In an age when many physician practices face tightening business margins, some are exploring new services they may be able to offer patients. One such area is the in-office treatment of patients who suffer from allergic rhinitis.
PhysBizTech recently contacted Fred Schaffer, MD, chief medical officer of United Allergy Services (UAS), a company specializing in delivering allergy testing and customized immunotherapy services, to gain insight into the scope of opportunity for in-office allergy treatment. His observations appear in the following transcript.
Q: What are the demographics of allergy sufferers across the United States in terms of total numbers of potential patients? Male/female split? Are there age groupings in which allergies are more prevalent than others?
A: More than 60 million Americans currently suffer from allergic rhinitis. Allergic rhinitis is typically more prevalent in females then in males (with the exact percentages in the available medical literature varying).
Allergic rhinitis has been associated with, and often found to precede, other chronic medical conditions, including allergic asthma, upper respiratory tract infections, recurrent sinusitis, dental disorders, sleep disorders, and due to persistent disease morbidity, depression. The Centers for Disease Control and Prevention recently reported that not only has the prevalence of asthma increased from 7.3 percent in 2001 to 8.4 percent in 2010, but that minority and lower income populations are being hit hardest. African Americans and Hispanics manifest the highest asthma prevalence, respectively 11.2 percent and 16.1 percent in contrast to that of Caucasians (7.7 percent) and Asian Americans (5.2 percent). Today, 11.2 percent of individuals living below the poverty line have asthma.
Q: Is the number of allergy sufferers increasing in the U.S.?
A: Yes, the prevalence of allergic rhinitis is on the rise. Since 1995, the number of Americans suffering with allergic rhinitis has doubled. It is ranked as the third-leading chronic disease in the United States among individuals younger than 45 and the fifth leading chronic disease among all Americans. [Editor's note: See citations 1 and 2 in list of references supplied by Dr. Schaffer. Citations appear at the bottom of this interview.]
Q: The "scratch test" for environmental allergens is the gold standard for determining what may be troubling a patient. What makes the scratch test so effective and reliable?
A: Skin testing (i.e., skin puncture tests or SPT) is considered to be the gold standard based on the test’s sensitivity and specificity in comparison to other available forms of allergy testing. [Citation 3] Other testing modalities have been helpful in assessing a handful of food allergies, but there is no equivalent to skin puncture testing for the majority of aeroallergen allergies available to date. Furthermore, these studies are significantly more expensive than SPT, can require up to a week to acquire results, and the number of tests covered by insurance companies is limited in many states. In contrast, SPT results are available in 20 minutes, are less expensive and are often fully covered by third-party payers.
As every patient is uniquely reactive to different allergens, physicians working with UAS test patients by SPT for 48 geographically specific allergens, including: products from dust mites, cockroaches, proteins from pet hair and dander, molds, feathers and pollens from trees, grasses and weeds.
Q: Why are primary care physicians well positioned to provide care for allergy patients?
A: Primary care is the only entity charged with the long-term care of the whole patient. The primary care provider is typically the first and often times the only medical provider seen by a patient with allergic diatheses. Putting immunotherapy into the hands of primary care providers ensures that one physician is meeting with the patient on a regular basis, discussing all related health issues and overseeing any allergy concerns that could arise.
There are only about 2,800 practicing board certified allergists, an insufficient number to provide care for the 60 million Americans with allergic disorders . [Citation 3] The need for allergy care is expected to rise by 35 percent in 2020, while the availability of certified allergists will diminish by almost 7 percent . [Citation 4] This discrepancy between need and available care provides the primary care physician with an expanding role in preventative health care, as it applies to allergy. This method of treatment also aligns with the healthcare reform goals to create coordinated patient-centered medical homes (PCMHs).
Q: Why does it make sense for physicians to consider partnering with a healthcare services company for the care of allergy patients within a practice, especially in the small-practice environment?
A: Few primary care physicians are familiar with the complexity or have the experience of establishing and directing healthcare specialty support services. As a result, many primary care physicians have turned to healthcare businesses like UAS to assist them in providing specialty services.
In addition, working with companies like UAS saves physicians time, while allowing them to expand the level of care they are able to provide each patient. For example, UAS manages all functional aspects of an allergy center, freeing the physician to focus on the clinical side. UAS provides all personnel, technology services, ongoing education for the physician and his or her staff, reimbursement assistance, quality assurance, and supplies and equipment needed for the allergy center to function smoothly and efficiently.
Q: Do patients ever ask, "Shouldn't I see an allergist?" If so, what is the response?
A: Yes, primary care physicians often simply inform their patients that allergists are a specialty community who are best trained and equipped to manage patients with the most serious allergic conditions and reactions. UAS protocols are very specific on which patients are appropriate candidates for testing and immunotherapy within the primary care office, and which need to be referred to a board-certified allergist. Below is a list of the types of patients who should see a board-certified allergist for care.
- Those with severe or uncontrolled asthma.
- Patients with serious comorbidities such as cardiovascular disease, neoplastic disorders, COPD, etc.
- Those with significant MAST cell and Eosinophilic disorders.
- Patients with immunodeficiency disorders or on immunomodulating medications.
- Patients who experience moderately severe collagen-vascular or systemic disorders or uncontrolled seizure disorders.
- Patients using beta blockers or other contraindicated medications.
- Women who are pregnant.
- Patients with previous anaphylaxis to aeroallergens.
Q: Do you have some numbers you can share about the success of patients who have undergone a full course of treatment?
A: When patients have undergone a full course of treatment, the UAS model has shown significant improvement in clinical scores. For example, 94 percent of patients surveyed reported improvement in allergic rhinitis symptom scores, 86 percent reported improved quality of life scores and 79 percent reported a significant decrease in medication scores. [Citation 5]
Q: Is the treatment expensive for patients?
A: Typically, no. Most insurance plans cover allergy testing and immunotherapy and insurance is verified prior to testing. Furthermore, receiving treatment through a primary care physician often saves patients money when compared to seeing an allergist. Studies have also shown that there can be a 41 percent decrease in healthcare costs when immunotherapy treatment is utilized . [Citation 6] There are also significant long-term benefits that are a direct result of a course of immunotherapy which include the diminished chance of developing allergic asthma and new allergies.
Q: Is the care model and treatment protocol applicable to treatment of other diseases?
A: Currently, this model is very specific to allergic rhinitis and allergic asthma and UAS only treats these allergic patients. However, it could likely translate well to other disease states in the future, such as the use of immunotherapy to ameliorate atopic dermatitis. Particularly as the PCMH grows as a healthcare delivery model, primary care physicians will be expected to address a wider range of diseases. It makes sense for them to consider adopting this model to treat a variety of specialty conditions.
1. Chronic conditions - a challenge for the 21st century. National Academy on an Aging Society Washington, DC 1999
2. Meltzer E.O., Blaiss M.S., Derebery M.J., et al. Burden of allergic rhinitis: results from the Pediatric Allergies in America survey. J Allergy Clin Immunol 124. (Suppl 3): S43-S70, 2009.
3. Physicians Providing Allergy and Immunology Services. August 2005. Retrieved from http://www.aaaai.org/Aaaai/media/MediaLibrary/PDF%20Documents/Education%20and%20Training/FinalSurveyReport.pdf
4. Allergist report.(n.d.). Retrieved from http://www.acaai.org/press/Documents/AllergistReport08Final.pdf
5. Schaffer, FM, Welchel, L, and Garner, L, "The Safety of Home Immunotherapy Utilizing the United Allergy Services Protocol. Manuscript in preparation. (2012)
6. Hankin CS, Cox L, Wang Z, et al. Does allergen specific immunotherapy provide costs benefits for children and adults with allergic rhinitis? Results from a large-scale retrospective analyses jointly funded by AAAAI and ACAAI. Oral presentation presented at the 2011 Annual Conferences of the American Academy of Allergy, Asthma and Immunology. San Francisco (CA), March 18 -22, 2011.
By Frank Irving
December 18, 2012