Medical Expenditures Attributed to Asthma and Chronic Obstructive Pulmonary Disease Among Workers — United States, 2011–2015

Asthma and chronic obstructive pulmonary disease (COPD) are respiratory conditions associated with a significant economic cost among U.S. adults (1,2), and up to 44% of asthma and 50% of COPD cases among adults are associated with workplace exposures (3). CDC analyzed 2011-2015 Medical Expenditure Panel Survey (MEPS) data to determine the medical expenditures attributed to treatment of asthma and COPD among U.S. workers aged ≥18 years who were employed at any time during the survey year. During 2011-2015, among the estimated 166 million U.S. workers, 8 million had at least one asthma-related medical event,* and 7 million had at least one COPD-related medical event. The annualized total medical expenditures, in 2017 dollars, were $7 billion for asthma and $5 billion for COPD. Private health insurance paid for 61% of expenditures attributable to treatment of asthma and 59% related to COPD. By type of medical event, the highest annualized per-person asthma- and COPD-related expenditures were for inpatient visits: $8,238 for asthma and $27,597 for COPD. By industry group, the highest annualized per-person expenditures ($1,279 for asthma and $1,819 for COPD) were among workers in public administration. Early identification and reduction of risk factors, including workplace exposures, and implementation of proven interventions are needed to reduce the adverse health and economic impacts of asthma and COPD among workers.

the medical condition or conditions associated with each medical event reported by the participant, using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Each medical event could be assigned one or more ICD-9-CM codes. Medical events associated with treated asthma were identified using ICD-9-CM code 493 and medical events associated with treated COPD were identified using ICD-9-CM codes 490, 491, 492, and 496. § Expenditures were calculated from the sum of payments from Medicaid, Medicare, private insurance, out-of-pocket expenses, and other sources ¶ for each treated asthma-and COPD-associated medical event. The annualized, total and per-person unadjusted medical expenditures for workers with asthma and COPD were estimated by type of medical event and source of payments. Workers were those who were "currently employed," "had no job at the interview date but had a job to return to" or were employed at any time during the survey year. Information on participants' current industry was categorized into 15 industry groups.** § https://meps.ahrq.gov/data_stats/download_data/pufs/h180/h180doc.pdf. ¶ Veterans Administration/CHAMPVA, TRICARE, and other federal sources include Indian Health Service, military treatment facilities, and other care by the federal government. Other state and local sources include community and neighborhood clinics, state and local health departments, and state programs other than Medicaid, and workers' compensation. Other unclassified sources include sources such as automobile, homeowner's, and liability insurance and other miscellaneous or unknown sources. ** https://meps.ahrq.gov/data_stats/download_data/pufs/ind_occ/ind3.pdf.
Data were weighted to produce nationally representative estimates using sample weights adjusted for the 5-year data. Data were analyzed using SAS software (version 9.4; SAS Institute) to account for the complex survey design. Estimates with relative standard error (standard error of the estimate divided by the estimate) ≥30% are not reported. All expenditure values were expressed in 2017 U.S. dollars using the Medical Care Consumer Price Index. † † During 2011-2015, among the annual average estimated 166 million U.S. persons aged ≥18 years who were working at any time during the survey year, 8 million (5%) workers had at least one asthma-related medical event, and 7 million (4%) had at least one COPD-related medical event, which accounted for 21 million asthma-associated and 15 million COPD-related medical events ( Table 1). The proportion of current smokers among workers who had an asthma event during the study period was 13%; 24% had a COPD event. Annualized average per-person medical expenditures attributable to treated asthma and COPD were $901 and $681, respectively. Highest annualized expenditures per person attributable to treated asthma and treated COPD were among non-Hispanic whites ($923 and $742, respectively), persons with health insurance ($914 and $705, respectively), and current nonsmokers ($936 and $692, respectively). By age group, annualized per-person expenditures for asthma and COPD were highest among persons aged 45-64 years ($1,081) ≥65 years ($1,090), respectively.
Prescription medication accounted for the highest number of events for asthma (15 million) and for COPD (8 million) ( Table 2). The total annualized medical expenditures for treated asthma-related medical events among workers were $7 billion, and they were $5 billion for COPD. Derived using the pooled population-attributable fraction of 16% for asthma and 14% for COPD (3), annualized expenditures attributable to workplace exposures exceeded $1 billion for asthma and $700 million for COPD.
By type of medical event, prescription drugs for asthma ($5 billion) and inpatient visits for COPD ($2 billion) accounted for the highest total annualized expenditures. Annualized expenditures per person were highest for inpatient visits (excluding prescription medications): $8,238 for asthma and $27,597 for COPD. By source of payment, private health insurance paid for 61% ($4 billion) of expenditures attributable to treated asthma and 59% ($3 billion) of expenditures attributable to treated COPD. The highest annualized expenditures per person were paid by private insurance for asthma ($811) and Medicare for COPD ($983).
Among industry groups, the annualized expenditures per person for treated asthma were highest among public administration workers ($1,279), followed by transportation and utilities workers ($1,222) ( Table 3). The annualized expenditures per person for treated COPD were highest among public administration workers ($1,819), followed by construction workers ($1,198).

Discussion
COPD and asthma combined were among the top five most costly medical conditions among U.S. adults in 2012 (4). Among workers, the total medical expenditures attributable to the treatment of asthma and COPD were substantial ($7 billion for asthma and $5 billion for COPD) and varied by sociodemographic characteristics and industry. Workers in the public administration industry (e.g., police officers, correctional officers, jailers, firefighters, and secretaries and administrative assistants) § § had the highest annualized perperson expenditures for both asthma and COPD. In the public administration industry, an estimated 7.4% of workers have asthma, and 3.5% of workers have COPD. ¶  in expenditures by industry might reflect the differences in prevalences, health insurance status, and access to medical care. Overall, workers with no health insurance had lower medical expenditures for asthma and for COPD than did those who had health insurance, suggesting that the uninsured population might have sought services through free clinics or might have limited their care-seeking (1,3). Based on the 2019 pooled population attributable fraction estimates of 16% for asthma and 14% for COPD, the estimated expenditures attributable to workplace exposures among workers exceeded $1 billion for asthma and $700 million for COPD. Among workers, prescription medications accounted for the highest proportion of total medical expenditures attributable to the treatment of asthma, as did inpatient visits for the treatment of COPD, similar to previous findings among all U.S. adults (1,5). Inpatient visits accounted for the highest per-person expenditure for treated asthma and COPD. Higher expenditures related to inpatient visits have been highly correlated with asthma and COPD exacerbation severity (5,6). An estimated 67% of total asthma-attributable medical expenditures were

Summary
What is already known about this topic?
Asthma and chronic obstructive pulmonary disease (COPD) are associated with substantial economic and health costs among U.S. workers.
What is added by this report?
During 2011-2015, total annualized medical expenditures among U.S. workers were $7 billion ($901 per person) for asthma and $5 billion ($681 per person) for COPD. Inpatient visits were associated with the highest average per-person expenditures for both conditions. Insured workers incurred higher expenditures than did uninsured workers.
What are the implications for public health practice?
Early identification and reduction of risk factors, including workplace exposures (e.g., vapors, gas, dusts, and fumes), and implementation of proven interventions are needed to reduce the adverse health and economic impacts of asthma and COPD among workers.
associated with prescription medications, which is higher than the 51% observed previously among all U.S. adults (1). The higher prescription medication expenditures might be associated with new and more costly treatment options or could be a result of inflation adjustments (1,7,8). Moreover, workers are more likely to have health insurance than are nonworkers (9); therefore, they might have fewer financial barriers to purchasing prescription medications, which might also partially explain the higher expenditures among workers. The findings in this report are subject to at least four limitations. First, the number of medical events and expenditures associated with asthma and COPD were self-reported by respondents and might be subject to recall bias. However, self-reported medical events and expenditure data, including office-based visits, emergency department visits, and hospitalizations, have been shown to correspond well with health care utilization data (10). Second, workers could have been treated for comorbidities during their asthma-or COPDrelated medical encounter; therefore, a portion of medical expenditures might not be directly associated with asthma or COPD. Third, workers might have changed employment from the industry in which they were employed at the time of their asthma-or COPD-related medical events; therefore, medical expenditures by industry group might not reflect the actual industry the worker was employed in when the expenditure was incurred. Finally, small sample sizes for some groups resulted in unreliable estimates.
Annualized overall and per-person medical expenditures attributable to treated asthma and treated COPD among workers were substantial. Early identification and reduction of risk factors, including workplace exposures (e.g., vapors dusts gas and fumes), and implementation of proven interventions are needed to reduce the adverse health and economic impacts of asthma and COPD among workers. Prioritizing intervention efforts aimed at preventing asthma and COPD among workers, especially among those with higher medical costs, by supporting workplace programs and policies (e.g., smoke-free workplace policies, smoking cessation programs, and workplace exposure control measures) can reduce the impact of disease and improve worker health.*** Continued surveillance is important to identify workers with high prevalences of asthma or COPD and less consistent access to health care. *** https://goldcopd.org/wp-content/uploads/2018/11/GOLD-2019-v1.7-FINAL-14Nov2018-WMS.pdf; https://ginasthma.org/wp-content/ uploads/2019/06/GINA-2019-main-report-June-2019-wms.pdf.