Penny-Wise and Pound-Foolish: A Cost-Effectiveness Analysis of Unrealized Gains and Hidden Costs of 95165 Reimbursement.

Abstract

Allergen immunotherapy (AIT) for aeroallergens can be an effective and cost-saving approach for patients with allergic disease. Dose definition limits reimbursement for the Current Procedural Terminology code 95165, which is used for the supervision of preparation and provision of antigens for AIT. The degree to which reduced reimbursement may impact health-economic outcomes is not well characterized. A cost-effectiveness model was developed to evaluate possible health and economic consequences of improper 95165 reimbursement as both a penalty and a potential subsidy in aeroallergen AIT. Cohort analyses were evaluated from societal and health care perspectives with an annual 95165 penalty alternatively considered as a subsidy or a cost-neutral lever causing variable impacts on subcutaneous AIT access. Probabilities and costs were derived from the medical literature and private practice estimates. Population-level microsimulation was carried out to evaluate broader societal impacts of current 95165 reimbursement policy over a 5-year treatment course. A nonpenalized approach to AIT was preferred in all nonsubsidized analyses. Even if the 95165 reimbursement penalty was modeled as a subsidy discount, an approach of withholding allergist-immunologist reimbursement based on a statutory volumetric definition of dose was not cost-effective if it limited access to therapy by more than 9.3% (societal perspective) or 11.1% (healthcare perspective excluding indirect costs) of individuals seeking therapy. With 85% of AIT services unaffected, assuming a 5% prevalence of moderate to severe allergic rhinitis (AR), if only 1.2% of those with AR received subcutaneous immunotherapy, costs of incomplete allergist-immunologist reimbursement reached $353,946,504 (with subsidy) and $1,386,125,127 (without subsidy) over a 5-year course of AIT. Withholding allergist-immunologist reimbursement for mixing of allergen extracts has high potential of health-economic harm for patients and populations. Under highly conservative estimates, costs without subsidy could exceed $1.3 billion per treatment course.