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What a Community-Based Asthma Care Program Teaches Us About Payment Reform


A Boston Children’s Hospital asthma initiative serves as a case study for payment reform. Photo via higherperspective.com

It’s clear as day that the American method of paying for healthcare is broken. But things get murky when it comes to finding appropriate solutions. Debates about the “ideal” payment model, a model that offers quality and manageable costs, continues year after year. Noticeably, the traditional institutions that play a central role in providing care (such as hospitals) are stepping into this problem, attempting to decalcify our old model and find innovative and cost effective solutions.

At the forefront of these efforts is Boston Children’s Hospital (BCH), where providers are proposing innovative solutions to curtail the spiraling costs of chronic illnesses, using pediatric asthma as a model. Asthma is prevalent in urban populations with large racial and ethnic disparities, and it’s a condition that can be extremely costly for low-income families. 9 million children in the United States have pediatric asthma, and the chronic condition accounts for 14 million ambulatory care visits per year. Because of the nature of the disease, most families end up making emergency clinic visits that lead to hospitalization and sky-high costs. In fact, the direct cost of this behavior accounts for $3.2 billion per year, mostly via hospitalization, which tolls half of the direct cost.

So here’s the case study: BCH proposed that community-based case management and home visits could have positive impact on children and families dealing with chronic pediatric asthma. They conducted a quality improvement study to understand the value of enhanced care and community initiatives in overall wellness care for patients and payers. In their study, community health workers were provided to address environmental challenges (for example, the need for vacuum cleaners) and personal issues (like explaining medication adherence); these workers did not provide direct care by prescribing medications or replacing doctors.

Patients in this program were compared to similar independent patients at six and 12 months, and the results were fascinating. Findings revealed that a combination of community health workers and office-based nurse education resulted in cost effectiveness and improved quality of life. In fact, there was a 65% reduction in emergency care visits. There was also a large improvement that came from consistent follow-ups. Moreover, the clinical program was $2,529/child, but yielded the families savings of $3,827/child over 2 years through the intervention program. In other words, for every dollar spent on the program, 1.46 dollars was saved because of overall effective care – astonishing indeed!

What’s even more encouraging is that consistent results have continued to come out of the study since then. This is true even though the program has changed its core components to make it more cost efficient and to still reap similar results. For example, now community health workers have a larger role and nurses assist in the management aspects of the program. Dr. Elizabeth Woods, director of the community asthma initiative, says that this is an example of the cost benefits of preventative care. So far, Medicaid has approved an asthma pilot bundle payment program, which covers the cost of highly vulnerable patients.

“It’s not about keeping people from hospitals – they just don’t need them,” Dr. Woods says. “Doctors and subspecialists have been extremely receptive because patients, who they sometimes don’t have close relationships with, are coming to regular check-ups and adhering to care.”

Unnecessary and avoidable emergency care visits are a huge cost for payers. With programs like these, insurers can invest and reduce overall costs through preventative care. In fact, the asthma community care workers may be used to indirectly tackle other medical challenges of the patients and push towards holistic wellness management, too.

It’s said that it takes a village to raise a child; perhaps it takes a community based approach to raise effective health care system as well.

Shreya Iyer

Shreya Iyer

    Shreya specializes in health communications and is a copywriter for an advertising agency. She was previously at Bayer Healthcare, Janssen Pharmaceuticals and Ogilvy CommonHealth Worldwide

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