GERD Disrupts the Workforce and Your Company’s Workday By F. RANDY VOGENBERG, PHD, FASHP and MURRAY L. HARBER
Author affiliation: Dr. Vogenberg is Principal, Institute for Integrated Healthcare and Board Chair, the Employer–Provider Interface Council (EPIC). Mr. Harber is Executive Director of the Mississippi Business Group on Health and Co-Leader, WellSpent Southeast. Address for correspondence: F. Randy Vogenberg, PhD, RPh, Institute for Integrated Healthcare, P.O. Box 8215, Greenville, South Carolina 29604-8215. Email: randy@iih-online.com.
GERD is a common diagnosis and frequently diagnosed in a high cost of care setting. More than one-quarter of the US population are reported to suffer episodes of gastroesophageal reflux disease (GERD). Despite widespread access to medications, mild-to-moderate GERD accounts for increasing total claim cost per year in total employer-sponsored health plan expenditures. Over 5 million new GERD diagnoses are made in the U.S., of which almost 10% diagnosed occurred in the highest cost emergency room setting. Depending upon the seriousness, a hospitalization can occur and frequently a 30-day readmission related to GERD. Surgical options have evolved since the first use of Nissen fundoplication 65 years ago for patients. Many can access or seek medications if they are compliant, respond to therapy or don’t suffer adverse events. For the smaller and more expensive group of plan members with chronic GERD, non-invasive surgical options have evolved since 1956.
Advances in Technology Technology and techniques have evolved while coverage has remained unchanged or episodic from a national perspective, including GERD. One example is Transoral incisionless fundoplication (TIF®) that was introduced in 2005 and TIF2.0 that had device improvements (TIF) approved by FDA in 2007. That latest iteration of TIF employed today, avoids laparoscopic surgery and several complications associated with invasive anti-reflux surgical procedures. While newer, less invasive and proven safe procedures became available, including TIF, medical coverage guidelines don’t always feature those advances that can also reduce the care cost for plan sponsors. Many economic benefits of TIF procedure are in less time off and faster return to work versus just medical claim costs. From the perspective of the plan sponsor (e.g., corporate employer), a key factor in the economic impact of GERD is the indirect costs of GERD, particularly its effect on absenteeism and productivity measures. Researchers have found that workers with GERD had had 41% more sick leave days and 59% more shortterm disability days (P < 0.0001) than matched employees without GERD. On-the-job productivity was also found to be significantly lower annually (by 6.0%) in the employees with GERD.
More Insight About What Can be Done Easy access to effective symptomatic remedies, such as OTCs, has helped a large proportion of the GERD population, but a significant subset group experience chronic or refractory symptoms, despite changes in lifestyle and diet. Medical therapy with PPIs do not resolve 30
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symptoms in 10% to 40% of those patients. When these patients do seek care, they are more likely to have advanced or refractory disease, which may result in referral to gastroenterologists with higher claims costs. Surgical treatment may be recommended in the following scenarios: (1) failure of medical therapies to control reflux symptoms; (2) patients are nonadherent to long-term therapy with PPIs; (3) chronic GERD complications (e.g., Barrett’s esophagus); (4) patients with adverse reactions to medications; or (5) the patient suffers from chronic asthma, cough, or hoarseness. Surgery seeks to address the basic anatomical issue underlying GERD—the Gastro Esophageal Valve dysfunction. Among surgical options available, TIF efficacy and safety data confirm that it significantly diminishes esophageal acid exposure while associated with lower rates of serious adverse events. Recurrent use of GERD medications and the unavoidable need for follow-up procedures have been reported in some. This aligns with typical risk-management stratification, where a small proportion of members are associated with substantially greater costs than average plan members over time. The health economic implications of GERD or TIF have not been revisited nor fully explored for more than a decade. Finding a cost-effective solution over a timespan that reflects real-world duration of employment or plan enrollment may be more meaningful to carriers and employer-sponsored health plans (employer). From that perspective, several key factors must be considered, including the time horizon chosen for determinations of total cost effectiveness. (see graphic Fig 1.0) Further, the greatest contributor to total expenditures by the employer-sponsored health plan associated with GERD is indirect costs, such as productivity and absenteeism. Other benefits for retention or recruitment may also be realized. A recent 150 million record U.S. database analysis of the commercial plan costs associated with the total cost of professional services for TIF and other procedures showed real savings and significant financial separation among the procedures. The objective of the dataset development was to create a series of datasets that contained the total cost of service ascribed to the management and remediation of GERD symptomatology. [Source: Abstracted from personal correspondence McCarty TR, April 2, 2021.] A univariate analysis of the allowed claim cost associated with the TIF Procedure (CPT 43210), the Nissen Procedure (CPT 43280), or the Linx Procedure (CPT 43284) showed that while the Nissen procedure was most frequently used at a mean claim cost of $ 3,006.05 (range $2,907 to $3,104), the lesser used TIF procedure mean claim cost was lowest at $2,298.78 (range
$1,982 to $2,615), and the least used Linx procedures’ mean claim cost of $2819.41 was also higher than TIF. The results shown were independent of patients with facility claims with the same CPT code. Interestingly, there was no difference by mean ages of plan members or gender but there were significant differences across the various regions and site of procedure. This illustrates that an employer may have no increase in claim costs from coverage of TIF to significant savings based on site of care (facility and geography) in a plan year. Cost effectiveness has been shown through modeling of that data up to 10 years. The 24% lower cost of TIF along with indirect savings for employer plans make total cost savings higher. Lastly, this means an employer is also likely to save on claim costs in subsequent years using TIF along with measures of improved unplanned absence and sustained productivity.
What Can Be Done About It Today? In the face of limited economic information, employers still decide on coverage policy by only looking at their direct claims costs as their financial risk. Careful trend analysis in high-prevalence, chronic disorders like GERD can reveal potential opportunities for reducing direct and indirect economic risks represented by such sub-groups through optimal coverage policies. Targeted efforts with patients with refractory or severe GERD, represent important opportunities around long-term conditions for employers as part of an enterprise-wide risk management approach that focuses on subpopulations of patients as members of plan associated with higher spending on healthcare. By understanding the impacts from a long-term condition like GERD one must consider its effect and impact on the workplace. It remains important to provide the right information at the right time and make available all coverage options to best help the plan member manage the impact of GERD. As an example, if the TIF procedure is not covered, employers can request their administrator or insurer add TIF coverage (CPT code #43210) to their commercial plan. Ultimately this helps the employees with their long-term medical condition, and out-of-pocket (OOP) costs while stabilizing the employers’ bottom line along with improved productivity and satisfaction with company benefits. Employers can use this information to better manage both fiscal and clinical aspects of their benefit plan today until guidelines catch-up to real-world practice along with technologies that can avoid care in higher cost settings along with productivity gains that both help the bottom line.
