Episode transcript
Time stamps
0:18 Introductions and overview on The Triple Aim approach to healthcare
2:48 Per capita cost of allergy in America for patients
6:28 Patients experience of allergy care in America
11:34 Debunking current dogmas related to serological allergy testing
14:27 Allergy population health insights
14:50 Patient adherence and effectiveness of clinical advice
18:58 Understanding the landscape of allergic patients in America and how it impacts healthcare stakeholders.
20:41 Advancing health equity for allergy patients
23:14 Wrap-up and review of the current status of allergy care in the US.
Transcript: Announcer:
ImmunoCAST is brought to you by Thermo Fisher Scientific, creators of ImmunoCAP™ Specific IgE diagnostics and Phadia™ Laboratory Systems.
Gary Falcetano:
I'm Gary Falcetano, a licensed and board-certified PA with over 12 years experience in allergy and immunology.
Luke Lemons:
And I'm Luke Lemons with over six years experience writing for healthcare providers and educating on allergies. You're listening to ImmunoCAST, your source for medically and scientifically-backed allergy insights.
So on today's episode of ImmunoCAST, we're going to be taking a look at allergic patients in America. We're going to be providing an update in a profile of these patients through the framework of the Triple Aim.
Gary Falcetano:
The Triple Aim was a concept that was brought forth, I think back in 2008 by the Institute of Healthcare Innovation. And it's really a way to look at healthcare and how it affects all of the stakeholders.
Luke Lemons:
So the Triple Aim is broken down into per capita cost, population health, patient's experience of care, and they added the well-being of the healthcare workforce, and then advancing health equity. So it's looking at, let's say, a healthcare system or a disease through these lenses to better our current healthcare operations.
Gary Falcetano:
Exactly. I think as clinicians, especially ones that are not in healthcare systems per se, we tend to think of healthcare are really centered around the patient, which is certainly where this framework came from, but it really expands out and it really looks at how what we do affects not only individual patients, but the entire healthcare system in total.
Luke Lemons:
This is important not just for allergists to know about the current state of a patient who has allergies in America, but also primary care, GI, pediatrics, pulmonologists, everybody should really try to be understanding where their patients with allergies sit in this grand scheme, because oftentimes allergists aren't the first line to see these patients. They're not the first clinicians to see it, and there is actually a report that happened in 2019 that revealed that there's only about 5,000 active allergists in direct patient care, but there's greater than 50 million people with allergies.
Gary Falcetano:
Exactly. And that combined with another workforce analysis that actually looked at there being a shortfall of just under 500 allergists by 2025, when you look at that and you also look at the growing demand, allergy prevalence is increasing, whether it be food allergy, respiratory allergy, we talked a little bit about climate change and how that's affecting the prevalence of allergy. With all these factors coming together, it's really incumbent upon everyone who sees patients with suspected allergies to take all of these considerations in mind.
Luke Lemons:
So why don't we start when we look through the tripling framework with per capita cost of allergy? There's a lot of costs that go into having allergies, and there's epinephrine auto-injectors, there's specific diets patients have to follow. We found that allergen-free products cost two to four times more than foods containing common allergens.
Gary Falcetano:
Exactly. And don't forget about clinician visits...
Luke Lemons:
Exactly.
Gary Falcetano:
... clinic visits. And then the majority of allergy relief medications for respiratory allergies are over the counter, so all of these costs are being borne by individual patients as well.
Luke Lemons:
So the cost of caring for children with food allergies is 25 billion, and for rhinitis, it's 11 billion in direct medical costs, and asthma is 50 billion in direct costs for Americans. So there's a lot of money out there that patients are spending on managing their symptoms on, like you said, appointments, over-the-counter medicine, specific diets, and medications. How can clinicians help these patients now?
Gary Falcetano:
It really comes down to properly diagnosing the patient. We know that there are a number of patients out there with suspected food allergy who have not received an adequate diagnosis, who these epinephrine auto-injectors are being prescribed for, and they may not need them.
Luke Lemons:
It's using the correct diagnostics when looking at these symptoms. So for example, allergen component testing, discovering whether they have a, let's say, a lactose intolerance versus a milk allergy because the symptoms for food allergy aren't anaphylaxis or nothing, there can be less severe symptoms that may get confused with some intolerances. And we actually have an episode on that after this. So recommend checking that out if you're listening in the future.
Gary Falcetano:
You're speaking of the future, but if we go back to the past, we have had episodes, especially I think important one to mention is the one we did on the European food allergy guidelines that were recently released. And I think there when it comes down to getting a proper diagnosis, those guidelines speak to the importance of a thorough clinical history combined with appropriate testing. And those guidelines spoke to specific IgE testing for both whole allergens and components.
Luke Lemons:
And looking even at respiratory, in one study found that about 65% of people who were prescribed antihistamines for allergies were in fact non-allergic, which means there may be patients now who are spending money every allergy season on antihistamines, which will do nothing for them if they don't have allergies. And that's, again, this is contributing to this high cost of allergy in America.
Gary Falcetano:
And with all of these over the counter, it really speaks to the fact that if they are taking inappropriate medications, they're not getting adequate relief of their symptoms, so they're coming to clinicians for answers.
Luke Lemons:
And when a diagnosis is made, it's looking to do more of a personalized preventative medicine approach of management. So this includes target exposure reduction, which is looking at allergens that a patient may be sensitized to and advising them on ways to avoid them. And it allows for appropriate medicines
to be utilized as well as making them more effectitious, potentially reducing the spend that a patient might be accruing.
Gary Falcetano:
Exactly. When we're talking about respiratory allergy, certainly more and more primary care clinicians are utilizing testing to actually make the diagnosis. I think in the past we saw clinicians typically did not, typically in the past, that wasn't as common where we would go right from a working diagnosis to empiric treatment and, again, changing the treatment to try to get the symptoms under control, where if we test patients and get clarity on exactly what's driving their symptoms, we can take that more preventative medicine approach.
Luke Lemons:
And not just preventative medicine approach too, but making appropriate referrals as well, because if a patient is being referred to a specialist that they maybe didn't need to be referred to, then they would be also spending money on that appointment as well, and also lost time at work. And I think this goes into another part of the Triple Aim framework, which is the experience of care. So now let's look at allergy in America and the experience of care that a patient may have.
Gary Falcetano:
I think you did a good job of discussing the cost with inappropriate referrals. That applies as well to the patient's experience of care. So I think it's important to look at what does that mean? So if someone is non-allergic, so you've tested them in primary care, you've ruled out allergies the cause of their symptoms, an allergist may not be the best referral here for those symptoms. It may be an otolaryngologist. On the case of foods, it may be a gastroenterologist.
So utilizing testing to, number one, confirm or rule out allergy can really affect those referrals. And then as you said, not just cost but the patient's experience of care. So think about being referred to a specialist that isn't appropriate for your diagnosis. That's just puts another kind of hurdle in the way of actually getting to the right specialist and the right diagnosis.
Luke Lemons:
It's also the added inconvenience of it all, taking kids out of school, missing work, arranging transportation. It's a lot that bears on a patient. And I think that you're exactly right, a way in which we can help these patients is to make sure that there is adequate testing when needed in primary care and then thoroughly managing as well. And in those instances where they do need to be referred, there's at least those results that help advise maybe who the best specialist may be to send to a GI allergist, et cetera, or those test results can help you manage your patients better in the primary care setting.
Gary Falcetano:
You mentioned missing school and work and transportation issues for sure. And I think depending on someone's location, they can be two hours away from a specialist. It can really add to the patient's burden of getting the right diagnosis and seeking care.
But that's not the only thing, right? We hear from patients all the time, they sometimes feel their providers aren't listening to them or are negating some of their observations.
Luke Lemons:
And the truth is patients today are probably the most informed they've ever been with the internet and looking online. Whether that information is valid or true is another topic completely, but they do know the opportunities they may have, the diagnostic options, or they may speculate what they may have. And so a patient obviously is going online and doing this research because they want relief. That's why they do that.
And so to then go into an office and say, "Hey, I found all of this. This is what I think it is, this is what I know is available." And then they may recognize they have allergies, and if a provider wants to instead just treat them empirically or say, "No, maybe you just need antihistamines." It may be a little frustrating being that they were so passionate enough to go and research on their own.
Gary Falcetano:
This can be for numerous reasons why we as providers may not want to follow what the patient is asking us for. And some of that is lack of comfort ordering and interpreting diagnostic tests. And that's one of the reasons we're doing this podcast and why we have so many resources available for primary care clinicians to really make this easy, seamless, and be able to give patients what they're seeking and the actual cause of what's driving their symptoms.
Luke Lemons:
And of course there may be patients who come in and are completely... they miss the mark on their research, but it's important to also educate these patients on why they did and giving them a bit of a background on their symptoms, because if a patient is just pushed off, this is why a lot of these unproven at-home testing kits have become so popular, because patients are feeling that they have to go online and buy their diagnostics themselves because they maybe haven't been educated on why that's not the best option because they might not have that disease or because they're unable to get in front of their provider as well.
Gary Falcetano:
And we've seen an explosion of these kits, and we'll talk about this in our next episode, the lack of validity for IgG testing that is so prevalent with these at-home tests, but there's a reason why they're so popular, and then because there's a gap, people want answers, and providers can really help give them the answers they need with FDA cleared, validated testing that can indeed confirm or help to confirm and rule out their suspected allergies.
Luke Lemons:
And so you had mentioned a bit ago about how providers, they may not be confident with ordering diagnostics, and we do have those resources and they'll be linked on this episode specific page in the link in the description here. We have interpretation guides, webinars, but what are some of the other dogmas that you would speculate, Gary, that a provider maybe wouldn't want to test a patient who should be getting tested, mind you? Let's say the case history checks out.
Gary Falcetano:
Look, I speak to primary care providers across the country every day and the dogmas that I hear, and then they're recurrent themes, right? One is that blood allergy testing, serological testing is not as accurate as skin testing done by specialists, by allergists, and that's just not true. As a matter of fact, allergists use the serological testing interchangeably with that. All of the major guidelines, physician papers, all speak to really the clinical equivalence of the blood testing with the skin testing.
In addition to that, one of the old dogmas is that it's not as accurate because it's what we learned as RAST testing or radioallergosorbent testing. The ImmunoCAP testing hasn't been that for 30 years. It's an immunofluorescent test that's very accurate.
And then finally, the other dogma is we tell patients to do things all the time. They're probably not going to do these. And if they do them, they may or may not work.
Luke Lemons:
And that's just not true because patients do listen. And there was one study that looked at inner city asthma patients, and they were counseled on how to reduce exposure to allergens in their bedroom. And they did this for about a year, and then they stopped and they found that these patients still were taking the advice of the provider and incorporating it. So the idea that patients may not listen to me, I think it's good to be optimistic because they really might do that.
Gary Falcetano:
Patients are better informed now than ever, and people are really seeking non-pharmacologic ways to manage their symptoms. And we know the best way to treat allergy is to reduce or eliminate the allergen that's causing the symptoms. So these things do work, as you said, with that inner city asthma study. As a matter of fact, they saw almost a little over three weeks less symptoms per year of these children with asthma, almost a week's less missed school days, and two less unscheduled office visits. So it absolutely does work. And as you said, they internalized those things they needed to do and kept doing them even when the provider stopped reminding them.
Luke Lemons:
So looking at experience of care in allergy in America, these patients, they're tossed into a whirlwind of referrals or maybe difficulty getting a first appointment, which can be a frustrating experience. They may also not feel like they're being listened to or maybe even educated on why they're wrong about an
assumption that they had. And so it really is important to educate patients on their symptoms. It's important to do the testing to make sure that referrals are optimized, that they're going to where they need to be, and managing where you can in the practice. But continuing down this Triple Aim framework, what about population health and allergy?
Gary Falcetano:
We talked about the cost per capita for patients, we've talked about the patient's experience of care, but then when we look at from a population health perspective, when we look at allergy and population health, it really comes down to a couple of things. It comes down to access or availability of care. And you mentioned there's between 4 and 5,000 clinically practicing allergists in the US. Wait times are in one study somewhere around 60 days, and we've heard anecdotal reports of three to four months, even as long as a year in some locations to get in with a specialist.
So I think that speaks to if there's such access problems, we really need to be better at managing these patients' conditions so that there can be more room, more availability for more patients to receive care.
Luke Lemons:
This unclogging the system. Does this patient need to be referred to an allergist or can this patient be managed in primary care?
Gary Falcetano:
And it's improving the management too in primary care. So we have a treadmill of patients coming in with the same symptoms at the same time of year. If we proactively address what's causing those symptoms, we may not have to see those patients for the same symptoms on a regular basis like that.
Luke Lemons:
Again, we keep saying at this episodes, diagnostic tools like serological testing can guide to these appropriate referrals. And some providers may say, "Oh, I know already it's allergy, it's spring." And it's not a nice to know, it's almost a need to know on exactly what a patient is reacting to or potentially reacting to before making a referral, choosing to manage in your office.
Gary Falcetano:
We've spoken to this before, Luke, yes, it's springtime so birch pollen's in the air, we're going to assume their allergic symptoms are to the birch pollen. Number one, they may not even be allergic symptoms, but let's give you that you're allergic to birch pollen. What you don't know is you're also probably allergic to one or two other things that may not be as obvious, dust mites, molds, pets, mice, cockroach, all of these potential indoor allergens that are really difficult to discern through history. And we know that most patients, so 90% of patients who are allergic to one thing have a second, at least one other allergy to something else. Uncovering those is so important at getting to the root of their symptoms.
Luke Lemons:
And again, just unclogging this system of referrals so that those who really do need to go to, let's say, a specialist for immunotherapy, can get in as quick as they can.
And we spoke about spending earlier, but from a population health point of view, spending is also pretty high with unnecessary visits. If you think about the referrals or ineffective medicine, we had talked about how some antihistamines might not even be working, but even rescue medication like albuterol or epinephrine auto-injectors, patients may be prescribed these when they don't really need them, if they haven't gone through and gotten diagnostic testing and look to the case history.
Gary Falcetano:
Or in the case of the rescue medications like albuterol, if we can reduce their allergic asthma by eliminating or reducing their triggers, they're not going to need those rescue inhalers quite as much. And also maybe even reduce their doses on their controller medications, their inhaled corticosteroids.
Luke Lemons:
And I think that that was from the inner asthma study that we were talking about earlier, the reduction of rescue inhalers [inaudible 00:18:06].
Gary Falcetano:
Symptoms. Yeah.
Luke Lemons:
But it's also important to remember too that we have a finite amount of healthcare spending, and if we spend it in areas we don't need to, we may be taking it away from other areas that could benefit. So understanding whether this patient really does need an epinephrine autoinjector or if maybe, you know what, they have an autoimmune disorder like celiac disease instead and that's causing their stomach to be upset not because they have a wheat allergy. So it's differentiating, narrowing your differential diagnosis for the greater good of the healthcare system.
Gary Falcetano:
So we've discussed cost per capita or per patient. We've discussed the patient's experience of care when it comes to allergy. And then finally the third leg of the Triple Aim, how being more coordinated with our efforts really affects population health as well. But you mentioned in the beginning we've expanded this out to the Quintuple Aim now. So what about these last two?
Luke Lemons:
So going into the next one, the fourth one, it's looking at the wellbeing of healthcare workers in allergy. And you had mentioned in the population health section that episodic visits, it's common. So medicine has become a constant treadmill.
Gary Falcetano:
You're fixing things with temporary measures like medications, and sometimes we're not getting at the root cause of the issues. If we can actually get at the root cause, we can prevent some of these episodic visits that may not be necessary and make more room in the schedules for additional patients who may have even more complex medical issues to address.
Luke Lemons:
But these episodic visits too, it puts a lot of stress on the whole staff of the office. Let's just think of a private practice. If it's the same people coming in and again and again, it's the front desk who's doing scheduling, it's the nurses, it's-
Gary Falcetano:
It's providers trying to finish charts after hours...
Luke Lemons:
Exactly. Yeah.
Gary Falcetano:
... because they had to fit in some additional patients that day.
Luke Lemons:
I don't know about you when you were seeing patients, Gary, but there was probably patients that you saw multiple times, probably more often than needed to be that you're on a first... Well, you should always be on a first name basis with your patients, but the regulars, I guess.
Gary Falcetano:
And that's fine for issues that we're not able to adequately address, but when there's ways to actually get at what's causing the symptoms and empower patients to take better control of their disease, I think everybody wins. Providers feel better about their workday, patients feel better that their experience of care improves and their symptoms improve, and they can do it with really minimizing the amount of medications they need and taking the appropriate medications as well.
Luke Lemons:
And so the last piece of this framework is advancing health equity. So looking at the last piece of this framework for the Triple Aim, it's advancing health equity. So let's think through here in America, how do we advance health equity for patients who have allergies?
Gary Falcetano:
We know, number one, that lower socioeconomic status patients are disproportionately affected by allergic disease. We also know that access to specialists is challenging for this group of patients.
Luke Lemons:
Those on Medicaid. In a recent study by Gupta and colleagues only 50... This is a wild stat. Only 55% of allergists were found to accept Medicaid. And 13 out of 51 states, including DC, had a less than 50% acceptance.
Gary Falcetano:
And I mean, those acceptance rates for Medicaid actually ranged from a low of 13% in New York State to a high of 90% in New Mexico. So I guess if you're going to have a need for an allergist, you should be in New Mexico.
Luke Lemons:
If you're on Medicaid, that 90% acceptance rate, it's really shocking to me that 13% for New York State, especially since New York City, especially the Bronx is known to have such high rates of asthma and allergies, that patients who are on Medicaid in New York State may not be able to even go to an allergist to get the immunotherapy that they need.
Gary Falcetano:
When we look at all of the struggles that patients have to get to the care that they need, whether that be transportation issues, whether it be inappropriate referrals, whether it be clinicians not accepting public insurances, all of this is really challenging, but what can primary care providers do? First of all, I think it's just maximizing the care within your setting, practicing to the full scope of your abilities to provide the best possible care.
But we don't want to put blame on our allergist colleagues on these acceptance rates. Medicaid reimbursement rates are not very good. So I think what we can all do is advocate for increased reimbursement rates from commercial as well as the public payers to make sure that all of our colleagues are getting adequately reimbursed for their services.
Luke Lemons:
And you had said it there with managing the highest quality of care within your practice. But for these Medicaid patients specifically, their primary care provider may be the closest that they get to allergy management depending on the availability of allergists in their area or just the location in general.
So for primary care, it's really understanding the severity of a patient who's only on Medicaid or only has Medicaid and has maybe some symptoms of, let's say, just food allergies in general. So again, doing appropriate diagnostic testing, like specific IgE testing to uncover and guide clinical decisions is extremely important within this patient population.
Gary Falcetano:
To sum up everything we've talked about today, we've applied this lens of the Triple or the Quintuple Aim, right? So when it comes to patients with suspected allergic disease, how can we improve the per
capita cost, the population health, the patient's experience of care, and also a little selfishly, improve the wellbeing of the healthcare workforce as well as advanced health equity. And it really comes down to practicing to the full scope of our abilities, utilizing routine diagnostic tools to improve the accuracy of the diagnosis, and also being more personalized with management recommendations and empowering patients to really take charge of their care as well as making really informed, appropriate referrals.
Luke Lemons:
And doing all of this helps to decrease the cost and improve the patient's experience and calling back to the population health section to help make the entire healthcare system more efficient.
We have resources for people who want to learn more about different types of allergies and also diagnostic testing. Again, they will be linked on this episode's page in the description, there's a link to that page. So we have webinars on specific allergies. We have interpretation guides for food, respiratory, stinging insect, alpha-gal syndrome. So if you have any questions, definitely check those out.
And if you're not primary care and you're listening to this, share with primary care. I mean, especially after that Medicaid section and those patients not being able to maybe get the relief that they need, this show is designed for primary care and to help really inform a greater clinical population about allergies so that patients can breathe easier and just live their life to the fullest.
Gary Falcetano:
Exactly. And if we all work together to achieve these Triple or Quintuple Aims, I think everyone will be much better off in the long run.
Luke Lemons:
Thanks for listening to today's episode of ImmunoCAST, and again, don't forget to subscribe and share.
Gary Falcetano:
Thanks so much. We'll see you next time.
Announcer:
ImmunoCAST is brought to you by Thermo Fisher Scientific, creators of ImmunoCAP™ Specific IgE diagnostics and Phadia™ Laboratory Systems.
For more information on allergies and specific IgE testing, please visit thermofisher.com/immunocast.
Specific IgE testing is an aid to healthcare providers in the diagnosis of allergy and cannot alone diagnose a clinical allergy. Clinical history alongside specific IgE testing is needed to diagnose a clinical allergy. The content of this podcast is not intended to be and should not be interpreted as or substitute professional medical advice, diagnosis, or treatment. Any medical questions pertaining to one's own health should be discussed with a healthcare provider.
