Medicaid Managed Care: Kansas City, MO

boy on bikeKansas City Children’s Asthma Management Program (KC CAMP)

Searching for Solutions

Although the acclaimed Kansas City Children’s Asthma Management Program has been operating since 2001, its roots can actually be traced back to 1997. During that year the National Heart, Lung and Blood Institute (NHLBI) issued new guidelines for the diagnosis and treatment of asthma. Also that year, Children’s Mercy formed its own Medicaid HMO, Family Health Partners (FHP), and was exploring new disease management programs.

A year later, 21 people, including 15 inner-city children, died from asthma in the metropolitan Kansas City area. Patients and providers alike demanded answers. “We were at the national average for emergency department admissions for asthma,” says Jay Portnoy, M.D., chief of the hospital’s allergy, asthma and immunology section. “But we wanted to explore better ways to handle asthma and prevent these tragedies.”

To map out a new approach to managing the disease, Children’s Mercy held a series of focus groups with physicians and patients in the area. Patients wanted to know more about their condition and how to manage it without paying more. Physicians wanted to educate asthma patients and provide disease management services, but said they lacked the time, training and tools they needed to do it effectively. And despite their wide dissemination, the NHLBI asthma treatments weren't being used consistently.

Information and Incentives

In response to the problems, Children's Mercy developed a program that put asthma management knowledge and resources where they were most needed—with primary care providers and the patients themselves.

With a three-year, $500,000 grant from the Robert Wood Johnson Foundation, the hospital launched the KC CAMP program in 2001. It focused on using certified asthma educators to train physicians and their staffs to improve patients’ self-management and ensure that FHP families had an asthma action plan.

To track patient information and outcomes and measure results, the hospital built a central asthma registry. This also helped segment asthma patients according to the severity of their disease for more efficient interventions.

Asthma educators then visited physicians’ offices eight times over the course of the three years to teach the standardized curriculum. Topics included: asthma 101, patient evaluation, spirometry (a pulmonary function test to measure lung function), action plans, case management, devices, environment and outcomes. The curriculum was also given to provider offices on CD-ROM for review and to train new employees. Tests with providers and their staffs showed the sessions not only improved their knowledge, but boosted retention of that knowledge as well.Asthma Action Cards

The program took into account that while knowledge is essential, changing behavior is the key to long-term success. To that end, the asthma educators used a behavioral approach to teaching that focused on the importance of making an accurate diagnosis of asthma, providing asthma education to patients and giving them an asthma action plan. The program developed Asthma Action Cards™, wallet-sized, color-coded tip sheets to help patients follow their one-page asthma action plans, and surveys that elicit feedback from patients and providers to measure the program’s progress.

Asthma Action Cards™ make asthma action plans portable and easy-to-use.

As an additional incentive to participate, providers become eligible for reimbursement when they complete the training. Family Health Partners activates a CPT code that pays physicians for their asthma education services: $40 extra for each asthma patient’s initial visit for education and $20 for subsequent sessions.

Results

Due to the program’s sustainability and bottom-line impact, Family Health Partners (FHP) renewed the contract after the Robert Wood Johnson Foundation grant expired. Since then, the program has continued to grow.

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Increase in percentage of asthma members with an asthma action plan. (Click to enlarge)

 

FHP has approximately 7,500 children identified as asthmatics. Over the course of the program, use of asthma action plans went from zero to 33 percent of plan members. Per member per month costs for FHP members fell by about $2 and costs for emergency room and hospital visits also decreased. Meanwhile, the percentage of asthmatic patients rose from 11 percent to 16 percent, indicating better identification and management. FHP now pays Children's Mercy $0.43 per member per month.

“The program’s flexibility has allowed it to expand in a variety of ways,” explains Dr. Portnoy. “We’ve been working with the Kansas City School District on an adapted model of the program, with school nurses implementing the asthma program instead of primary care providers. The same model also works with obesity and weight management.”

In January 2007, FHP also became a provider for Kansas Medicaid. With up to 160,000 more members, the asthma management program expects to reach thousands more children and adults in the region.

“Measuring outcomes is extremely important—it’s the key to our expansion,” Dr. Portnoy says. “While return on investment can be difficult to measure, we focus on things we can directly affect, such as education for patients and providers, prescription usage and emergency department visits.”

charts
Decrease in ED Visits per 1,000 health plan members for asthma from 2000 to 2004. (Click here for larger chart)

Decrease in Hospitalizations per 1,000 health plan members for asthma from 2000 to 2004. (Click here for larger chart)

In 2006, the program’s ratio of emergency department admissions among asthma patients was four per 1,000; that’s a dramatic contrast from the 10 per 1,000 ratio at the program’s inception—which is also the current national average, according to the Centers for Disease Control and Prevention.

Dr. Portnoy says 100 percent of persistent asthmatics in the program have controllers. “And because we went to the providers, it wasn’t just our patients they were reaching. So partly due to what we’ve accomplished, over 90 percent of persistent asthmatics in the Kansas City area now have controllers,” he says. “That’s unheard of in other cities.”


Summary

KC CAMP Family Health Partners improves delivery of asthma care with a team approach that works at the health plan, provider and patient levels. Certified asthma educators teach primary care providers and staff at clinics affiliated with the health plan how to educate asthma patients in their offices. The providers then teach asthma patients to manage their own disease with tools such as asthma action plans. Through partnerships with insurers, providers are reimbursed for the time they spend educating these patients.

Children’s Mercy Hospital (CMH) in Kansas City, Mo., developed this initiative using its partnership with Family Health Partners. The program was deployed throughout the Family Health Partners network of 357 providers in 78 offices around the Kansas City metropolitan area.

Strategies and Programs

  • Developed a central asthma registry to track patient information.
  • Implemented a standardized asthma curriculum.
  • Used certified asthma educators to teach providers how to educate patients.
  • Created an incentive for providers to teach patients the standardized curriculum.
  • Developed a training CD-ROM for providers’ review and use with new staff.
  • Created unique Asthma Action Cards™ and accompanying one-page Action Plans.

Children and Families Served

  • There are 45,000 members in Children’s Mercy Family Health Partners (CMFHP).
  • 16.8 percent of children in CMFHP plan have been diagnosed with asthma, up from 11 percent prior to the program, indicating better identification and management.
  • 65 percent of CMFHP members participating in asthma program are African-American, 27 percent are Caucasian and 4.7 percent are Hispanic.

Results

  • 40 percent reduction in asthma-related ER visits
  • 50 percent reduction in asthma-related hospitalizations
  • 35 percent reduction in asthma-related treatment costs
  • 2,500 CMFHP plan enrollees have asthma action plans

Costs

The approximate cost of the program is $0.43 per member per month. However, the cost of caring for members with asthma declined by about $2 per member per month. These savings outweigh program costs, ensuring the program’s sustainability while increasing the chances of adoption by other health plans.

Lessons Learned

This innovative approach to asthma management—educating providers and supporting them with resources at the health plan level—has shown several benefits. Children’s Mercy has seen improvements in the diagnosis, care and treatment of asthma; reductions in costs and unnecessary services; and a proactive approach to management of asthma by the patients themselves. The program can also be marketed to other health plans and applied to managing conditions such as obesity and attention deficit hyperactivity disorder; Children’s Mercy is currently pursuing both of those options.