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

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 eligibil- ity data and claims filed for services dated January 1, 1994 through December 31, 1994 in a private benefit plan including HMOs and pre- ferred 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 sub- mitted. 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 con- sistent 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 10% of the adult population? GERD may be associated with up to 50% of patients with noncardiac chest pain, 78% of patients with chronic hoarseness, and 82% of patients with asthma.' Cost-effective medical management of GERD should consider the range and severity of symptoms4 GERD management includes lifestyle modification and antacid therapy, pharmaco- logical medications (histamine H2 receptor antagonists, proton pump inhibitors, sucralfate, and prokinetics), and surgery for those 5% to 10% of patients with nonresponsive GERD1.5 resulting in what some consider to be a high rate of health care