Medicaid Managed Care: Bronx, NY

Nurse and girlAffinity Health Plan

Tackling a Common Problem

While pediatric asthma is a serious problem in New York City, it’s even more severe in many areas of the Bronx. With asthma prevalence rates of up to 20 percent, and inpatient and emergency department services a common approach to dealing with the issue, the Affinity Health Plan wanted to change the status quo.

Specifically, Affinity wanted to shift asthma treatment away from acute care to a chronic disease management model. With support from the Robert Wood Johnson Foundation, Affinity was able to do that successfully—even while its enrollment ballooned and spread throughout New York City and its surrounding counties.

Early Identification Drives Success

The key to Affinity’s model was early identification and stratification of children with asthma. The program coordinators felt—and later demonstrated—that learning about the severity of a child’s asthma upon enrollment and following up promptly with the most appropriate response would reduce the need for more costly services.

“The program really showed us the value of tracking multiple outcome metrics,” says Susan Beane, M.D., senior vice president and chief medical officer of Affinity Health Plan. “It became the model for how we reach and intervene with patients system-wide.”

Affinity combined several strategies to make its outreach and identification efforts more effective. It developed a health risk assessment (HRA) form that was sent to all new members when they enrolled in the plan. HRAs of new members were also conducted by phone. All responses were captured in a database and members with asthma were referred to the Asthma is Relieved (AIR) case management program. Also, members who had received inpatient or emergency department treatment for asthma were referred to the program. Using these combined methods, Affinity was identifying more than 300 new members per quarter with asthma by the end of the funding period.

Stratification and Outreach Improve Care

Once members were identified and assessed, Affinity was able to refer them to the most appropriate care very quickly through AIR. Outreach staff made appointments for asthma members categorized as moderate-to-severe who hadn’t yet seen a care provider. These new members and those identified through medical claims were also offered a respiratory therapy home visit.

Home visits from respiratory therapists included: an environmental assessment and recommendations for eliminating triggers; and patient education on asthma management, including medications, asthma action plans and equipment such as nebulizers, spacers and peak flow meters.

Asthma case managers followed up with members to check in on appointments, as well as to learn if other family members may have asthma. These combined outbound call efforts yielded more than half of the new members identified, of which half were stratified by outreach staff and many were referred to providers or home visits.

Educating Providers Pays Dividends

Recognizing that referring more asthma members to providers meant challenges in time and patient volume, Affinity also worked to make primary care practices more effective through specialized training.

Affinity developed a continuing education curriculum that was offered in tandem with CME credit. “The Asthma Dialogues” is a series of four case-based interactive multimedia training modules covering: diagnosis; level of severity and treatment; access to care; asthma action plans; and environmental assessments and tools for care.

Initially, the modules were delivered on-site by Robert Morrow, M.D., who designed the curriculum. The curriculum was also made available on CD-ROM. After completing the modules and receiving CME credits, providers became eligible for reimbursement for in-office nebulizer and spirometry treatments. More than 215 providers have been trained and demonstrated improved care in simulated cases. Most providers also reported greater confidence in treating asthma.

“The program worked because it brought all sides together,” says Dr. Morrow. “It reached out to practices, providers and patients in highly effective ways. Now it’s being modified to further improve the positive outcomes we’ve seen.”

Results

With its focus on early outreach and stratification of members, Affinity reduced the number of hospitalizations for childhood asthma by 300 percent and emergency department visits by 400 percent. Meanwhile, inpatient costs dropped from $12.50 per member to $7.50 per member. In addition to improving the care delivered through the patient and provider education initiatives, Affinity’s model offered a substantial return on investment: Every dollar invested in the project generated $10 in cost savings in childhood asthma care, and $3 in cost savings across the entire health plan.

Although plan enrollment has since grown to over 200,000 members, Affinity’s model has sustained its average of reaching 50 percent of asthmatics. Today, Affinity is working on ways to improve that rate even further. “The program is still running, but we’re taking it to the next level,” says Dr. Beane. “We’re incorporating new metrics to track return on investment and patient quality of life, and rolling it into our overall disease management strategy. The process has been instrumental in shifting our focus and looking at chronic illness in a broader way.”

Total Costs Chart

Total Costs for members receiving/not receiving asthma care.
(click to enlarge)

Emergency Department Costs chart

ED Costs for members receiving/not receiving asthma care.
(click to enlarge)

Inpatient Costs Chart
Inpatient Costs
for members receiving/not receiving
asthma care.
(click to enlarge)


Summary

The Affinity Health Plan program focused on early detection of asthma and prompt intervention. To reduce inpatient services and emergency department visits, strategies were implemented to identify and stratify children with asthma at key times: when they first enrolled in Affinity or after receiving inpatient or emergency department services. After identifying the patients, case managers taught them self-management techniques. Primary care providers were trained using a case-based interactive program entitled “The Asthma Dialogues,” for which they received CME credits and qualified for treatment reimbursements.

Affinity Health Plan partnered with its network of providers to create a program focused on asthma in the Bronx. However, Affinity grew rapidly during the program and today covers all of New York City and five surrounding suburban counties. Enrollment also soared when New York City mandated Medicaid managed care.

Strategies and Programs

  • Identified new plan members with asthma using a mailed risk assessment form and/or phone surveys.
  • Automatically referred those identified with asthma to Affinity's asthma outreach and case management program by clinical outreach staff, who then conducted risk assessments and made doctor appointments for children who had not yet seen a primary care physician.
  • Used a similar process for enrollees identified as having asthma from emergency department and inpatient claims data.
  • Offered new members with severe asthma a respiratory therapy home visit that included:
    • An assessment of the child's asthma condition and home; and
    • An educational review of symptoms, triggers, medications and how to use an asthma action plan.
  • Developed an asthma education curriculum for physicians consisting of four case-based training modules (“The Asthma Dialogues”) delivered on-site and also made available on CD-ROM and the Internet.
  • Reimbursed providers who completed all four training modules for in-office nebulizer and spirometry treatments and awarded those providers four continuing education credits from the New York Academy of Medicine.

Children and Families Served

From 2002 to 2004, over 3,000 new asthma patients were identified via the program. Due largely to its outreach efforts, Affinity was identifying between 300 and 400 new child members with asthma per quarter.

Results

  • Affinity significantly reduced costs for pediatric asthma care services.
  • Inpatient utilization of services declined threefold, and pediatric asthma-related emergency room visits dropped by more than 400 percent.
  • Per member per year costs for both inpatient hospitalizations and emergency room utilization fell by 50 percent.
  • The program produced a significant return on investment.
  • Every $1 invested in the project generated $10 in cost savings in childhood asthma care and $3 in cost savings across the entire health plan.

Costs

  • Total program costs were $529,988 (2002-2004).
  • The program cost was $77.79 per member per year for pediatric asthma patients, but only $3.37 per member per year plan-wide.
  • Reductions in emergency department visits, inpatient utilization of services and alterations in asthma medication prescription patterns resulted in significant savings: $800 per member with pediatric asthma for the three-year period and $10 per member per year plan-wide.

Lessons Learned

The importance of early intervention was underscored by the finding that most new child members with asthma were categorized as moderate or severe. By identifying children’s asthma severity level as soon as they entered the plan, Affinity greatly reduced the need for expensive inpatient and emergency department services.