Descriptive Analysis of Access to SMART Among a Population of Medicaid-Insured Pediatric Patients

Asthma is a common chronic condition of childhood with higher morbidity in neighborhoods with more Medicaid patients.1,2 Traditional therapy involves inhaled corticosteroids (ICS) or ICS-long-acting β2 agonist medications with a separate short-acting β2 agonist (SABA) for rescue. Recent studies demonstrate that ICS-formoterol inhalers used as single maintenance and reliver therapy (SMART) reduce severe asthma exacerbations when compared with traditional therapies.3,4 Formoterol provides rapid bronchodilatation like a SABA, providing relief of acute symptoms and maintenance therapy when paired with an ICS.5 SMART is recommended by the National Heart Lung and Blood Institute6 asthma guidelines for children aged 5 years and older, but its use has been limited in the United States due to insurance barriers and prior authorization challenges.7We sought to describe local managed care organization (MCO) coverage of guideline-directed asthma medical therapies, focusing on SMART, to investigate disparities related to formulary restrictions.We reviewed the preferred drug list (PDL) for each of 4 MCOs in a major US city to characterize access to guideline-directed asthma therapy, focusing on SMART. Pediatric patients will require 2 or 3 metered dose inhalers (MDIs) per month for SMART based on their maintenance dose (ranging from 1 inhalation daily to 2 inhalations twice daily) and size of inhaler (60 or 120 actuations).8,9 This translates to 1 or 2 MDIs at home and an MDI at school, which is analogous to having 1 SABA MDI for home and 1 for school as well as a controller MDI for home. Adequate SMART access was defined as coverage of at least 3 ICS-formoterol MDIs per month.We conducted a retrospective descriptive analysis of formulary coverage using a regional asthma registry, a novel population health tool that captures more than 90% of children with asthma in our city.10 The Children’s National Hospital Institutional Review Board approved the collection and use of these data for research purposes. Inclusion criteria were as follows: (1) aged 4 to 17 years at time of encounter, (2) residence in the MCO coverage area, (3) insurance coverage with a MCO, and (4) medical encounter for the treatment of asthma in our institution between September 1, 2022 and September 1, 2023. Encounters were limited to a 12-month period to capture the landscape of medication coverage from review of the formularies. Deidentified data were extracted from the citywide asthma registry. Analysis was performed using STATA 14 (StataCorp, LLC).The study sample included 12 122 patients. The average participant was aged 12 years. Eighty percent of the participants were Black, and 57% were male participants. The results demonstrated that, of the 4 MCOs, 1 (insurer A) does not provide adequate coverage of SMART; however, this single insurer covers a majority (58%) of the study population (7013 patients). Insurers B, C, and D collectively cover 42% of the patients and provide adequate access to SMART (Table 1). There were no significant differences in demographics among insurer groups and no significant differences in demographics when comparing patients with (insured by B, C, and D) and without (insured by A) access to SMART (Table 2).Our findings demonstrate that most of the MCOs provide formulary coverage of SMART; however, the majority of the study population does not have access to SMART. The lack of consistency between PDLs and guideline-based care is a barrier to incorporation of SMART into clinical practice, especially considering that SMART was first recommended by the Global Initiative for Asthma in 2020. There is strength and novelty in using a population health registry to report on pediatric asthma in a large metropolitan city. These findings reflect the capacity to prescribe SMART without prior authorization based on 2023 PDLs and not prescribing practices. Nonetheless, these results underscore a systems-level issue that lends to inequities in access to guideline-directed care. Independent PDLs for each MCO restrict medication access and create significant barriers to care with potential implications on asthma morbidity because most pediatric patients in our region with asthma who are insured through Medicaid do not have coverage for the medications needed to implement SMART. Providers must make treatment decisions based on coverage, which often conflicts with evidence-based guidelines.To address the barriers associated with separate PDLs, we propose a common Medicaid formulary with a single PDL as has been done in many states.11 This change would streamline advocacy efforts to implement guideline recommendations, potentially reducing health care costs by improving pediatric asthma outcomes.We would like to make the following acknowledgments: The Washington, DC Department of Health for supporting the Metro DC Regional Asthma Registry and Mr Badh, BS, manager of Business Intelligence and Clinical Analytics, for direct assistance with data extraction from the Asthma Registry.