Managing asthma patients can save your capitation dollars
July 1, 1998
Managing asthma patients can save your capitation dollars
Hartford Hospital in CT rides the cutting edge of established norms
If you've paid any attention to your emergency department's (ED) case mix data, the number of asthma patients presenting in your ED has likely risen in recent years. For many urban hospitals, especially those in high-transient, low-income communities, asthma cases are expected to rise steadily and sharply in future years unless there is some form of effective interdiction. In recent months, the disease has caused considerable concern among clinicians.
This is the disease to watch, according to public health specialists.
Scott Wolf, DO, director of ambulatory medicine at Hartford (CT) Hospital has been quite vigilant. Wolf virtually lives, eats, and breathes the subject of asthma. His hospital, an 819-bed facility that serves a predominantly inner city population, has seen the number of asthma cases in the ED skyrocket in recent years. And until the hospital implemented an integrated outpatient asthma management program in 1997, the respiratory disease had claimed a large chunk of the hospital's capitation budget as one of its biggest victims.
Explosion in asthma cases baffles experts
Hartford's clinicians have good cause for concern. Repeated, non-attenuated ED visits by asthma patients can wreak havoc on your risk contracts. They can geometrically multiply the number of future ED visits by the chronically ill, Wolf says. A lack of effective intervention within the acute-care setting may, in fact, help explain the recent explosive growth in asthma cases, some sources say.
That notion is getting widespread support. According to the University of Michigan School of Public Health in Ann Arbor, physicians are treating the symptoms of asthma but largely ignoring underlying causes such as lifestyle and environmental triggers that keep the disease prevalent in communities. By ignoring these factors, clinicians are disregarding established, prescribed clinical treatment guidelines for asthma, according to Noreen M. Clark, PhD, dean of UM's school of public health, who made these remarks at a recent American Medical Association (AMA) conference.
Nationally, asthma rates in the general population have soared to epidemic proportions. The number of cases has jumped 80% since 1980, according to the Centers for Disease Control and Prevention in Atlanta, GA. The incidence in young children is up 160% for the same period, a CDC report states. Presently, some 15 million Americans, including 6 million children, suffer from the chronic though manageable respiratory disease. In 1995, asthma-related disorders accounted for 1.8 million ED visits and 446,000 inpatient admissions.
Strangely, the growth in asthma cases has occurred during a time of marked advancements in the disease's diagnosis and treatment, asthma experts say. While physicians know more about the ailment today than ever before, they can't explain the reasons for the steady, alarming growth. The situation has left clinicians baffled, but, like Clark, concerned that clinicians are not paying sufficient attention to accepted treatment strategies.
At Hartford Hospital, the environmental factors can hardly go unnoticed. Some 60% of the institution's patients are on Medicaid managed care. The rest are on city or state assistance or simply can't pay for services, Wolf says. "The low-income nature of their circumstances makes them highly prone to lifestyle and environmental factors such as alcoholism, poor living conditions, and crime, which tend to aggravate the disease," says Rhonda Anderson, Hartford's chief operating officer and director of managed care.
Asthma cases were sinking the cap budget
The largely Hispanic (Puerto Rican) population in Hartford, CT, is also highly transient. Family members regularly travel back and forth to visit the island. "Puerto Rico has among the world's highest incidence of chronic asthma," Wolf adds, "which doesn't help our ability to control the disease." These extrinsic factors have also hit the hospital hard financially. In 1996, Medicaid asthma cases treated in the outpatient sector accounted for some 60% of the hospital's total number of cases. The rest were covered by commercial health plans.
On average, the facility was losing between $300,000 and $500,000 per month on these cases. Meanwhile, the hospital had contracted with Blue Cross and Blue Shield of Connecticut in Fairfield, the state's Medicaid carrier, to be at 100% risk for patients. With some 8,000 beneficiaries enrolled at $148 per-member, per-month (pm/pm) the facility was draining money, Anderson recalls.
Managing the disease, not just the patients, seemed to be the answer. Through an integrated approach that aligned the modalities and objectives of the ED and one of the hospital's dedicated outpatient clinics, physicians emphasized intervention and education. "The education component plays a key role in getting the patient early into the program," says Donna Rescorl, RN, a nurse educator in the ED.
Clinicians poured over the clinical literature from the Washington, DC-based National Institutes of Health and the National Heart, Blood, and Lung Institute and adopted a combined treatment and maintenance program that underscored patient collaboration in the process. They also adapted clinical protocols and benchmarking criteria from providers with similar maintenance programs.
An attending physician or respiratory therapist typically identifies the patient as a program candidate during the ED visit or at any clinic site throughout the hospital, Rescorl says. In the ED, once stabilization occurs, the education process begins with a five-minute "quick-teach" information session conveyed verbally by a bilingual nurse educator. The session focuses on how a maintenance program can help prevent future critical flare-ups that inevitably require unexpected emergency visits, which often occur at night. "The patient is then referred to the asthma education program and scheduled for a follow-up clinic visit," Rescorl says.
During the initial visit, the staff conducts a detailed history and physical in collaboration with the patient's Medicaid-assigned primary care physician. Through a series of intensive follow-up visits at three-, six-, and 12-month intervals, the patient's maintenance program is evaluated by a team composed in total of about 46 medical residents and nurse practitioners.
But, a core component of the program involves what occurs at the patient's home, Wolf observes. A social worker assigned to the case typically visits the patient's home and performs an in-depth assessment of potential asthma triggers in the patient's environment. Causal factors that can exacerbate the asthma condition can range from dust pollution, poor ventilation, and insect and rodent infestation to a lack of elevators in an apartment building. There are also lifestyle issues such as drug-abuse, poor nutrition, and domestic violence that constitute underlying causes, Wolf notes.
Patient education poses tough challenges
Hospital workers sent to the patient's home to make changes can alter the physical factors, such as poor ventilation and unclean pillows and mattresses. The lifestyle issues, however, are far more complex, Rescorl says.
Meanwhile, patients get placed on a self monitoring program in which they monitor their own medication regimen and lung capacity using established NIH peak-flow measures under the medical staff's guidance. During each follow-up visit, their performance records are checked and appropriate adjustments are made to their medication and maintenance program.
Although the program's effectiveness depends, in large part, on guided self-care, Wolf is quick to note that the asthma program's educational component should not be overlooked or minimized. Yet, patient education as important as it is to asthma treatment has its shortcoming. Compliance remains the single biggest roadblock to fully managing the disease, says Anderson.
Since its inception in January 1997, the program has achieved about a 60% success-rate in reducing episodic flare-ups. The remaining 40% means that the program is dangerously close to failing with one out of every two patients. And those numbers are too high for Wolf and his staff. "What's an acceptable failure rate? I'd like to get it down to 20%," he notes.
And despite the cost-savings-Wolf estimates the program's cost-per-patient to be less than one-fourth the average cost of an ED visit and even less than that for a two-day inpatient stay-the hospital has yet to translate the savings to its capitation budget. After more than a year, the program is still only breaking even on a pm/pm basis, says Anderson. (Officials declined to give specific dollar amounts.)
But they are making headway, Anderson notes, and they are confident that the program will achieve future cost-savings. Blue Cross officials are also hopeful. Why? The underlying basis for the integrated approach is sound, according to Wolf. And there is ample precedent for this argument.
In May, the Annals of Emergency Medicine summarized a definitive approach to asthma treatment in the ED.1 Virtually echoing the Hartford program objectives, the Annals authors emphasized the key role of education based on recommendations of a 1991 National Asthma Education Program Expert Panel report called "Guidelines for the Diagnosis and Management of Asthma (EPR-1)" sponsored by the NIH.
The guidelines were amended in 1995 as EPR-2 "and stresses that patient-centered asthma self-care should be systematically taught and reinforced at all clinical encounters, including ED visits," according to the Annals report.
The report goes on to outline established algorithms for initial assessment and treatment, including the use of inhaled corticosteroids (for persistent asthma) and anti-inflammatory nedocromils and leukotriene-modifiers for long-term control. (See the chart on page 77.)
To Hartford's medical staff, despite the low numbers, half the battle against asthma in their community is already being won. On a human level, "we now have a system that helps patients who normally fall through the crack. To clinicians, that's reassuring," says Rescorl.