Asthma program yields 4.5:1 return on investment
Program cuts inpatient days, improves medication
An asthma management program for a Medicaid population has achieved a 4.5:1 return on investment since the program began in 1996.
Hospital inpatient days have dropped 50%, and emergency room visits have decreased 15%, with a 10% increase in prescription costs among the asthma population covered by Horizon-Mercy, a Trenton, NJ, managed care organization covering the publicly insured.
In the two years Horizon Mercy has collected HEDIS information, the plan has been able to show a 25% improvement in appropriate medication for members with asthma.
The insurer started the program because of its high rate of members with asthma.
In fact, the cost and volume of asthma and respiratory disease to Horizon-Mercy is surpassed only by pregnancy, according to Alan Adler, MD, MS, FACP, vice president of the health services department.
"Asthma is huge in our population. We have a prevalence rate of around 9%. Because we have a large inner-city population, it’s a major issue for us," Adler says.
The Medicaid population covered by the program presents a unique set of challenges for the case managers who work with them.
For instance, many of the members who could benefit from a disease management program don’t have telephones. They move around a lot and face major obstacles to receiving quality health care.
Because the members are difficult to reach and have difficult issues, there’s no one-size-fits-all type of intervention for Medicaid patients, Adler says. "One scenario for outreach doesn’t work in a Medicaid program. You have to be very creative," Adler says.
Members are identified from hospital admissions, emergency room visits, and referrals from case managers, social workers, providers, and the members themselves. All members get a regular newsletter that includes information about the program.
About 11,000 members have enrolled since the program began.
When the case managers at Horizon-Mercy identify someone as a possible enrollee in the asthma program, they make at least three attempts to contact the member and gauge their interest in the program.
If the case managers are unable to contact members by telephone, they use other means, such as mailing them a letter or calling the primary-care physician, and in some cases, the pharmacist for updated contact information.
"Our members move around a lot, and sometimes the pharmacists are the only ones with the correct address and telephone number, " Adler says.
If members want to participate, the case managers conduct a brief telephone assessment that includes how long the member has had asthma, medical history, medications, how compliant they are, and triggers in the home.
They conduct a risk stratification assessment, with a level 3 being the most severe.
Depending on the level of risk, the members receive intensive telephone information, followed up by educational mailings.
If appropriate, the case manager refers the member to a specialist, enrolls him or her in an educational program at a federally qualified health center, or arranges for a home visit by a respiratory therapist.
"We have social worker case managers who can conduct a home evaluation if the situation warrants it. Our members have tremendous social issues which are barriers to good health care," Adler says.
In some cases, the case managers ask the medical director to consult with the primary-care physician about patient care.
Case managers may be able to handle the education on the telephone with some members. Others may require multiple social worker or respiratory visits. Compliance is a problem as well.
Many of the members rely on their rescue medication instead of taking the appropriate controller medication.
"Ultimately, the program is all about education. A major issue is to try to get people to understand the difference between controller medication and rescue medication," Adler says.
Horizon Mercy has set up a mentoring program with the primary care physicians. Instead of conducting typical continuing medical education for the physicians, the plan pays specialists to go into the physician offices and work with the doctors and their staff to educate them on updated guidelines.
"It’s been very effective in bringing the message to the physicians," Adler says.
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