Managing COPD From a Health Systems Perspective

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AJMC^®: What is your role in the management of patients with chronic obstructive pulmonary disease (COPD)?

Klares: As a practicing pulmonologist, my role is primarily advisory, supporting primary care physicians in navigating the complexities of managing patients with COPD. The challenge lies in the extensive guidelines that primary care physicians must juggle during routine visits, which makes it difficult to stay updated. My key responsibility is to keep them informed about the latest guidelines, therapies, medications, and nonmedication interventions.

I play a crucial role in the management of severe COPD cases while still collaborating with internists when the complexity goes beyond their scope. Open dialogue with both primary care physicians and patients is essential. However, integration can be challenging due to existing system limitations, and patients often have multiple comorbidities requiring collaboration with specialists such as psychiatrists, cardiologists, and vascular disease specialists.

In essence, my primary role involves assisting patients, primary care physicians, and specialists in navigating these complexities and staying current with the ever-expanding medical information landscape. The explosive growth of medical information poses a real challenge, and I aim to address it by facilitating communication and knowledge dissemination among health care professionals.

AJMC: Could you describe the economic burden that COPD poses to the health care system?

Klares: The economic burden of COPD is substantial. It disproportionately affects individuals of lower socioeconomic status globally, including in the United States. Beyond medication costs, frequent hospitalizations, work loss, and decreased wages add to the financial strain. Families of patients with COPD also bear a significant burden.

This economic impact extends to health care systems, with high costs stemming from both the disease’s prevalence and the expenses associated with newer but expensive therapies. Coverage challenges often emerge due to these costs, contributing to the overall economic burden. As the aging population grows, the economic toll is expected to increase.

Mitigating this burden requires addressing hospitalization rates and health care use, which present a significant challenge for health care decision makers and clinicians alike. Reducing these impacts can lead to substantial cost savings in the management of COPD.

AJMC: Over 70% of patients with COPD may be undiagnosed.¹ What strategies can a plan employ to improve the rate of COPD diagnosis?

Klares: Addressing the challenge of diagnosing COPD effectively requires a nuanced approach. Firstly, in communication from health plans, clarity is crucial. Instead of solely diagnosis codes, brief notes on diagnosis and management can greatly assist clinicians, especially when codes are cluttered with extraneous information.

Regarding screening, routine assessments for asymptomatic patients lack recommendations. However, plans can focus on trigger points like symptoms (eg, smoking history, cough, wheezing, shortness of breath), particularly in older patients who face higher risk. This targeted approach, when integrated into data collection efforts, can prompt necessary communication for patient screenings.

Primary care physicians are often aware of these challenges, but gentle reminders from health plans can reinforce the importance of screening. Using available diagnosis codes as triggers for reminders is a practical strategy that facilitates the identification of patients who may not have undergone screening.

Additionally, recognizing the overlap between asthma and COPD in older patients is essential. General screening that emphasizes typical symptoms like cough, wheezing, recurrent infections, sputum production, and chronic bronchitis can prompt timely interventions.

To further assist clinicians, reminders can include concise blurbs on guidelines without unnecessary verbosity. Simplifying information is crucial, considering the substantial amount of data physicians navigate daily. By implementing these streamlined strategies, we aim to enhance the diagnosis process for COPD and ensure that patients receive timely and appropriate care.

AJMC: Problems with access to spirometers and proficiency with spirometric testing contribute to underdiagnosis, particularly in primary care.² What can be done at the health systems level to improve access to spirometry?

Klares: Addressing limited access to spirometry in primary care is straightforward. Providing spirometers to primary care physicians is a practical solution. Office spirometry, considering the overall burden of COPD, is cost-effective. The machine and software are reasonably priced, and the test can be administered by a medical assistant, eliminating the need for a respiratory therapist and extensive training.

Moreover, there’s synergy in using spirometry for patients with COPD and/or asthma. Rather than placing the burden on physicians to acquire equipment, proactive steps from insurance companies or health plans can make a significant impact. Offering spirometry equipment, potentially coupled with telehealth or online training, streamlines the screening process.

During this initiative, a focus on reinforcing screening criteria (including symptoms, exposures, and medical history) adds value. By taking these steps at the health system level, we can effectively improve access to spirometry, ensuring timely and accurate diagnosis of respiratory conditions.

AJMC: What data-based strategies might a plan employ to identify patients with COPD?

Klares: In addressing the question of data-based strategies for COPD identification, the focus lies on key triggers within patient databases. Smoking and occupational history are obvious markers, but symptoms serve as primary indicators for screening.

Chronic cough, wheezing, and shortness of breath coupled with a patient’s history of hospitalizations or respiratory issues—especially in those with risk factors like smoking or occupational exposures—should prompt attention. Implementing a plan-wide, data-driven approach can effectively serve as reminders for primary physicians.

Frequent repetition of specific diagnosis codes, often mistaken for allergies or seasonal issues, can signify potential COPD cases. Using these codes as cues within a plan’s data system helps to remind physicians of the need for COPD screening. By employing these targeted data-based strategies, we can enhance the identification of COPD patients and facilitate timely intervention.

AJMC: COPD exacerbations are costly and are associated with high rates of hospital 30-day readmissions.^3,4 How might plans identify patients at risk of COPD exacerbations?

Klares: The challenge of preventing costly COPD exacerbations and reducing 30-day readmissions is crucial for health care stakeholders. A clear risk indicator is a patient’s history of previous hospitalizations, with a mortality rate of up to 40% to 50% within 4 to 5 years post admission.

The low-hanging fruit in identification lies in those with prior exacerbations, as they face significant risks. Monitoring medication adherence, assessing affordability, and ensuring that refills are consistent offer another avenue for identifying at-risk patients.

Examining comorbidities is essential, especially within the first year post exacerbation. Conditions such as congestive heart failure, vascular disease, and mental depression, as well as male sex, elevate the risk of death or subsequent exacerbations. Focusing screening efforts on these high-risk patients enables targeted resource allocation to prevent admissions.

Pulmonary rehabilitation, a factor often overlooked due to accessibility challenges, plays a significant role in decreasing exacerbation risk. Improving access to pulmonary rehabilitation, whether through home-based or formal programs, is a valuable strategy. These multifaceted approaches—including addressing history of hospitalization, medication adherence, comorbidity screening, and enhanced access to pulmonary rehabilitation—collectively offer a comprehensive strategy for plans to identify and manage patients at risk of COPD exacerbations effectively.

AJMC: Value-based health care (VBH) may reduce economic costs associated with COPD by paying providers according to patient health outcomes.⁵ What role—if any—do VBH agreements play in your plan?

Klares: Qualifying the role of VBH agreements in our plan is complex. Physicians encounter challenges, particularly with social determinants and treatment costs impacting patient care. For instance, prescribing effective triple-based inhaler therapy, which is known to reduce hospitalization risk and mortality, often faces denial, placing a perceived burden on individual practitioners.

There’s a sentiment that addressing these issues requires a systemic approach rather than individual interventions. Collaborative efforts within value-based models and emphasis on a team-based approach could be beneficial. Instead of a traditional model in which approval is sought, a more collegial approach involves the plan proactively reaching out to physicians. For patients with severe COPD and a history of exacerbations, presenting actionable options and solutions fosters a more cooperative relationship, reducing the prevalent back-and-forth dynamic seen in day-to-day interactions.

In summary, the effectiveness of value-based methods relies on a collective effort, with enhanced collaboration between plans and providers that moves beyond denials to a more proactive and collegial exchange for improved COPD management.

AJMC: How—if at all—does your plan use patient-centered medical homes (PCMHs) or accountable care organization (ACO) models?

Klares: While we’ve engaged with PCHMs and accountable care organization ACO models, the effectiveness appears nuanced. At a granular level, current electronic medical records (EMRs) involve substantial box clicking with unclear evidence of improved outcomes.

To optimize our approach, it’s crucial to pinpoint specific areas where these models have demonstrably enhanced care. As of now, I’m not aware of conclusive evidence suggesting that medical homes consistently provide superior care overall. While I may not be an ACO expert, this observation aligns with my general experience in the field. Streamlining our focus on proven improvements within these models ensures more targeted and effective use in our plan.

AJMC: Treatment according to guideline recommendations has been associated with lower COPD-related health care resource use and COPD-related medical costs and with improvements in exacerbations.⁶ Moreover, lack of familiarity with treatment guidelines among primary care providers may contribute to the high rate of COPD underdiagnosis.⁷ How may plans work with providers to improve guideline use?

Klares: Improving guideline adherence among primary care providers requires strategic communication. Using prescription data and diagnosis codes as triggers can initiate targeted reminders. However, it’s crucial to streamline these communications, avoiding unnecessary information.

For instance, in the transition from inhaled corticosteroids with long-acting β₂ agonists (LABAs) to long-acting muscarinic antagonists (LAMAs) plus LABAs, plans can communicate directly with primary physicians. Clear, concise messages, including diagrams from recent guidelines that outline recommended medications and coverage details, facilitate informed decision-making.

The challenge of medication coverage necessitates plans to proactively provide information on covered medications and suitable substitutions. Often, the back-and-forth between physician, patient, and plan regarding coverage is complex and time-consuming. Plans can play a pivotal role by offering clarity on what is covered and suggesting appropriate substitutions.

In summary, enhancing guideline use requires straightforward and precise communication. Clear instructions on standards of care, medication recommendations, and coverage details contribute to a more streamlined process for primary care physicians, specialists, and patients. This approach minimizes confusion and ensures that all stakeholders are well informed as guidelines evolve.

AJMC: Authors of the 2023 annual report from the Global Initiative for Chronic Obstructive Lung Disease (GOLD) have updated their guidance regarding initial pharmacologic treatment and follow-up treatment. For instance, a LABA plus inhaled corticosteroid (ICS) (LABA + ICS) is no longer recommended as an option for initiation of treatment or to control dyspnea or exacerbations.⁸ How significant is this change?

Klares: The recent shift in recommendations by the GOLD regarding the initiation and control of COPD treatment, specifically the discontinuation of LABA + ICS, holds considerable significance. As a pulmonologist, I often encounter patients on this combination due to prior recommendations.

From a plan perspective, leveraging diagnosis codes associated with COPD and LABA + ICS prescriptions can serve as triggers for targeted communication. A concise outreach that incorporates brief GOLD guideline outlines and simplified diagrams can effectively inform prescribing physicians. This streamlined approach, highlighting prescribed medications and coverage details, minimizes the challenge of plan-specific medication knowledge.

Implementing changes becomes more seamless when the plan offers patient-specific coverage information and suggests appropriate substitutions. This proactive approach empowers physicians to make informed decisions, facilitating the transition away from LABA + ICS. It addresses real-life challenges faced daily, ensuring that both physicians and patients are well informed and that they can adapt to evolving COPD treatment guidelines.

AJMC: How, if at all, might health care systems encourage providers to attend to changes in medication management recommended by the GOLD guidelines?

Klares: Encouraging providers to adhere to changes in medication management as recommended by the GOLD guidelines requires strategic health care system interventions. A primary focus should be on ensuring coverage for the inhalers, acknowledging their often-higher costs. Physicians, while aiming for guideline-based practices, encounter obstacles related to these expenses, particularly when transitioning patients to new therapies.

Mitigating this cost barrier becomes a crucial intervention. Plans can play a pivotal role by negotiating better prices, potentially placing these medications in lower tiers. Addressing affordability issues, especially posthospitalization when transitioning to triple-based therapy, is a daily challenge. Creative pharmacologic recommendations, even if involving multiple inhalers to achieve the same combination, present viable alternatives. Rather than the common not-covered, what-next? scenario, plans can engage in more formative interactions with physicians, offering tailored suggestions.

Ultimately, a collaborative approach between plans and physicians that prioritizes patient benefit can alleviate frustrations for patients, physicians, and pharmacists alike. Optimizing these interactions ensures a smoother transition to guideline-based medication management, benefiting all stakeholders involved.

AJMC: The GOLD 2023 report authors note that, for fixed-dose triple therapy (LABA + LAMA + ICS), use of a single inhaler may provide clinical benefit over use of treatment using multiple inhalers.⁸ How important are considerations such as these in coverage decisions?

Klares: Addressing the GOLD 2023 report’s insight on fixed-dose triple therapy and emphasizing the use of a single inhaler is of paramount importance in coverage decisions. Inhaler therapy implementation is intricate, with adherence decreasing significantly when multiple inhalers are involved due to varied actuation methods.

Considering the complexity and potential mortality benefits of triple therapy, it becomes a major challenge to ensure adequate coverage. Financial constraints often hinder prescription accessibility and limit physicians in providing this clinically beneficial treatment. Aligning coverage decisions with current guidelines is vital in allowing patients access to fixed-dose triple therapy.

Furthermore, appropriate prescription considerations are essential. Gentle reminders in pharmacy communications can guide providers to tailor prescriptions based on patient needs, preventing unnecessary use for those who may not benefit. While navigating the challenges of accessibility, recognizing the overall burden of costs, hospitalizations, and outcomes underscores the significance of making fixed-dose triple therapy accessible where clinically indicated. This approach aligns with optimal patient care and contributes to cost-effective management strategies.

AJMC: What final thoughts should payers keep in mind with respect to managing COPD?

Klares: In managing COPD, a holistic approach is essential, especially considering that the prevalence of multiple comorbidities in these patients increases based upon socioeconomic factors. Beyond focusing solely on lung health, addressing peripheral vascular disease, heart disease, depression, and osteoporosis is crucial.

Lung cancer screening remains underused, with only 6% of eligible patients being screened. This process can unveil additional comorbidities. Depression is a key concern, as is ensuring access to pulmonary rehabilitation programs, which is known to impact readmission rates and overall quality of life.

Smoking cessation is paramount, given that up to 40% of patients with COPD continue to smoke. Coverage for over-the-counter cessation therapies should be considered, as it aligns with the goal of creating a smoke-free environment. Additionally, providing benefits for medication assistance akin to gym benefits can further support these patients.

Recognizing that COPD management goes beyond spirometry and medications is vital. High-risk patients often are admitted to the hospital and require special attention. Outreach programs and care navigators can play a pivotal role in helping these individuals manage not only COPD but also their associated health issues. This comprehensive approach benefits both plans and patients, addressing the diverse needs of individuals with COPD and facilitating collaborative care.

References

1. Martinez CH, Mannino DM, Jaimes FA, et al. Undiagnosed obstructive lung disease in the United States. Associated factors and long-term mortality. Ann Am Thorac Soc. 2015;12(12):1788-1795. doi:10.1513/AnnalsATS.201506-388OC
2. Baldomero AK, Kunisaki KM, Bangerter A, et al. Beyond access: factors associated with spirometry underutilization among patients with a diagnosis of COPD in urban tertiary care centers. Chronic Obstr Pulm Dis. 2022;9(4):538-548. doi:10.15326/jcopdf.2022.0303
3. Stanford RH, Engel-Nitz NM, Bancroft T, Essoi B. The identification and cost of acute chronic obstructive pulmonary disease exacerbations in a United States population healthcare claims database. COPD. 2020;17(5):499-508. doi:10.1080/15412555.2020.1817357
4. Jacobs DM, Noyes K, Zhao J, et al. Early hospital readmissions after an acute exacerbation of chronic obstructive pulmonary disease in the Nationwide Readmissions Database. Ann Am Thorac Soc. 2018;15(7):837-845. doi:10.1513/AnnalsATS.201712-913OC
5. What is value-based healthcare? NEJM Catalyst. January 1, 2017. Accessed August 7, 2023. https://catalyst.nejm.org/doi/full/10.1056/CAT.17.0558
6. Palli SR, Zhou S, Shaikh A, Willey VJ. Effect of compliance with GOLD treatment recommendations on COPD health care resource utilization, cost, and exacerbations among patients with COPD on maintenance therapy. J Manag Care Spec Pharm. 2021;27(5):625-637. doi:10.18553/jmcp.2021.20390
7. Foster JA, Yawn BP, Maziar A, Jenkins T, Rennard SI, Casebeer L. Enhancing COPD management in primary care settings. MedGenMed. 2007;9(3):24.
8. Agustí A, Celli BR, Criner GJ, et al. Global Initiative for Chronic Obstructive Lung Disease 2023 Report: GOLD Executive Summary. Eur Respir J. 2023;61(4):2300239. doi:10.1183/13993003.00239-2023

For other articles and videos in this AJMC^® Perspectives publication, please visit "Managed Care Considerations in COPD: Value-Based Strategies and Updated Guidance From GOLD"