Disease Mangement

Missouri Hospital Markets Successful Asthma Disease Management Program

Reprinted from the Dec. 16, 2005, issue of INSIDE DISEASE MANAGEMENT.

Buoyed by success in improving asthma care through its intensive, physician-centric asthma disease management (DM) program, Children's Mercy Hospital and Clinics in Kansas City, Mo., is branching out by marketing pieces of its program to local health plans.

In doing so, the newly formed hospital business unit — Children's Mercy Health Management — is bucking the national trend of "one-stop shopping," where purchasers of DM services want one single vendor to provide most or all of their DM programs.

Jay Portnoy, M.D., chief of allergy, asthma and immunology and director of health management at Children's Mercy, says he sees a niche for the DM services Children's Mercy can provide.

"Most [larger] health plans have national programs for disease management," says Portnoy. "The local Humana branch isn't going to scrap that and buy ours. But what they could do is buy a part of the program. We could possibly be a supplement to their programs."

Although a potential contract with Heartland Health's 25,000-member Community Health Plan has been put on hold because of issues unrelated to the contract, Portnoy maintains "we're pretty confident we'll get some contracts." He says there's been a fair amount of interest from other plans, and notes that he's meeting with officials from Humana this month to discuss the program.

Portnoy says he has huge confidence in the model Children's Mercy has developed for the asthma DM program, which involves training the physicians and then letting the physicians manage the patients. "It's more laborious — it involves eight weeks [for educators] in an office," he says. "But on the other hand, once they're trained, they're trained."

It's taken Children's Mercy almost 10 years of development to reach the point where its asthma DM program can be marketed to outside health plans, Portnoy says.

"We started to develop the program in the mid-1990s in response to an observation that patients with asthma weren't doing so well," says Portnoy. In fact, about 10 years ago Kansas City reported a series of 15 deaths from asthma among inner-city children, he says.

"This was all taking place despite the fact that we had evidence-based [treatment] guidelines," Portnoy says. "It was clear that these treatments weren't being used."

However, he points out, hospitals make money when patients visit the emergency room or are admitted, so the incentives weren't aligned for Children's Mercy to tackle the problem of asthma morbidity and mortality.

Formation of Medicaid HMO Created DM Need

But that changed in 1997 when Children's Mercy formed its own Medicaid HMO, Family Health Partners (FHP), which now has approximately 50,000 covered lives. "That required us to think more in terms of a disease management-type program," says Portnoy.

In 1998 and 1999, the hospital conducted a series of focus groups with patients and physicians to determine the best way of approaching an asthma DM program, he says.

Based on that, the hospital determined that patients wanted more information about their disease, and they wanted that information to come from their physicians. In addition, they didn't want to pay extra for a program, and they wanted the program to work in helping to manage their asthma. Physicians, meanwhile, wanted to be able to provide education, but they didn't have the time. They also wanted payment for asthma DM training, and to actually provide the services. And they wanted tools that would help them provide the services, along with clinically useful feedback.

"We decided to develop a program in which we hired asthma educators to spend time in physicians' offices, training physicians and their staffs," Portnoy says. In fall 2001, Children's Mercy received a three-year, $500,000 grant from the Robert Wood Johnson Foundation, which allowed the hospital to hire two asthma educators, a social worker and a database specialist, he says. The foundation paid the grant money to the health plan, which then contracted with Children's Mercy to provide the services.

The asthma educators went into physicians' offices, shadowing the doctors and staff members as they identified and provided care to asthmatic patients, Portnoy says. The educators spend eight weeks in each physician practice and encourage the physicians to write individualized plans for each asthmatic patient.

After the training period ended, the health plan activated a CPT code that allowed the physicians to get paid for their services; the doctors receive $40 extra for management at the initial visit of an asthma patient and then $20 for each subsequent visit.

As part of the program, Children's Mercy identified the "frequent flyers" — patients whose asthma was poorly controlled — and had the program's social worker contact them and begin case management, Portnoy says.

FHP now has about 7,000 to 7,500 children identified as asthmatics; the percentage of asthmatic patients has gone from 11% to 16% in the three years of the program, indicating better identification and management, he says. Approximately 55 physicians in 24 offices have completed the training so far, Portnoy says.

Per-member, per-month costs of FHP members, which currently run about $65, have fallen by about $2 PMPM as a result of the asthma DM program, Portnoy says. Costs for emergency room and hospital visits decreased by more than the costs for drugs increased, he says.

The Robert Wood Johnson grant expired in fall 2004, but FHP renewed Children's Mercy's asthma DM contract, since "the health plan noticed that their bottom line started to improve," he says. The health plan now pays Children's Mercy 43 cents PMPM on a two-year asthma DM contract.

Other Providers Exit Single-Disease DM

As Children's Mercy tries to break into the DM market, other hospital-based, single-disease DM programs are getting out.

For example, National Jewish Medical and Research Center said in October that it would sell its DM programs in asthma and chronic obstructive pulmonary disease (COPD) to Alere Medical, Inc., for an undisclosed sum. The move gave National Jewish an opportunity to grow with a partner that can meet client needs for DM programs that cover multiple disease states. At the time, David Tinkelman, vice president of health initiatives at National Jewish, said that National Jewish no longer could compete in a DM landscape where clients demand the capability to manage multiple diseases from a single vendor.

However, Portnoy notes that Children's Mercy is different in that it is willing to sell just pieces of its program to outside insurers, such as the asthma DM trainers but not the social worker to manage frequent flyers, or even just consulting services to enable health plans to hire their own educators and replicate the program.

Still, Children's Mercy's asthma DM program could be difficult to grow much because it is so physician-centric, warns William Bria, M.D., associate professor of medicine and director of the Airways asthma DM program at the University of Michigan Medical School. "I'd be concerned with scaling something like that," he says. Although the university participates in CMS's Physician Group Practice pay-for-performance demonstration project, Bria also says the key in asthma DM is educating the patient, not the physician.

Portnoy says he's not concerned about scaling the program, since it's likely to grow slowly. In fact, he says, he doesn't see any barriers to selling it on a regional or national basis, since the issues in asthma DM are similar from region to region and since care guidelines are national in scope. "Other plans are talking about buying pieces of it," he says, although he won't disclose which ones aside from Humana.

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