Health Plans and Managed Care Organizations
Insurance Coverage for Asthma: A New England Gap Analysis
In 2010, the Asthma Regional Council of New England designed and conducted an insurance coverage survey. The survey responses were collected from 25 public (Medicaid) and private (commercial) payers across the six New England states. This report provides a general analysis of the responses and identifies where there are gaps in coverage. [pdf; Asthma Regional Council of New England]
Centene (MO, IN)
As an experienced, comprehensive service provider, Managed Health Services, a Centene Corporation Medicaid health plan, understands the need to customize asthma solutions for diverse populations. As a result, in 2007 Managed Health Services and sister company, Nurtur, Centene life, a health and wellness company, established a comprehensive asthma program designed to address the needs of several specific target audiences; these include persons with asthma in addition to other complex chronic conditions, as well as pregnant women and children with asthma. Medical records, pharmacy records, and claims data are scanned by predictive modeling software to identify patients that meet these criteria, who are then referred to the asthma team. A case manager follows up with each patient to assess their level of need and recommends an appropriate asthma intervention. Educational materials for children and adults, trigger identification training, goal-setting exercises, home visits, and barrier assessments are just some of the many tools used as a part of this holistic asthma care process. The patient’s treatment plan is also updated by the asthma team and sent to the physician for review. Continuous monitoring and evaluation are integral to this program, and results from 2007 to 2009 indicate an incredible 17.3% decrease in emergency department visits for child participants and a 9.4% decrease for adult participants. In addition, visits to primary physicians for children and adults were up by 11.1% and 16.4%, respectively, indicating improved preventive care.
L.A. Care (CA)
Committed to offering accessible, affordable, and high-quality healthcare, L.A. Care Health Plan is an independent local public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. With more than 1.4 million members in seven product lines, L.A. Care is the nation’s largest publicly operated health plan. L.A. Care Health Plan established the comprehensive disease management program L.A. Cares About Asthma® in 2003. L.A. Care selected asthma as a disease management focus because of the large number of members with asthma enrolled in L.A. Care and the success of programs like these in helping patients with chronic illness improve their health status over the course of the disease. L.A. Cares About Asthma is a collaborative program designed to improve member self-management through education, empowerment, monitoring, and member input and communication. On a monthly basis, L.A. Cares About Asthma identifies health plan members with asthma and provides them with a variety of educational materials and tools to help them take control and manage their disease. To be inclusive to its community’s needs, the program ensures that linguistically and culturally appropriate materials are available for all potential enrollees. L.A. Cares About Asthma also partners with several community-based organizations to expand its reach and depth to serve individuals most in need. An in-home visitation program with Long Beach Alliance for Children with Asthma in the Los Angeles South Bay area and specialist referrals with Harbor-UCLA Medical Foundation Inc. throughout Los Angeles County offered to high-risk members with asthma are just two examples of such successful partnerships. Thanks to these efforts, L.A. Cares About Asthma achieved a member satisfaction of 97.6%, which exceeded their 2011 goal. In particular, members reported great satisfaction with the program materials and felt the materials educated them on how to control their asthma.
Monroe Plan for Medical Care (NY)
The Monroe Plan for Medical Care is a managed care organization, located in the Rochester, NY, area. The Monroe Plan covers 5,633 children with asthma in Monroe County and 12 neighboring rural counties. With a high asthma burden among children in the area, the Monroe Plan saw trends in pediatric asthma and noticed high admission rates that disproportionately affected minorities. In partnership with ViaHealth, a healthcare delivery system, the Monroe Plan launched a program to shift asthma care away from emergency services and in-patient care and toward improved patient self-management. The program now covers all of the plan’s members with moderate to severe pediatric asthma and includes assistance to providers in creating asthma action plans and comprehensive provider and member education. Home assessments are conducted by bilingual asthma outreach workers to identify and reduce environmental triggers. As a result of these interventions, ER visits decreased from 1.1 visits per person to .95 visits per person over the first three years of the program. In-patient admissions decreased from 98.3 admissions per thousand to 84.15 per thousand in the first three years of the program.
Neighborhood Health Plan (MA)
Neighborhood Health Plan (NHP) is an NCQA-accredited, not-for-profit health plan that provides coverage to over 300,000 commercial and MassHealth members. For more than 25 years, employers, individuals, and families across Massachusetts have turned to NHP for healthcare coverage that is both affordable and of high quality. NHP is known for plans that are easy to understand and manage. Members have access to a robust network of top doctors, community health centers, and academic and regional hospitals. Founded in 1986 with a commitment to promote health equity for members within the diverse communities we serve, NHP’s service and care management programs today continue the tradition of personalized and high-quality care. NHP is a member of Partners HealthCare. [pdf; EPA]
Optima Health Plan (VA)
The staff at Optima Health Plan – the managed care division of Sentara Healthcare that operates in southeastern Virginia – noticed a disturbing trend: Despite pharmacological advances in asthma therapy, the number of emergency room visits, hospitalization rates, and medical costs for asthma patients continued to rise. The quality of life for the approximately 8,500 asthma patients enrolled in Optima’s plan was not as high as Optima’s staff thought it should be, and staff was committed to helping their asthma patients understand everything they could do to prevent asthma attacks. Optima’s staff also knew that education and management advice were often most effective when delivered at home so they developed an innovative “Asthma Life Coach” program that sends nurses and respiratory therapists to asthma patients’ homes, where they work with patients and their caregivers to identify environmental triggers, such as secondhand smoke, cockroaches, dust mites, mold, and other sources that can cause asthma attacks. Optima’s staff understood that many asthma patients simply don’t know that things in their homes, schools, and other environments can trigger asthma attacks and that many asthma triggers can be eliminated through simple management techniques. The Asthma Life Coach program provided an easy way for Optima’s asthma patients to learn about environmental asthma triggers and how to reduce exposure to them. Optima’s staff visited patients at home where they surveyed their environments, reviewed their use of medicines, and developed individualized written asthma treatment plans incorporating medical and environmental components. Optima’s asthma life coaches serve as coordinators helping patients take action based on disease management suggestions and physician recommendations and ensuring that patients know how to use medical and environmental controls to manage their asthma. Since instituting the Asthma Life Coach program in 1999, Optima has seen a significant decrease in the number of hospitalizations and emergency room visits for their members with asthma.
Peach State Health Plan (GA)
Peach State Health Plan in Atlanta, GA, is a statewide Medicaid managed care organization that delivers a customized asthma program for teenagers. The plan is part of the Centene Corporation, an integrated health enterprise that delivers Medicaid services in 19 states. Peach State Health Plan has a targeted asthma improvement program focused on their teen members with asthma because almost 20% of teens in the plan have an asthma diagnosis (13,159 members with asthma out of 66,138 members ages 13 to 19.) Peach State’s innovative program has successfully engaged teens with asthma—a notoriously hard group to engage—and has demonstrated success in improving teens’ ability to understand their asthma, improve their asthma, and address the environmental and social factors that can make asthma worse.
Priority Health (MI)
In 1999, Priority Health partnered with the Asthma Network of Western Michigan (ANWM) to provide home-based case management for members in their service area with moderate to severe asthma. Priority Health reimburses ANWM for providing asthma education, conducting home assessments, meeting with providers to develop individual asthma management plans, working with social workers who provide social service referrals for members, and conducting in-service training for schools and daycare centers. A particular focus is reducing exposure to secondhand tobacco smoke, and implementing measures to reduce triggers in the home. [pdf; EPA]