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Gaps in care are common in high-risk patients

Medicaid programs reveal ways to better manage asthma patients

Numerous studies have shown that it is difficult to produce both clinical and financial results from DM interventions focused on asthma. Further complicating management of this disease is the reality that asthma is more prevalent among certain minority groups, and the morbidity and mortality associated with asthma is particularly evident among disadvantaged youths who reside in urban areas. Despite these challenges, there are clear gains to be made from better management of asthma. Statistics suggest that asthma accounts for one-quarter of all ER visits and an estimated 500,000 hospitalizations every year. Yet such utilization can often be avoided with proper management.

What clinicians and healthcare organizations struggle with is how to improve management of asthma without spending more money on interventions than will be saved in reduced utilization. It is a difficult balancing act, but there is evidence that it can be done. For example, the Medicaid program in Arkansas is having success with an intervention that focuses on arming PCPs with timely information about their patients’ medication purchases and utilization histories so that PCPs can make better treatment decisions. Alternatively, Dallas-based Parkland Community Health Plan has achieved impressive outcomes by working with a local vendor to quickly identify and reach out to Medicaid recipients affected by asthma.

Outsourced effort delivers returns

Parkland serves a young population—110,000 out of 135,000 members are under the age of 18—and 13% of the pediatric population has asthma, explains Barry Lachman, MD, the health plan’s medical director. “When their problems are out of control and not being well managed, it is a tremendously bad thing for them, and it is a big burden on the health plan, so it was important for us to come up with a plan to deal with asthma early on,” he says.

However, Lachman adds that although the health plan was interested in developing asthma DM programming, administrators felt that it would take too long to develop such programming internally. “We didn’t feel like we could easily put some of the elements in place that we needed to have a DM program that would get to the needs of our population very quickly,” he says. For example, Lachman explains that health plan staff members did not have experience with stratification or in selecting suitable materials for education. “There were just numerous things that we were going to have to learn from the ground up that we could get by outsourcing to a good vendor.”

Consequently, in 2003, Parkland teamed up with Dallas-based AirLogix to develop a program that would meet the needs of its growing asthma population. And the partnership has proven successful with gradually improving results in each of the last three years. Third-year results were most impressive, compared to baseline, says Lachman, pointing to a nearly 32% decrease in ER visits and a 29.8% decrease in hospitalizations.

“We were able to document fairly robust results in terms of real decreases in utilization, and that has not been the community experience,” says Lachman, noting that there have been no parallel improvements taking place in the larger community with respect to asthma.

Access is an issue

Lachman believes that the program’s success is, in part, attributable to the early identification of members with asthma and a stratification system that prioritizes outreach efforts for patients at highest risk. This process takes place every month—AirLogix analyzes the latest claims and pharmacy data from Parkland to identify all members with asthma and then uses a predictive model that was developed by Airlogix to assign each patient a risk score, explains Julie Sizemore, chief operating officer for AirLogix.

She says that the software looks at such factors as whether a patient has been filling his or her prescriptions for long-term controller medications, or whether he or she has been filling his or her short-acting bronchodilator every month. “We also take into consideration ZIP codes,” says Sizemore. “The software can determine that there are certain geographic areas that are more likely to have [problems with asthma] than other areas.”

Once the data have been fully analyzed, and patients have been loaded into the AirLogix system based on their risk score. Sizemore explains that respiratory therapists and, in some cases, nonclinician personnel begin to make outbound calls to the members to further assess the state of their asthma care. “We are looking for people who have uncontrolled symptoms because those are the people who need our help,” says Sizemore. “People who are on good medication regimens and not having symptoms aren’t the people who really need our program.”

Information gleaned from the initial phone call will be added to the AirLogix database and used to develop a treatment plan for the member that indicates what level of ongoing program interaction the patient or family needs. In many cases, subsequent phone consultations will be scheduled to address the issues uncovered during the initial encounter. In other cases, Sizemore says, staff members will schedule a home visit for the member with a respiratory therapist.

“When people are on good medication regimens, saying that they are taking their meds as prescribed, and yet they are still very symptomatic—those are the people we are really going to focus our home visits on because there is probably something in the environment that is causing them to be ill, or maybe they really are not taking their meds as prescribed,” says Sizemore. “We can find all this out if we are sitting face to face with them.”

Throughout the process, Sizemore says, PCPs are kept informed about their patients’ encounters with AirLogix as well as any information gleaned through these encounters that may be pertinent to the physician’s treatment approach. In addition, AirLogix works closely with Parkland’s social workers to address any psychosocial issues that are interfering with asthma control.

For example, Sizemore points out, many families have difficulty accessing care, either because they lack transportation or are unable to schedule visits with their PCP during office hours because they cannot get time off from work. Families in these types of circumstances tend to use the ER more often as a practical matter. However, Sizemore notes, these difficulties can often be resolved with the assistance of social services as well as patient education designed to improve management of the asthma. In addition, she points out patients can call AirLogix at any time of the day or night with questions or concerns about their care.

Working with AirLogix, Parkland has clearly made a dent in reducing unnecessary utilization. However, Lachman believes there is room for further improvement in a couple of different areas. “We are always looking for strategies involving earlier engagement of clients,” he explains, noting that the process of identifying patients for intervention through claims can be excruciatingly slow, especially with Medicaid recipients who may be enrolled in a DM program only for a short period of time. In addition to looking for new ways to reach people earlier, Lachman would also like to develop additional strategies for dealing with the most complex patients. “The people who have that combination of psychosocial problems and severe asthma are the hardest to reach and deal with,” he explains. “We have done some things to cross that frontier, but I think there are some others we can do in that area.”

Arkansas targets high-risk asthmatics

Statewide interventions aimed at making providers aware of evidence-based treatment guidelines for asthma care have helped Arkansas’ Medicaid program gradually improve its standing on asthma-related HEDIS measures. However, in 2004, recognizing that there were still huge opportunities for clinical improvement and cost savings, health planners decided that they needed to do more. “We noticed early on that a small subset of asthma patients consumed a very large percentage of acute care services,” says William Golden, MD, vice president for clinical quality improvement at the Arkansas Foundation for Medical Care (AFMC), a nonprofit organization that spearheads and supports healthcare quality-improvement efforts.

Working with the Hamilton, NJ–based Center for Health Care Strategies, AFMC decided to focus new interventions on the 4% or 5% of asthmatics who were responsible for the lion’s share of ER visits and hospital admissions. However, Golden stresses that administrators were well aware that implementing a cost-effective strategy would involve a delicate balancing act of making sure that the state didn’t spend so much on interventions that it was impossible to achieve ROI.

To make sure that staff members reached out to the highest-risk patients, AFMC developed a priority code system that stratifies asthma patients based on their hospital and ER use. This system—which establishes four risk levels—was then used to guide the frequency and level of outreach to asthma patients. Further, concluding that in-person or in-home visits would be too expensive, AFMC decided to have nurses reach out to the identified patients by phone or mail—in some cases multiple times.

“We knew what their pattern of care was, so we knew which patients had come to the ER several times and had never seen a physician in the outpatient sector, and we knew which patients had been to the ER many times but had only filled prescriptions for beta-agonists,” says Golden. “So [the nurses] would tailor their discussions with the families about the potential gaps in their care.”

In addition to the patient interventions, providers received profile reports of the asthma patients in their care along with each patient’s pharmacy data and utilization patterns. Through these reports, physicians could see which patients were not filling their prescriptions and which patients had been to the ER twice since their last office visit.

“We have been doing [these profiles] with other diseases, so this is not something new. And we also have academic detailers who go visit the physicians’ offices, so they are used to seeing this [kind of communication] from us,” says Golden, emphasizing that AFMC staff members are careful to approach physicians in a neutral way. “We basically say that there are some opportunities here, and they should look them over. One way or another, we get the message across.” In fact, AFMC is now in the process of making the profile reports available to physicians online through a portal—a move Golden says has been well received by providers.

Thus far, the approach of targeting high-risk patients has paid off for AFMC. Golden indicates that the program has delivered an ROI of $5 or $6 on every dollar spent toward the interventions.

Golden acknowledges that the program is targeting a tricky population that can be very difficult to reach by phone or mail, but he is encouraged by these results and is hopeful that the approach can yield further gains with the online portal.