Gastroesophageal Reflux Disease in a Managed Care Setting: Professional, Facility, and Pharmacy Charges

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Abstract
The objective of this study was to compare the overall health care charges of managed care organization (MCO) patients with gastroesophageal reflux disease (GERD) with comparison groups of MCO members. The study consisted of a retrospective review of eligibility data and claims filed for services dated January 1, 1994 through December 31, 1994 in a private benefit plan including HMOs and preferred provider organizations serving commercial and Medicare markets in the Midwest and South. Patients were continuously eligible for drug benefits and were not enrolled in a capitated benefit plan. The GERD group (n=5,254) inclusion required a claim with a diagnosis of GERD. Three comparison groups, age- and gender-matched to the GERD group, were randomly selected (n=5,254 in each group). The first comparison group inclusion required membership in the MCO plan in 1994 whether or not claims were submitted. The second group inclusion required that at least one claim had been submitted in 1994. The third required a claim with a diagnosis of low-back pain (LBP). The groups were mutually exclusive. The measurements used were overall average charge per member per month (PMPM), disease-attributable average charge PMPM overall claim types and for professional, facility, and pharmacy claim types, by age category. Overall charges were derived from any claim; attributable charges were derived from claims with diagnoses or prescriptions consistent with GERD or LBP. Study results showed that GERD patients had facility, professional, and pharmacy average overall charges PMPM 1.7 to 4.8 times greater than those of the comparison eligible or claims groups. All GERD average charges PMPM were significantly greater than the comparison-eligible or claims group averages (pless than.05). GERD facility, professional, and pharmacy average overall charges were from 1.1 to 1.7 times greater than those of the LBP group. The GERD facility and pharmacy charges PMP M were significantly greater than the LBP average charges PMPM (pless than.05). GERD-attributable professional and facility average charges were significantly lower (by 63% and 33%, respectively) than LBP attributable charges. However, GERD-attributable pharmacy average charges were 2.4 times higher than LBP-attributable charges. Total charges for MCO patients with GERD were significantly higher than total and component charges for MCO members without GERD and were generally comparable to charges for patients with a comparison condition, LBP. GERD-specific charges were lower than LBP-specific charges, except for pharmacy charges. These results suggest that GERD patients require significantly more MCO resources in general than do typical MCO members. Further analysis of the sources of GERD resource use is necessary to understand how quality of care can be improved and made more efficient.

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