Resource when arguing with your HMO/insurance carrier.

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Posted by Bob Johnson ( on February 07, 2000 at 10:15:24:

These two abstracts can be given to your HMO if they are resisting giving you adequate treatment. Suggest that you print them out and tuck them away in case the day comes when you need them.

Don't be concerned that they reference migraine. Several folks have noted that their carrier did not recognize the Dx of "cluster" and only when their doctor gave the Dx of "migraine variant" did they get a response. The issue is that migraine and cluster are often defined as one in the same disorder.

Archives of Internal Medicine
Vol. 159, pp. 857-863, Apr. 26, 1999
Changes in Resource Use and Outcomes for Patients With Migraine Treated With Sumatriptan: A Managed Care Perspective
Background: Migraine headaches result in significant patient suffering and high costs to managed care organizations and employers. Studies that evaluate patient outcomes and the financial consequences of migraine treatment are important from a clinical and an economic perspective.
Methods: This prospective, observational study assessed the outcomes of migraineurs in a mixed model staff/independent practice association managed care organization for patients previously diagnosed as having migraine who received their first prescription for sumatriptan. Data collected included medical as well as pharmacy claims and patient surveys to measure changes in satisfaction, health-related quality of life, workplace productivity, and nonworkplace activity after sumatriptan therapy was initiated.
Results: A total of 178 patients completed the study. Results showed significant decreases in the mean number of migraine-related physician office visits, emergency department visits, and medical procedures in the 6 months after sumatriptan therapy compared with the 6 months before sumatriptan was used (P<.05). Four of the health-related quality-of-life dimensions and the physical component summary score measured by the SF-36 (which is a valid, reliable general health status instrument) showed significant improvements at 6 months compared with patients' scores before use of sumatriptan (P<.05). Health-related quality of life measured by the disease-specific instrument MSQ (Migraine-Specific Quality of Life Questionnaire-Version 1.0, 1992 Glaxo Wellcome Inc, Research Triangle Park, NC) showed significant improvement at 3 and at 6 months compared with baseline scores (P<.05). There were also improvements in patient satisfaction and significant reductions in time lost from workplace productivity and nonworkplace activity.
Conclusion: In the 6 months after sumatriptan therapy was initiated, health care resource use and time lost from workplace productivity and nonworkplace activity were reduced, while health-related quality of life and patient satisfaction scores improved for the managed care migraineurs enrolled in this study.
(Arch Intern Med. 1999;159:857-863)
(1999;159:857-863) Jennifer H. Lofland et al, Office of Health Policy and Clinical Outcomes, Thomas Jefferson University, 1015 Walnut St, Suite 621, Philadelphia, PA 19107.

Archives of Internal Medicine
Vol. 159, pp. 813-818, Apr. 26, 1999
Burden of Migraine in the United States: Disability and Economic Costs
Background: Migraine is a common disabling disease but its economic burden has not been adequately quantified.
Objective: To estimate the burden of migraine in the United States with respect to disability and economic costs.
Methods: The following data sources were used: published data, the Baltimore County Migraine Study, MEDSTAT's MarketScan medical claims data set, and statistics from the Census Bureau and the Bureau of Labor Statistics. Disability was expressed as bedridden days. Charges for migraine-related treatment were used as direct cost inputs. The human capital approach was used in the estimation of indirect costs.
Results: Migraineurs required 3.8 bed rest days for men and 5.6 days for women each year, resulting in a total of 112 million bedridden days. Migraine costs American employers about $13 billion a year because of missed workdays and impaired work function; close to $8 billion was directly due to missed workdays. Patients of both sexes aged 30 to 49 years incurred higher indirect costs compared with younger or older employed patients. Annual direct medical costs for migraine care were about $1 billion and about $100 was spent per diagnosed patient. Physician office visits accounted for about 60% of all costs; in contrast, emergency department visits contributed less than 1% of the direct costs.
Conclusions: The economic burden of migraine predominantly falls on patients and their employers in the form of bedridden days and lost productivity. Various screening and treatment regimens should be evaluated to identify opportunities to reduce the disease burden.
(Arch Intern Med. 1999;159:813-818)
(1999;159:813-818) X. Henry Hu et al, PO Box 4, WP39-164, West Point, PA 19422.

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