COPD: Exploring the value of care

This article is part of the COPD Resource Center.

As the third leading cause of death in the United States, chronic obstructive pulmonary disease (COPD) represents a major public health concern. But in addition to the prevalence and expenses associated with this debilitating chronic disease, a broader societal cost exists.

So what is the prevalence? Six percent of the population-an estimated 15 million adults-is affected by COPD, according to the Centers for Disease Control and Prevention (CDC). And as with all widespread chronic disease, treating COPD comes with a high cost; an estimated $37 billion is spent annually on the care of patients with COPD in the United States.

Societal costs include the effect on the workplace. “It’s one of the biggest reasons of days lost from work,” says Barry Make, MD, a pulmonologist at Denver, Colorado-based National Jewish Health.

According to a September 2012 report by the National Business Coalition on Health, employed people with COPD had missed an average of 4.6 days of work during the previous 6 months. What’s more, employers spend approximately $17,000 per year in healthcare costs on employees with COPD, three times more than those without the disease.

“It’s very expensive for the healthcare system and represents a huge number of outpatient visits,” Make says. In fact, combined with asthma, COPD accounts for 20% of visits to family physicians.

The prevalence of COPD and its role in driving avoidable healthcare costs means that practicing physicians have much to gain by adopting strategies for helping to prevent, properly diagnose, and develop effective interventions for this chronic disease.

Despite decades of anti-smoking public health campaigns, in 2011 45.3 million people, or about 19% of adults in the United States, were still smoking cigarettes. Twenty-one percent of the population is former smokers, according to a CDC survey. In roughly 85% of those in whom COPD has been diagnosed, cigarette smoking is the primary cause. For that reason, establishing protocols to help patients quit the habit should be a top priority for primary care physicians (PCPs).

“If you treat or prevent COPD in cigarette smokers, you’ve accomplished tremendous benefits for patients and their health and also have decreased long-term costs,” says Steve Shapiro, DO, interim chief medical officer with Flint, Michigan-based HealthPlus.

Although fewer people smoke today than in decades past, smoking rates haven’t changed much in recent years within the general population. And smoking rates among women only recently have flattened.

Getting patients to stop smoking is difficult. Shapiro, however, points out that numerous studies make clear how critical physicians’ input is in starting a patient down that path, as well as the positive influence a doctor discussing smoking cessation directly with patients can have on their willingness to stop. “The doctor bringing it up with them is very effective, more so than any other way to address it,” he says.

The key to change is to make sure the conversation continues over time.

“You have to keep up with it. You can’t just mention it once, and you can’t just mention it in passing,” Shapiro says. “The patient has to pick up that you’re really serious about it.”

According to Jeffrey Cain, MD, president of the American Academy of Family Physicians, doctors also need to adjust their own views of tobacco use and look at it as a chronic rather than acute problem.

“Tobacco use is much more like a rheumatoid arthritis that tends to flax and flare,” he says. “We have to think of this as an ongoing management issue. So even though the patient in front of you may not have changed at this visit, if you’re using the stages-of-change model, giving them effective counseling even in early stages helps move people forward.”

Taking a team approach

Family physicians and internists face pressures to add more tasks to their daily routine. A roster of patients with serious health conditions, such as COPD, with a host of challenges associated with effective medical management has become overwhelming for many physicians practicing in primary care today.

Larger market and regulatory forces are encouraging team approaches to primary care, which can be very helpful in addressing chronic health conditions such as COPD, which often require various types of interventions.

Due in part to the Affordable Care Act, Cain says, the United States is demonstrating a greater value for primary care that is based on the Patient-Centered Medical Home (PCMH) and on population management, which will become an important part of participation in accountable care organizations.

“What these models of care point to is the growing role of team-based care,” Cain says.

This approach, he adds, can improve the lives of people with COPD and decrease unnecessary hospitalizations. “This is the good news for family doctors. America is investing in primary care to reduce overall costs, and COPD is an example of where team-based care can be effective.”

For smaller practices not partnered with larger systems, outside resources are available to help family physicians address the needs of patients with COPD, particularly with the goal of reducing smoking rates among a patient population.

Make points out that patients with COPD often have other medical and lifestyle issues that can both affect their health and make the important step of quitting cigarette smoking challenging. Depression, anxiety, and heart disease-another condition also closely linked with smoking-are common among this patient population.

In this case, it may be useful to bring other healthcare professionals into the process.

“You don’t have to do it if there’s someone better to do it,” Make says.

Consider behavioral approaches to smoking cessation, dietary services for patients who are both overweight and underweight (which is common among COPD patients with advanced disease), and other ancillary interventions. Social workers, psychiatrists, and other professionals may be most effective at helping patients achieve success.

Other resources for physician practices are also readily available, Shapiro says, “All the pharmaceutical companies that have introduced drugs have educational materials, the health plans have that, a lot of the hospitals at one time had their own smoking cessation classes for free and the Local Lung Association can be another resource,” he says.

He adds that HealthPlus, like other health plans, works closely with physicians to identify patients who smoke and then provide them with access to case managers, care counselors, and others who will work with the patients individually.

Efforts to support medication adherence is also critically important in controlling COPD, and health plans with disease management programs often send patients reminders to fill their prescriptions. Direct physician support is also often made available in the form of patient education materials about smoking cessation, weight management and in some cases in-office educational programs.

Most health plans offer such services and can be considered a good resource for physicians.

Diagosis, management tools

Despite its widespread prevalence, COPD is under-diagnosed. Make points to a 2000 CDC report in which widespread lung function testing was conducted. The results showed that although roughly 24 million people in the United States appeared to have COPD, the disease was only diagnosed in about half of them.

Make, however, says that with COPD, over-diagnosis is a concern as well. “There may be other reasons for shortness of breath,” he says.

Simple screening questionnaires can help to identify patients who are at risk, but perhaps the most important tool for both diagnosing the disease and managing the treatment of people with it is in-office spirometry. Yet, according to Make, spirometers are not as common as they should be in PCP offices. Historically, he says the reason for that is the cost of the equipment, but in recent years, that’s become less of an issue.

“It’s not common in primary care offices because it used to be more expensive,” he says. According the Make, the cost of the equipment now ranges from $1,000 to $2,000. “If you think about the cost of an electrocardiogram, it’s a lot less expensive and quicker [to perform],” Make says.

In addition, using an electronic health record (EHR) system can greatly assist when it comes to identifying patients who either have COPD or are at risk for the disease.

“Every [EHR] includes tobacco use as one of its required measurements for meaningful use. So there are keys inside every EHR that can help physicians move forward,” Cain says.

Cain points out, however, that not all EHR systems come equipped with the tools needed to conduct effective case management. And this functionality will be an important component, given that population case management plays an integral part in PCMHs. Therefore, finding ways of incorporating this functionality into a practice’s system will be important going forward. Unfortunately, Cain says, these are not add-on packages.

Billing for COPD-related services

As is the case with the diagnosis and management of many chronic illnesses, it behooves physicians to consider how to maximize billing for the services that relate to evaluating, managing and counseling patients with COPD. Offering COPD-specific services isn’t just the right thing to do for patient health, Shapiro says, it can also benefit the practice financially.

“What we’ve found in working with physicians is that the way to get them to change their practice is to find a way to reimburse for the appropriate services,” Shapiro says.

Make points out that physicians often fail to understand how to properly bill. In the case of COPD he says there are a few ways to bill for encounters with a patient.

“You can bill based on the amount of history taking, the physical exam and decision making [involved]. You can also bill based on time. The major allowance is that you have to spend more than 50% of the time counseling. Make explains. It’s important that the time spent is documented in counseling notes.

Counseling codes can be billable more than once a year, Shapiro points out. These codes include:

• 99406 for three to 10 minutes of counseling

• 99407 for more than 10 minutes of counseling, and

• 305.1 for a diagnosis code of tobacco use disorder. This must accompany the counseling codes for payment.

In addition, many physician practices are experimenting with group visits for people with chronic diseases, including COPD, Cain says. “Larger practices may have large groups of people with COPD come in together. They bill for a group visit and there is often cross learning and motivation that happens with people living with a chronic condition that can be helpful,” he says.

Shapiro adds that many physicians have nurse practitioners and physician assistants who can take on the counseling role. Their work often can be billed as well. So, too, can the services of dietitians and other healthcare professionals who can counsel patients about living with and managing COPD.

Overcoming financial barriers

When it comes to adherence to medication regimens or other treatments, the expense of medical care can be a barrier for some patients. With COPD patients who smoke, however, no matter their socioeconomic status, doctors can help them find the money they need to care for themselves.

“Patients will tell you they can’t afford the pharmaceuticals, that it’s too expensive,” Shapiro says. “All you have to do is ask them what they smoke and multiply that, and suddenly they have the money. A pack of cigarettes a day can cost a patient $150 or more each month, depending on where they live. That’s more than medicine,” Shapiro says.

In addition, the Affordable Care Act puts in place financial incentives for people to quit smoking. Starting in 2014, insurers will be prohibited from denying anyone coverage because of a pre-existing condition or charge them more for when purchasing an insurance policy. The law does allow insurers to charge smokers up to 50% more than non-smokers for their coverage, however. One way patients can cut their premiums in half is by participating in a smoking cessation program.

“Up until now, people haven’t seen a direct cost when they are asymptomatic smokers. It’s a way to remind people that tobacco use is a problem for them and our country,” Cain says.