The Community Asthma Initiative buys $150 vacuum cleaners and dust mite-proof bedding for the homes of its patients. And that speaks to what's right with the healthcare system.
Now five years into the program, 626 low-income asthmatic children who used to have expensive, frequent episodes of hospital care have been enrolled. In addition to the vacuums and bedding, families receive other non-toxic ways to reduce other pests, such as garbage cans with tight covers or copper gauze to fill in holes, all worth up to $300. They also get help with eliminating household clutter that traps dust. And an exterminator may be called in to deal with rodents.
Families also receive case management home visits, environmental assessments to detect household mold and moisture. In rare cases, city inspectors are nudged to pressure landlords to repair or seal areas with obvious mold or water leaks.
So far, the program is a quality success, reducing emergency room visits by 62%. Hospitalizations are down 82%. According to Children's, the average asthma hospital costs per child in CAI including all hospitalizations and ED visits are about $3,000.
And it costs about $2,600 per child, but avoids $3,900 in hospitalization costs over a two-year period, hospital officials say. Elizabeth Woods, MD, who directs the hospital's initiative, says cost analyses point to a 1.46 return on investment. The hospital has papers in press that illuminate its progress.
"The hospital does it because it's the right thing to do for kids and families for asthma care and provide it as a model. But it's primarily a saver to the payers....who are reducing their expenses (but) they're not paying us currently for the services," says Woods. "What we've been advocating for is that there be a more sustainable way of funding this, that also takes into account the money upfront to prevent the hospitalizations."
So here's a great program, but one whose success could hurt the hospital's bottom line, one that costs money and reduces business.
Brigham and Women's Hospital surgeon and author Atul Gawande wrote me in an e-mail this week that he was told by Children's CEO Jim Mandell that the asthma prevention efforts are "a good example of the tension between doing great work on quality and safety that then threatens you with major money losses," since such a huge portion of revenue comes from hospitalizations of children with uncontrolled asthma.
In a recent talk to hospital leaders, Gawande suggested the hospital could be looking at "bankruptcy" if this major source of admissions revenue dropped significantly.
Use of that word irritates Josh Greenberg, Children's Hospital Boston's vice president for government relations, because he insists that's not the way his hospital's chiefs are thinking about this. "That's complete nonsense," Greenberg says, adding that he knows Gawande "likes to say that."
Rather, Greenberg says, the hospital will do "the right thing for kids," and that involves keeping them from needing inpatient care. Some of the losses might be made up by not providing worthless or futile care, he says.
But, he adds, that doesn't escape the ugly truth, which is that "the current financing system for healthcare in this country doesn't support these kinds of programs," even though they have lifetime benefits for the children, their families, for the healthcare system and for society at large.
"Everyone worries about their member-per-month costs, but not the long-term health impact from providing healthcare programs (like this one) for kids, and that's a real problem," Greenberg says.
Woods says the cost of these remedies may seem like a lot, but in context, it really isn't. For example, a $150 HEPA vacuum cleaner costs less than a month's supply of inhaled corticosteroid medication, the need for which may be reduced by regular carpet cleaning to prevent airborne allergen exposures, and is certainly less costly than hospitalization. The hospital pays, but Medicaid and private insurers get the savings from the avoided need for expensive healthcare services.
The hospital also spends its own money – including revenue from grants and philanthropy – to keep the program staffed with a director, clinical director, clinical nurse, community outreach worker, community nurse educator, an evaluator and a program coordinator.
The idea that an industry might undertake expensive projects to avoid selling its products is not new, although in some cases companies have been forced to do so. Utility companies now pay for home insulation and special meters that detect overuse. Some of these efforts are now "rate-based" which means that these expenses can receive a rate of return, encouraging utilities to do more of the right thing. One hopes the automobile industry is building its cars more safely and in ways they last longer.
Greenberg and hospitals colleagues have gone to officials with MassHealth, the state's Medicaid program, to demand "they bear some responsibility," and pay for the savings they're getting, he says. Discussions have been initiated with some private health providers as well.
In response, Massachusetts lawmakers recently passed legislation that calls for the state to develop "a global or bundled payment system for high-risk pediatric asthma patients enrolled in the MassHealth program."
That payment "shall reimburse expenses necessary to manage pediatric asthma, including, but not limited to patient education, environmental assessments, mitigation of asthma triggers and purchase of necessary durable medical equipment."
In two years, the project shall "ensure a financial return on investment through the reduction of costs related to hospital and emergency room visits and admissions."
Asked for the status of the effort, MassHealth spokeswoman Jennifer Kritz says the pilot is in the development process, but that "a new payment methodology in a manner that is prudent, both clinically and financially, is a complex undertaking."
The pilot is expected to include multiple providers, and "will be based on the bundle of services that are required to provide high quality care to MassHealth-covered children with asthma," she says.
The number of children to be included has not yet been determined.
Asthma is the leading cause of hospitalization at Children's Hospital, and children in low-income neighborhoods right near the hospital have rates as high as one in four. Seventy percent of children followed by CAI are covered by MassHealth.
Children's Hospital Boston would like to share their success with all providers who offer pediatric care. "But we have a challenge bringing this program to scale, taking it out of the four walls of Children's Hospital's laboratory of innovation and research," Greenberg says.
"We need to make it accessible to community health centers, community hospitals, to the mom and pop pediatric primary care setting with two or three physicians – those are still very much the norm. And we need to develop infrastructure and financing systems to do that."
Somehow, healthcare policy leaders need to figure out how to financially incentivize hospitals to do what Greenberg and Woods suggest, to reach beyond their walls to reduce the need for their services. Children's Hospital Boston is one cool example of an institution that is doing the right thing, but others won't follow unless they have the resources to do so.