The business case for addressing disparities in asthma

The Community Asthma Initiative (CAI) at Boston Children’s Hospital has been improving the health and quality of life of children with asthma for more than a decade — and now there’s exciting new evidence about the financial benefits of doing so.

CAI works to address the disproportionately high rate of asthma in children from mostly low-income families of color through case-management and home-visits, provided by a community health worker. For years, research has shown that secondary prevention programs, such as the CAI, result in better outcomes for children with asthma.

Now, for the first time, there is a business case — using actual insurance claims data — that shows that CAI generates a positive return on investment. Cost analyses conducted by researchers at Boston Children’s showed that after three years, CAI actually saves money. This research, recently published in the Journal of Asthma, makes the business case for CAI, by capturing all costs associated with asthma that an insurer would incur such as cost of diagnoses, treatments, procedures and prescription medicines, as well as clinical care (inpatient hospitalizations, emergency department visits, primary care visits, and specialist consults).

“It’s very exciting that we were able to look at the total cost of asthma,” says Dr. Elizabeth R. Woods, director of the CAI and associate chief of the Division of Adolescent/Young Adult Medicine at Boston Children’s. “This allowed us to see that CAI saves more than it costs.”

A history of improving health

Since its launch in 2005, CAI has provided case management to 2,132 patients. The patients are identified when they visit the Emergency Department, hospitalized for uncontrolled asthma, or referred from their primary care providers.

“It’s incredibly scary when a child can’t breathe,” says Woods. “It’s also an important teachable moment.”

Once the family enrolls in CAI, a community health worker visits them at their home and completes three visits, followed by phone calls and additional visits, as needed, at 6 months and 12 months. The community health worker helps families to improve their understanding of asthma and adherence to asthma control medications, reduce exposure to known asthma triggers in homes (such as pests, dust and mold), and provides support and case management.

A different kind of data

Previous studies have also shown cost-savings and a positive return on investment for programs like CAI. However, most of these studies relied on estimated costs, rather than actual insurance claims data, which can be difficult to obtain.

Researchers at Boston Children’s conducted the cost analyses using actual claims data from a Medicaid Managed Care Organization (MCO) in Massachusetts that included all asthma-related utilization costs between January 1, 2011 and December 31, 2016. The data was used to determine cost reductions at the following intervals: one year prior to intervention with the CAI and one, two, and three years post-intervention. The cost reduction refers to how much lower total asthma treatment costs were than those of a similar comparison group.

The analyses involved 45 patients enrolled in the CAI program and 45 from a cost-matched comparison population of patients with similar demographics who had visited Boston Children’s for asthma but were not enrolled in the CAI.

Asthma is the most common diagnosis for children admitted at Boston Children’s. The majority of these children live in predominantly low-income, neighborhoods of color.

The return on investment (ROI) was calculated as the difference in cost reduction for CAI patients and a cost-matched comparison population divided by CAI program cost. The adjusted ROIs were 0.31, 0.78, and 1.37 after 1, 2, and 3 years post-CAI intervention.

When ROI reaches 1.0, it indicates the break-even point where costs equal savings. When ROI is greater than one, it means that savings are greater than costs (a program is saving money).  ROI is important because it helps businesses and organizations take the guesswork out of investing in a program (like the CAI). It shows that an organization can recover the cost of making an investment — and when that investment will become profitable.

Implications for insurers

These new cost analyses show that health insurers and Accountable Care Organizations (ACOs) can recover the cost of programs like the CAI within three years. The cost reduction trend suggests that benefits may continue past three years — resulting in even larger net benefits. The findings support the business case for programs like CAI to be covered by insurance or integrated into ACOs.

“You have to be able to talk about the business case to insurers,” says Woods, who has been involved with CAI since it began.

For the first time, the CAI is receiving funding from the Boston Children’s Medicaid ACO. About half of the core clinical costs for the CAI team are being covered by the ACO under temporary funds, explained Woods, reflecting the fact that about half of the patients followed by CAI receive their primary care at Children’s.

“The CAI program aligns well with the ACO’s efforts to provide quality health care and contain costs by keeping children healthy,” says Susan Sommer, clinical director of CAI. “We are doing population management and focusing on the higher-risk kids and their social determinants of health and then applying additional resources to keep those kids out of the hospital — and we end up saving money in the long run.”

The future of social determinants of health

Health care providers and payers are increasingly recognizing the role of social determinants (those issues that affect someone’s health such as poverty or housing issues) on a patient’s health and wellness.

Programs that address these issues seldom get insurance reimbursement under traditional fee-for-service payment models. Instead, the programs often rely primarily on grants or other types of short-term funding that are unsustainable long-term.

However, this could change in the future.

“As the focus in health care financing shifts from fee-for-service towards alternative payment models that incentivize measures to reduce expensive hospitalizations through care coordination and public health interventions which address social determinants, there is an ever more compelling rationale for providing sustainable funding to such interventions,” according to the CAI’s research

Learn more about the Community Asthma Initiative.