Transcript New England Asthma Innovations Collaborative

Advancing Home-Based Asthma Interventions
and
Sustainable Payment Systems:
Lessons from the New England Asthma Innovations Collaborative
Ohio Healthy Homes Summit
Stacey Chacker, Director of the Asthma Region Council of New England
September 30, 2014
The Cost of Asthma
Health Resources in Action
Asthma Regional Council of New England
Working for
13 years,
across New
England, to
improve
pediatric
asthma
outcomes
and reduce
disparities
through
partnerships
and policy
Health Resources in Action
Building the Case to Insurers
 Interviews with Medical Directors.
 Payer Symposium in 2004 & 2010
 “Business Case for Payers”- 2007 & 2010.
 Pilots with two payers -- payment & policy change.
 Collaboration with CDC-funded NE State Asthma
Programs to promote financing.
 Insurance coverage survey – Gap Analysis
 New England Asthma Innovations Collaborative
Health Resources in Action
Tools for Advocacy
In February 2011, HHS Secretary Sebelius cited “Investing in
Best Practices for Asthma” in a guidance letter to all
Governors regarding Medicaid cost-saving opportunities.
New England Asthma Innovations Collaborative
Controlling Asthma, Controlling Costs
NEAIC is a project of the Asthma Regional Council of New
England, a program of Health Resources in Action.
“The project (NEAIC) described is supported by Grant
Number 1C1CMS331039 from the Department of Health
and Human Services, Centers for Medicare & Medicaid
Services. The contents of this publication are solely the
responsibility of the authors and do not necessarily represent
the official views of the U.S. Department of Health and
Human Services or any of its agencies.”
Health Resources in Action
New England Asthma Innovations Collaborative
CHW-led Home Visiting for Children with Poorly
Controlled Asthma
• Improve quality of care
• Improve health and quality of life outcomes
• Decrease health care utilization costs
• Advance sustainable payment systems
Health Resources in Action
NEAIC Partners in VT, MA, CT and RI
• 9 Clinical Partners
• Policy and Training Partners
• 6 Medicaid Payers
– 4 Medicaid Managed Care Organizations
– 2 State Medicaid Offices
CHW Core Competency Training
• Designed and implemented by the Outreach Worker Training
Institute at the Central MA Area Health Education Center.
• Two - 48 hour training sessions held for NEAIC over two years.
Health Resources in Action
CHW Asthma Home Visiting Training
• Product of MA DPH. Developed and delivered by
Boston Public
Health Commission with support from MA DPH using NIH ARRA
Funding.
• Two – 24 hour training sessions held for NEAIC over two years.
Intervention: CHW-led Home Visiting
Three to four Home Visits to:
• Assess patients’ needs and home environment
• Provide asthma self-management education
• Deliver cost-effective environmental supplies
• Improve quality and experience of care:
o Client-centered, use of motivational interviewing
o Promote asthma action plans
o Promote connections to primary care & prevention
o Referrals for social services
o Review of needs and progress
Participants
• 1100 + children
• Aged 2 – 17 years old
• Medicaid or CHIP beneficiary
• A diagnosis of asthma from an authorized clinician
• Evidence of poorly controlled asthma
–
–
–
–
Asthma-related ER visit
Observation stay
Hospitalization
Oral corticosteroids
Evaluation
Home visit / follow-up phone call data
1. Caregiver self-report – 1st & last home visit, 6, 12 mos.
2. Environmental observations – 1st & last home visit
 Collected/observed by CHWs
 Standardized assessments
• Focus group data – end of year 2 / beginning of year 3
• Claims data – Fall 2014 and December 2015
Key Measures
 Asthma control
 Health care utilization
 Pediatric asthma caregiver’s quality of life
questionnaire
 Environmental measures
Demographics
 N = 698 (through June 30, 2014)
 Age: 6.1 years
 Sex: 59% male
41% female
 Race/ethnicity
• Latino 60.3%
• White 24.7%
• Black
39.1%
• Asian
27.1%
Demographics
 Caregiver education level:
•
•
•
•
•
•
.4%
9.6%
18.9%
31.2%
26.5%
13.4%
didn’t go to school
8th grade or less
some high school but did not graduate
high school or GED
some college/vocational or technical school
graduated from college or grad school
 Language spoken most at home:
•
•
67.9% English
38.2% Spanish
Environmental Factors
Mean Environmental Composite Score (maximum score = 6)
Visit 1 2.55
Visit 3 2.03 (p=.000)
Environmental
Factor
Visit 1
Visit 3
Mold
35.2%
30%
Pests
58.25%
26.6%
Smoke
48.9%
41.2%
Pets
29.4%
28.6%
Chemicals
73.4%
64.1%
Dust
45.1%
9.3%
Asthma Control
Asthma Control Categories
Well controlled
Not well controlled
Poorly controlled
Visit 1
15.6%
49.1%
35.3%
Visit 3
49.5%
42.9%
7.6%
p = .000
Health Care Utilization
Health Care Utilization Pre- and Post- Intervention
# of times, days or visits in the past 6 months
2.5
2
1.5
1
0.5
0
TIMES admitted to hospital
Home Visit 1
Health Care Utilization
DAYS in hospital
Home Visit 3 (post intervention)
ED visits
Urgent care visits
6 month follow-up call
N = 295 V1 – V3, N = 138 V3 – 6 mos call, p < .05 except for days in the hospital and urgent care visits
between V3 and 6 mos call
Pediatric Asthma Caregiver Quality of Life
 Juniper’s Pediatric Asthma Caregiver Quality of Life
 13 questions – dimensions of how the child’s asthma makes the
caregiver feel
 Assessed on a 7-point Likert scale - “1 = all of the time” through
“7 = none of the time”
 Maximum score = 7
 Visit 1 = 5.08 v. Visit 3 = 6.00 (N=350, p=.000)
Asthma Action Plans & Flu Vaccines
Other CMS Self-Monitoring Measures
Measure
Home Visit 1
Home Visit 3
Percentage of patients who have received
an asthma action plan
59.0%
79.5%
Percentage of participants who used the
asthma action plan the last time their
child’s asthma got worse
50.3%
65.9%
Percentage of participants who have
received the flu vaccine in the past 12
months
74.4%
80.0%
NEAIC Payer Engagement
•
•
•
•
Claims and Encounter Data
Payer/Provider Meetings
Payer Assessment
Paying in Year Three/Four for Patients
(with demonstrated results)
• Policy Change
Payer Assessment - Purpose
Gain a better understanding of:
• Factors important to payers when
considering providing/paying for home-based
asthma interventions for pediatric patients with
poorly controlled asthma; and
• Their views about supporting CHWs as part of
clinical teams for asthma.
Methodology
• Semi-structured interviews by telephone
• 14 interviews across the New England states:
- 6 NEAIC: 4 MMCOs & 2 state Medicaid
- 8 non-partners: 2 MMCOs, 2 state Medicaid,
3 commercials and one health reform office
June 18, 2014
|
NEAIC Annual Meeting
Payer Assessment – Key Findings
• Receptivity to asthma home visiting programs and
CHW workforce, as long there are assurances of
standards in training and qualifications.
• Priority for evidence:
• Cost-benefit and improved health outcomes.
• Need
• Impact on QI measures and patient satisfaction.
• Technical and cost-related challenges (e.g. billing and
IT changes, capacity to take financial risks) to changing
payment structures.
Recommendation
Environmental Trigger Mitigation Supplies
Provide information to payers about:
- recommended environmental supplies
- rationale for the provision of these supplies
- average cost of these supplies.
June 18, 2014
|
NEAIC Annual Meeting
Recommendations to Influence Decision Making
• Provide evidence of improved control/health
outcomes, quality of life, reduction in health
care utilization and shift to prevention.
• Provide evidence of improved medication
adherence for NEAIC patients.
• Provide estimates of the cost of asthma
home visiting
• Provide a snapshot of impact on the specific
payers’ members, including impacts on
patient satisfaction.
Factors Influencing Decision Making for
Reimbursement for Asthma Home Visiting
Concerns about Organizational Capacity to Offer Reimbursable
Home CHW Visiting Services
• some employers of CHWs, such as community-based and public health
organizations, do not have capacity to file insurance claims
• the lack of widespread provider capacity to offer the intervention with CHWs
would make it difficult for payers to offer the service across the board to their
eligible membership.
Concerns about Patient Acceptance & Quality of CHW Home Visits
• non-NEAIC, in particular, concerned about assuring reasonably high rates of
acceptance by Medicaid and other patients.
• how to ensure the quality of the services provided through appropriate
supervision.
Challenges Related to Payment System Changes
• For global payment, providers need to have financial wherewithal
and infrastructure to assume risk
• Moving from a FFS to a bundled payment or global payment
system may require new contracting system/mechanism
- NEAIC intervention not big enough to be influencing factor
• Patient churning makes new service investment models less
appealing.
• Discussing important, but timing for changes is premature.
Opportunities and Strategies for
Advancing Changes in Reimbursement Policies
Medicaid Policy and Reimbursement for CHWs- Easier if:
• CMS requires coverage for asthma home visits and/or CHWs
• CMS or state Medicaid office set standards and rates for CHWs.
• Medicaid State Plan Amendments – new CMS
Opportunities :
• State Medicaid offices adopt new CMS Ruling – State Plan
Amendment
• Inclusion in Medical Home services and/or Accountable Care
Organizations or Communities
Next Steps in Promoting Sustainability
• Conduct cost analysis
• Payer/Provider Summit
- Share successful payment models
- Communicate health outcomes and ROI
• Individual meetings with payers
• Solicitations for “short-term” interim payment
structures.
• Researching Social Impact Financing
July 21, 2015
|
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Questions
• Stacey Chacker, Project Director/Co-PI [email protected]
• Heather Nelson, PhD, MPH, Senior Research Scientist/Co-PI
[email protected]
• Annie Rushman, MSPH, Program Coordinator [email protected]
www.asthmaregionalcouncil.org
“The project described is supported by Grant Number 1C1CMS331039 from the Department of
Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this
publication are solely the responsibility of the authors and do not necessarily represent the official
views of the U.S. Department of Health and Human Services or any of its agencies.”
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