Under the present managed care public health insurance policy in Puerto Rico, the financial burden of asthma treatments and prescriptions becomes the responsibility of the contracted provider. This survey documented that physicians perceive this policy as a barrier to the prescription of long-term control medication for children with asthma and public health insurance on the island. Our group has demonstrated substantial under-treatment of children with public insurance compared to those with private insurance.13
Other U.S. surveys found that family financial status was an important barrier for controller anti-inflammatory medication use10,16
Our study documents another financial barrier to appropriate long-term control medication use for children with persistent asthma—Medicaid managed care policies that place the individual physician at financial risk for the cost of these medications.
Pediatricians in our survey reported a number of strategies for providing long-term control medication to children with public health insurance. These strategies include giving away samples, shifting from brand medications to generic, and prescribing oral medications. The survey did not ask pediatricians what generic, oral, or sampled medications they prescribed. At the time of the survey there was no asthma controller medication available that was generic. We suspect that leukotriene modifiers represent only a small number of the oral medications prescribed. Previous research from our group presented elsewhere shows that few children with public insurance in Puerto Rico (5.7% of children with at least one asthma claim) were dispensed leukotrienes in 2005–2006.13
Similar to other Medicaid systems, the Puerto Rico Health Reform has an approved medication formulary based on the NAEPP treatment guidelines.2
The average cost to the physician of the least expensive inhaled corticosteroid medication in the formulary is $84.00 for a 30-day supply, which represents 2 to 3 times their current PMPM capitation. The cost of long-term control medications for asthma that exceeds the PMPM capitation is likely to contribute to the low prescription rates of long-term control medication previously documented.13
Other common barriers to providing asthma care to children from low-income groups reported by pediatricians in this study were lack of personnel to assist in asthma education (78%) and lack of educational resources (70%). This is consistent with surveys of pediatricians elsewhere in the United States.10
Further research is needed to examine the extent to which the low rates of controller medication filling in the island (reported previously)13
are a result of primary nonadherence by the population with publicly financed health insurance and the extent to which it is related to under-prescription by providers.
A majority of pediatricians had access to the guidelines, and close to three-fourths reported familiarity with both the general NAEPP guidelines2
and the recommendations for prescribing controller anti-inflammatory medications. These rates are similar to previous self-reported surveys in the United States that indicate 70%–90% of physicians being aware, having access to a copy, and having read the practice guidelines.16–18
Just under one-third of pediatricians, nevertheless, reported not having a copy, and just over one-quarter of respondent pediatricians reported slight or no familiarity with asthma treatment guidelines. This is troubling, as familiarity with guidelines is an important predictor of guidance adherence.10,16
Our results suggest that access to guidelines and education of physicians on asthma guidelines are needed to improve the care of asthmatic children in Puerto Rico.
The vast majority of pediatricians (99.6%) reported positive beliefs and attitudes toward prescribing controller anti-inflammatory medications. Nonadherence to practice guidelines in spite of familiarity with and access to the same has been reported in U.S. studies in which only about half of the medical providers actually seem to adhere to the guidelines.9,19
Several limitations of this study should be noted. Response bias20,21
and reporter desirability may impact survey validity. Although familiarity with guidelines, beliefs, and attitudes about prescribing controller anti-inflammatory medications reports may be affected by response bias, it is less likely that the information obtained pertaining to the strategies used in prescribing controller anti-inflammatory medications and the barriers relating to pharmacological treatment would be impacted by social desirability. Bias could also be introduced if responders differ systematically from nonresponders. This is especially important when response rates are low. Our study had a response rate of 63% similar to average response rates obtained in studies that use mail surveys and above average to response rates obtained in other mail surveys of physicians.20,21