Wednesday, January 9, 2013

Guess What? Docs Now Get Paid for Oral Food Challenges (OFC)

I've spent a lot of time in the column complaining that parents are too timid when it comes to insisting on an oral food challenge to confirm their child's allergy. As I've said elsewhere, there are a huge number of parents who believe their child has an allergy based on testing only, when those kids really have a harmless cross-reaction to pollen.

Let's run those numbers for fun, shall we? There are around 76 million kids in the United States. According to FARE (love the new name!), about 8% of parents believe their child has a food allergy, so around 9.5 million kids.

However...researchers say a good portion of these kids are sensitized, not allergic. In one study, of 11.8% of kids who showed up on a peanut panel as sensitized to peanut, only 1-2% actually demonstrated an allergy when challenged. That's just 17%. Studies have varied on the sensitization-to-allergic ratio, ranging from 20-50% of OFC fail rates after a positive skin or blood test, but the number is huge.

Depending on which ratio you use, we're talking about between five and eight million kids whose parents believe they have an allergy, but who really don't.

 Why? Why in the world is there so much uncertainty with something that should be so easy to demonstrate?

The reasons are complex, and I've talked about many of them before. Some of these children are too young to reasonably challenge. Much of the time it's because parents are not willing to tolerate a few hours of anxiety and discomfort for their child (in a carefully controlled environment) to have a firm answer. Doctors sometimes underestimate the social and psychological challenges of living with food allergies and don't want to press anxious parents. However, there's another reason that infuriates me: doctors simply weren't getting paid enough to make these challenges worthwhile for them to conduct. 

You read that right. More times than we would like to admit, U.S. healthcare is predicated on whether a doctor is actually reimbursed for a procedure. And guess what — until this year, oral food challenges were reimbursed by insurance companies using a diagnostic code that didn't fully cover the time required to perform the challenge. As a consequence, some doctors just didn't bother. (How many of you have been told "we don't do challenges in this office" in the past?)

The good news is that the coding issue has been fixed. Two new codes have been added that allow doctors to bill for the staff-heavy first two hours of a challenge, and then on an hourly basis for food challenges that run longer than two hours.

It's infuriating that something so simple has stood in the way of more parents getting a definitive answer about their child's food allergy. I'm happy to finally see the financial incentives being aligned to address this issue for physicians. It would be great if the parents' emotional incentives could also be appropriately aligned.

That's where support groups and advocacy organizations come in. If you manage one of these groups, for heaven's sake, stop telling your members that food challenges are something to be feared and avoided! It's in everyone's best interest to identify the kids who are truly allergic: both so that those children can get appropriate social support and so children without a true allergy can stand down from a baseless fear.

A food challenge done in a proper setting is about as risky to your child as a vaccine. It's time to put the risks of oral food challenge in perspective and consider more strongly the benefit of knowing.


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