By Dr. Paul Ehrlich
Wither the allergy shot? This oldest and best-proven allergy therapy is under pressure from some of the same forces that have put medicine out of reach for many patients even as more people are covered by health insurance. You won’t find me declaiming against the ACA.
A few weeks ago, our guest writer Dr. Robert Y. Lin (like me a former president of the New York Allergy and Asthma Society) warned about proposed new rules that allergen extracts be made available in standardized concentrations and pre-measured vials that must be discarded after 30 days to guard against contamination instead of letting us use open vials at our discretion, sharing particular extracts among patients who have the same allergies and adjusting doses for individual patients. The current system is a very efficient use of resources both for providing individualized medicine, which is supposed to be encouraged, and maximizing the use of still-potent drugs.
A new policy to make efficient and effective treatment more wasteful and lucrative for manufacturers comes at a time when over-prescription and waste are under attack elsewhere in pharmaceutical land. Oversized prescriptions of opioids for iffy pain complaints are blamed for the proliferation of prescription drug addiction and an overdose epidemic. Doctors will now be encouraged to write for as little as three days to keep pills from ending up on the street. Cancer drugs have their own oversupply problems, although fueling a black market is not among them. Researchers at Sloan-Kettering estimate that $3-billion in chemo goes down the toilet annually. “Drug companies are quietly making billions forcing little old ladies to buy enough medicine to treat football players, and regulators have completely missed it,” said Dr. Peter B. Bach, director of the Center for Health Policy and Outcomes at Memorial Sloan Kettering and a co-author of the study. “If we’re ever going to start saving money in health care, this is an obvious place to cut.”
So why is the United States Pharmacopeia and The National Formulary (USP–NF) pushing allergists in the other direction? Who makes money from forcing people to buy more stuff than they need and throw the surplus away? I’ll tell you: not the allergist. We are trained to customize the dosing and our safety record is stellar. Our mistakes come from occasionally computing the wrong dose, not infecting patients, and are covered by the observation period after the injection.
But that’s not why I am writing this. I am responding to a fascinating piece I came across while catching up on my allergy literature. A September article in the Annals of Allergy, Asthma & Immunology called “Non-adherence to subcutaneous allergen immunotherapy: inadequate health insurance coverage is the leading cause.”*
The authors studied 555 patients with allergic rhinitis and/or asthma who quit their shots before they were done. In descending order, of the 75% who gave a reason, they were: “requirement of copayment for allergy injections and/or payment for allergen extract by their health insurer (40%); inconvenience of travel (15%); change of residence (8%); concurrent health problems (5%); patient-perceived ineffectiveness (4%); patient-perceived lack of need to continue immunotherapy (2%); adverse effects from injection (local reaction 1%; systemic allergic reaction 0.5%); and trial of alternative medicine (0.1%).“
The long-term payoff from allergy shots has been well established. A 2013 study of Florida patients of health care costs over an 18-month period showed significant savings starting within three months of initiating therapy. For the full 18 months, the saving was 38% compared to controls, $6,637 for patients receiving immunotherapy vs $10,644 both for kids and adults. This is just one such study. When you add in the savings from emergency asthma hospitalizations, school and work absences, and greater productivity at both, the savings become much higher.
Shots get a bad name with patients because their doctors seem to regard them as a cash cow for 3-5 years. This is both bad medicine and bad business. In my practice, when people come in asking for shots I put them through the ringer educating them on the realities of treatment, and I would even if it were free to the patient. I don’t want them to start and stop or find excuses not to take the subway or not go out because it’s too cold or too wet. By raising the bar and getting patient buy-in, my compliance rate is about 90%, compared to less than 25% in the universal health care environment of the Netherlands, where this has been studied, and even lower for sub-lingual immunotherapy.
We also require that patients come in for regular follow-up visits, instead of farming out the injections to primary care doctors on autopilot, as often happens. (A retiring doctor once “bequeathed” a patient to my practice who had been on a sub-therapeutic dose for 50 years.) Office visits allow us to evaluate whether the treatment is working, adjust concentrations—sometimes up and sometimes down—and even to respond to patient questions about whether they really might be better off just on over-the-counter medication. These visits are even more important for those who also have asthma.
Regardless, cost should not be an object when you look at the big picture. I.e. there ought to be a way to discount the cost of actual treatment based on the savings as a whole. But it’s hard for individuals to make the investment in tomorrow’s benefits in today’s money. As a structural matter, the insurance industry ought to paying for the future today. This is precisely what the authors recommend:
“If health insurers cover the cost of subcutaneous allergen immunotherapy fully, it will clearly allow for better use of this treatment option. This will not only improve quality of the life of the patient and lessen the direct and indirect costs related to the disease but also will be economical to the health care system.”
*Lead author, Ravi Vaswani, I’m pleased to note, is affiliated with the NYU School of Medicine where I am on the faculty, although he is not an MD.