1. The Business Case for Asthma Addressing Health Disparities and Health Equity: A New England Approach U.S. HUD’s Office of Healthy Homes and Lead Hazard Control Health Insurance Coverage of Services Critical to Asthma Care: A Pilot Summit September 21, 2012 Presented by: Stacey Chacker Director of the Asthma Regional Council, Health Resources in Action

2. HRiA Mission: To help people live healthier lives and create healthy communities through prevention, health promotion, policy and research. ARC’s Mission: To help people to live full and active lives by reducing the impact of asthma through collaborations of health, housing, education, and environmental organizations with particular focus on the contribution of schools, homes, and communities to the disease and with attention to its disproportionate impact on populations at greatest risk. Asthma Regional Council of New England a program of Health Resources in Action

3. History of ARC In existence for more 12 years Founded by Federal Region I Administrators of HHS, EPA and HUD Comprised of public agencies, health care providers, private organizations and researchers Started with environment; kids Expanded to comprehensive asthma management - clinical and environmental contributors; kids and adults Unique in that we work across the six New England States on joint strategies.

4. Asthma: A Study in Disparities and Poor Outcomes More common in low income urban residents; African American and Latino communities Higher rates of urgent care and deaths Unacceptable : A Disease Out of Control – 2/3 cases have “poor”, “very poor” control NHLBI: Bridging the Disparity Gap  Culturally competent education  Mitigation of environmental triggers

5. CONTEXT: Costs for Asthma Health Care Cost - $ 50.1 billion/year Societal & Business Cost: o10.5 million missed school days/year  Average of 4 missed days/child with asthma) oTop 10 conditions affecting employees:  Per capita employer expenditures 2.5x higher than for employees without asthma  Productivity: 4th leading cause of absenteeism; 7th leading cause of presenteeism  Workers with asthma may miss as many as 125 million workdays/yr: $23 billion

6. Five of Promoting Healthcare Best Practices

7. CONTEXT-Costs for Asthma Will a new service/coverage: o Evidence-base for best practices o Expected outcomes o Anticipated costs o What is the standard practice and models of care o What providers and purchasers want Payers (Insurers) Want to Know

8. ARC’s History Working with Payers (Insurers) Interviews with Medical Directors. Symposium in 2004 First “Business Case for Payers” in 2007. Worked with two payers to develop pilots and work on policy change. Working in collaboration with CDC-funded NE State Asthma Programs to continue to promote financing.

9. Business Case for Health Care Payers Business Case for Employers & Purchasers Business Case for Integrated Pest Management Insurance Purchasing Checklist Provider Consensus Statement Insurance Coverage Survey Six Tools Developed

10. In February 2011, HHS Sebelius cited ARC’s “Investing in Best Practices for Asthma” in a guidance letter to all Governors regarding Medicaid cost-saving opportunities.

11. Best Practices for Asthma Management: NAEPP/NHLBI Guidelines 1. Lung Function: Assessment and monitoring 2. Education for a partnership in asthma care 3. Control of environmental factors 4. Pharmacologic therapy Newest guidelines underscore importance of patient education & environmental interventions

12. Take-aways Investing in Best Practices for Asthma Effectiveness of Asthma Education & Environmental Interventions on Health Outcomes Established: - Across risk levels Increased symptom free days & other quality of life measures Improved lung function Reduced use of rescue medications

13. Take-aways Investing in Best Practices for Asthma Establishing a Business Case for Health Care Decision Making Are there cost savings? Savings from reduced health expenditures exceed the cost of the program (ROI) Is there cost-effectiveness? Investments in a new service are reasonable for a given health outcome

14. Take-aways Investing in Best Practices for Asthma Health sector stands to benefit from investing in asthma education & environmental interventions – Education COST SAVINGS: (~$7 to $36 for every $1 invested) – Home-based environmental interventions Assessment, services & supplies COST EFFECTIVE: ($2-$28 per symptom free-day gained) Comparison with accepted pharmacotherapy: $7.50 per SFD for inhaled corticosteroid $11.30 per SFD for budesonide $523 per SFD for Xolair

15. Take-aways Investing in Best Practices for Asthma Evidence on Costs: Practice Based Models Combining asthma education & environmental interventions in comprehensive asthma management – Optima Health: saved $4.10 for every $1 spent on their high- risk member program – Monroe Plan for Medical Care: realized a 20% reduction in total asthma-related medical costs – Asthma Network of Western Michigan: comprehensive care costs $2,500 per person annually; saves $800 per child per year.

16. Take-aways Investing in Best Practices for Asthma

17. Overarching Recommendations Align reimbursement policies with research and national guidelines, with emphasis on addressing disparities: -Asthma education reimbursements in the clinic and home -Provide home assessments and supplies for high risk patients -Use a range of non-physician trained and certified providers -Reduce medication co-payments -Offer smoking cessation and nutrition counseling -Monitor prevalence, quality of care, outcomes/control and disparities

18. New England Insurer Survey Sent to 45 Payers; 48 questions to assess payer’s asthma programs & coverage 25 responses: – 6 Medicaid Managed Care Organizations (MMCOs). – 5 fee-for-service (FFS)/PCC state Medicaid – 14 commercial insurance Analyzed Data Against Best Practices from: NAEPP, CDC, and Published Research

19. Gap Analysis Focus Rationale Used Best Practices from: NAEPP, CDC, and Published Research Limitations Full report and Executive Summary: www.asthmaregionalcouncil.org

20. Findings About 1/3 of all payers will reimburse for separate or extended asthma education sessions; others will only do so in limited circumstances

21. Home based clinical & environmental services provided by less than ½ of plans. Findings

22. Overarching Findings Many instances where policies fail to align with best practices Coverage inconsistencies extend within and across all payer types Inconsistencies symptomatic of lack of alignment with science and national recommendations

23. ARC tools and Gap Analysis Shifting healthcare environment: opportunities and challenges to providing more effective care. Promising models for delivery and financing. Open dialogue: fostering and investing in an environmental management approach; barriers to delivery. NCQA HEDIS measures. Bringing the Tools to the Table - Convening 2010 ARC Symposium for Payers and Policy Makers

24. CMS Health Care Innovation Challenge $1 billion to implement the most compelling new ideas for delivering the three-part aim: Improved care Better health Lower costs

25. New England Asthma Innovation Collaborative Project Summary Goal: Create New England Asthma Marketplace Outcomes: Enhanced quality of life and success of children with asthma Reduced disparities Demonstrated savings New workforce Policy change, sustainability

26. New England Asthma Innovation Collaborative Project Components: Service delivery expansion Workforce development Committed Medicaid payers Payer and Provider Learners Community

27. New England Asthma Innovation Collaborative Funding and Financial Impact CMS Funding: $4,040,657 over three years Projected health care savings (3 yrs): $4.1 million Projected Return on Investment: $1.54 to $5.22 (home visiting – clinic based asthma education

28. Acknowlegements Funding for 2009-2011 provided by Kresge Foundation, Boston Foundation, DHHS (Region One) ARC Business Cases authored by: o Polly Hoppin, ScD – U of MA, Lowell o Laurie Stillman, MMHS - HRiA o Molly Jacobs, MPH - U of MA, Lowell Funding for NEAIC provided by CMMI Health Care Innovation Award

29. Contact and Resources Contact: Stacey Chacker, ARC Director Health Resources in Action 617-279-2240 ext. 536 schacker@hria.org www.asthmaregionalcouncil.org