to pay for these drugs based on the average sales price plus 6 percent, as opposed to the old way of basing the price on average wholesale price.

While the proposed cuts ultimately were approved, their impact was greatly reduced because Medicare also raised the dispensing fee for the two drugs. Before, the dispensing fee was a nominal $5, Dr. Marcus said, but now it stands at $57 for a month’s supply of therapy and $80 for three months.

So, in the end, the new fees balanced out the cuts. “It’s a rather nice fee,” Dr. Marcus said. In fact, he believes the fee may actually improve business for home care companies.

–John Crawford