By Karen Bobbitt
An employee calls in sick – she was up late the previous night with terrible pain, almost like a knife in the chest. Fearing a heart attack, she called 911 and, after hours of cardiac testing and monitoring at the hospital, costing thousands of dollars, the diagnosis is an episode of sudden onset gastroesophageal reflux disease, known as GERD.
Days later another employee on an assembly line suffers a severe cut to the hand. While one co-worker rushes the injured employee to the hospital, other employees scramble to cover the workload. During the physical evaluation, the employee reveals he is suffering from extreme exhaustion and that the lack of sleep impacted adherence to safety standards. Uncontrolled stomach pain has made it impossible to sleep unless the employee is sitting completely upright – a common way that many manage sleep-interrupting GERD symptoms. The employee has to file for workers’ compensation and short-term disability, while the team leader shuffles schedules for the next four weeks.
These stories demonstrate the potential workplace impact of one prevalent and often under-the-radar disease. Many human resource (HR) professionals do not think much about GERD. Everyone gets heartburn occasionally, right? With gastric acid treatments like proton pump inhibitors (PPIs) – such as Nexium® or Prilosec® – available over the counter, HR professionals might assume the cost of reflux mostly falls on the employee, not the employer. Dig a little deeper, and a more complex picture is revealed.
GERD, also commonly known as acid reflux, occurs when acid or other stomach contents back up into the esophagus from the stomach due to a faulty valve. The most common symptom of GERD is heartburn, which, while rarely life-threatening, can greatly reduce a person’s quality of life by affecting daily activities, sleep and eating. Those with GERD may have other typical symptoms including abdominal or chest pain, reflux and/or regurgitation and difficulty sleeping. Other atypical symptoms can include chronic cough, sinusitis, asthma, chronic laryngitis/voice disturbances and dental erosion. According to a study in The American Journal of Gastroenterology, if left untreated, GERD can lead to costly, potentially life-threatening conditions like esophagitis, Barrett’s esophagus and even esophageal cancer.
And reflux is not a small problem. GERD is one of the most prevalent gastrointestinal disorders. The National Ambulatory Medical Care Survey (NAMCS) estimated GERD may affect as much as 30 to 40 percent of the U.S. population. An article in the American Journal of the Medical Sciences reported more than 80 million Americans experience GERD symptoms at least monthly and 19 million experience daily symptoms.
Assessing the Impact of GERD
When faced with a clinical diagnosis, an HR professional’s possible thought is, “How does this affect the health plan?” With skyrocketing health care costs, containing premium increases is a key HR responsibility. The impact of reflux, unlike cancer, is not seen in “shock claims” but instead in the broader health benefit costs. For GERD sufferers, the overall difference in direct and indirect health benefit costs was $3,355 more per employee annually, according to a study in Alimentary Pharmacology & Therapeutics. When GERD affects three to four out of 10 health plan members, as shown in the NAMCS, it’s critical to manage the disease to achieve long-term health plan savings.
HR professionals must also factor in the effect of GERD on employee productivity in absenteeism and presenteism. The International Foundation for Functional Gastrointestinal Disorders reports that reflux costs the U.S. nearly $2 billion each week in lost productivity. Employees with GERD may experience 41 percent more sick leave days, according to a study in the Journal of Occupational and Environmental Medicine.
And another study published in Alimentary Pharmacology & Therapeutics showed that 30 percent of GERD sufferers reported reduced productivity. Much of this can be due to symptom severity and instances of nocturnal heartburn, particularly when it interferes with sleep.
The HR Professional’s Role
Given the disease’s potential impact on the workplace, HR professionals must increase their understanding of GERD to have a greater appreciation of plan enrollees who may be suffering. A quick way to assess this is to run a health plan claims report identifying those costs associated with GERD diagnoses. It is often a top 10 claims cost category alongside more recognized and addressed diagnoses like diabetes and heart disease. A search should include:
ICD-10-CM Description K21.0 Gastro-esophageal reflux disease with esophagitis K21.9 Gastro-esophageal reflux disease without esophagitis K30 Functional dysphasia R10.13 Dyspepsia NOS K44 Diaphragmatic hernia without obstruction or gangrene R12 Heartburn
The next step is to raise awareness among employees, including offering programs which highlight the prevalence of GERD and the treatment options available. A wealth of information also can be found at www.GERDHelp.com.
For GERD sufferers with infrequent symptoms, their health care provider may suggest simple dietary and lifestyle changes such as:
- Losing weight
- Avoiding “trigger foods” known to cause reflux, such as chocolate, caffeinated beverages and acidic foods like tomatoes and spicy sauces
- Eating smaller, well-timed meals
- Avoiding eating at least four hours before bedtime
- Quitting smoking
- Limiting alcohol intake
Impact of Prolonged PPI Use
When lifestyle changes become impractical or do not reduce symptom frequency or severity effectively, an employee’s physician or gastroenterologist may suggest medical treatment. Some GERD sufferers may take over-the-counter or prescription PPIs to control symptoms, but many do not realize that PPIs are approved to be used for just a few weeks, not months or years. Recent research has shown long-term PPI use may be linked with other health issues including:
- Chronic kidney disease (as reported in JAMA Internal Medicine),
- Dementia (as reported in JAMA Neurology),
- As well as increased pneumonia risk, vitamin B12 deficiency and increased risk of fundic gland polyps (as reported in the World Journal of Gastroenterology).
Long-Term Treatment for GERD
Employees with persistent symptoms may need to seek a medical evaluation from a gastroenterologist or foregut surgeon specializing in GERD. This provider can definitively determine if an employee has GERD and the likely cause of it. Often, it’s caused by an anatomical defect, such as a hiatal hernia. In these cases, lifestyle changes and PPIs may not provide adequate relief and an interventional procedure may be needed. In fact, a study published in Expert Review of Medical Devices reported that, over time, approximately 17 to 32 percent of GERD patients do not experience adequate symptom relief with lifestyle changes and medication.
Many health plans consider a laparoscopic Nissen Fundoplication to be the “gold standard” for patients with an anatomical reason for their GERD. This surgical procedure developed in the 1950s has given many relief from the bothersome symptoms of GERD and has helped many to get off their PPI medications, but it is linked to long-term side effects like dysphagia (difficulty swallowing), gas bloat and inability to belch or vomit, as outlined in an article in JAMA.
There are a variety of options available for the long-term treatment of GERD. However, health plan medical coverage guidelines do not always feature the most recent advances in technology. Newer, less invasive and very safe procedures have become available, including the TIF® procedure. TIF is an acronym for transoral incisionless fundoplication, and it is performed through the patient’s mouth, which means there are no incisions. While under general anesthesia, a special device is inserted and is used to manipulate and recreate the valve between the stomach and the esophagus, correcting the anatomical defect causing symptoms and providing similar benefits as a Nissen surgery but without as many side effects common to that surgery.
The TIF procedure has been largely embraced by the medical community and medical societies such as the American Gastroenterological Association (AGA), the American Society of General Surgeons (ASGS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). It is also substantially less expensive than a Nissen fundoplication. The 2017 average, unadjusted Medicare reimbursement for the TIF procedure is $4,392.22 versus the Nissen procedure, which can range from $8,573.89 to $33,810.71 – two to almost eight times more expensive than the TIF procedure – depending upon the degree of complications (www.cms.gov). More importantly, the cost savings do not compromise outcomes.
Unfortunately, the TIF procedure is not always covered by third-party administrators – greatly limiting options for treatment of GERD. HR and benefits managers should review their plan administrator’s Medical Coverage Guidelines to find out which treatments for GERD are covered. If the TIF procedure is not covered, self-funded employers can easily request that coverage for CPT code 43210 is added to the plan. Fully-insured employers can apply pressure to their insurer to add TIF coverage to commercial plans. In addition, employers can direct their employees to GERDHelp.com for more information about GERD, treatments and locating specially-trained physicians.
By understanding GERD and its effect and impact on the workplace, providing the right information and ensuring health plans cover varying treatment options, HR professionals can help their company and fellow employees better manage the impact of this prevalent disease. This helps keep everyone from feeling the workplace burn of GERD on employee productivity and the employers’ bottom line.