Module 1: Making the Case for Asthma Care Quality Improvement

Learning Objectives Upon completion of Module 1, the user(s) will be able to: Assess the need for asthma care quality improvement in the State. Consolidating available information will help State leaders "make the case" for improvement in asthma care by showing why it should be a priority. Estimate the cost of asthma care statewide and for Medicaid. Estimating the total costs of asthma care is an important part of understanding the need for quality improvement in the State. Estimate a State's potential cost savings by using targeted disease management and reducing pediatric hospitalizations for asthma. Estimating the potential savings for Medicaid and for the State by improving asthma management and reducing avoidable hospitalizations is a vital part of making the case for asthma care quality improvement.

1. Assess the Need for Asthma Care Quality Improvement in the State

Go to The Need for Asthma Care Quality Improvement and The Quality Improvement Opportunity in the Resource Guide to learn about important reasons for addressing asthma and quality of care for asthma—increased prevalence, high cost, racial/ethnic and income disparities, and treatment variations—as well as the potential for return on investment through quality improvement in asthma care.

1. Table 1.1 shows how asthma prevalence (cases for every 100 people) has changed from 2000 to 2003. In Maryland in 2000, for example, 10.6 percent of the population had been diagnosed with asthma at some point in their lifetime, similar to the national average of 10.5 percent; in 2003, Maryland's lifetime asthma prevalence was 12.3 percent, higher than the national average of 11.7 percent. The lifetime asthma prevalence rates in Table 1.1 are from the Centers for Disease Control and Prevention's Behavioral Risk Factor Prevalence System (BRFSS).

   1. What was the asthma prevalence in your State in 2000? (Table 1.1) ________
   2. What was the asthma prevalence in your State in 2003? (Table 1.1) _________
   3. Has the prevalence increased in your State since 2000? _____________
   4. How does your State compare with the national average? ____________
      
      

2. Asthma prevalence may vary among subgroups of the population in your State (such as by age, racial or ethnic group, or income). For example, Table E.3 in Appendix E of the Resource Guide shows the current prevalence of asthma by State among adults by age group (18-64 and 65 and older) in 2003.

   1. What was the current asthma prevalence for all adults in your State in 2003? (Table E.3) __________

      How does your State compare with: the national average? _______ the top decile of States average? ________ the bottom decile of States average? _________

      Note: The States in the "top decile" (1/10^th) are the States that have the lowest average of asthma prevalence. The States in the "bottom decile" are the States with the highest average o7f asthma prevalence.

   2. What was the current asthma prevalence for age 18-64 in your State in 2003? (Table E.3) _________

      How does your State compare with: the national average? ________ the top decile of States average? ________ the bottom decile of States average? _________

   3. What was the current asthma prevalence for age 65 and older in your State in 2003? (Table E.3) ________

      How does your State compare with: the national average? ______ the top decile of States average? _______ the bottom decile of States average? ________

   4. Are there other groups (racial, ethnic, low income, etc.) in your State for which you have asthma prevalence data from your State health data agency? ___________________________________________________________________________
      
      

3. Go to Table 1.2 in the Resource Guide. This shows the hospitalization rate for asthma (admissions per 100,000 population) by State for different age groups. This is an important quality improvement measure because many hospital visits for asthma can be avoided with high quality outpatient care. Knowing your State's rate compared to the national average may help determine whether asthma care quality improvement, especially as it affects the cost for asthma care, should be a priority in your State. Find your State and write your State's rate for each age group in the table below.

   If your State is not listed in Table 1.2, or if your State collects its own hospitalization data for asthma, contact your State health data agency for these rates and write them in the table below.

   Hospital admissions for asthma per 100,00 population among—	U.S. rate	Best-in-class rate	Your State's rate
   Children under age 18	188.6	72.3
   Adults age 18-64	112.8	60.2
   Adults age 65 and older	170.6	118.2

   
   

   1. How does your State compare with the U.S. rate? ___________________________

   2. "Best-in-class" States have lower rates of avoidable hospitalizations for asthma. How does your State compare with the best-in-class averages for the three age groups above?
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   3. What do you see as the potential for quality improvement in this measure in your State? ____________________________________________________________________________
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2. Estimate the Cost of Asthma Care Statewide and for Medicaid.

Go to Estimating the Costs of Asthma Care and Potential Savings From Quality Improvement in the Resource Guide to learn about estimating direct and indirect costs of asthma statewide and for Medicaid. Direct costs are expenditures associated with asthma treatment: routine services, treatment of complications, and medical conditions attributable to asthma. Indirect costs are additional costs of living or the lost opportunities that affect individuals because they have asthma: the cost of dealing with disability, lost wages and productivity, premature death, and so on.

1. Go to Table 1.3 of the Resource Guide. It lists current asthma prevalence and direct and indirect cost estimates for asthma by State. Find your State's estimates and list here.

   Direct/indirect Cost Estimates	Equals	Cost
   Direct cost of asthma to your State	=	$ __________
   Indirect cost of asthma to your State	=	$ __________
   Total estimated asthma costs to your State	=	$ __________
   Asthma prevalence in your State	=	$ __________
   Average cost to your State per person with asthma (Divide State's total costs by State's asthma prevalence)	=	$ __________

   
   

2. Next, compare your State estimates for the total population to estimates for neighboring States in your region. Again using Table 1.3 of the Resource Guide, find the figures for your State and the two States with similar characteristics to yours and write them in the blanks below. How does your State compare?

   Prevalence/Cost	Your State	State A	State B
   Asthma prevalence
   Total asthma cost
   Average cost per person (divide total cost by prevalence)
   Cost difference (+/-)

   
   

3. Go to Table 1.4 of the Resource Guide. It gives the Medicaid population with asthma and the estimated costs to each State's Medicaid program for three age groups: 0-17, 18-64, and 65 and older. Find your State's Medicaid population and estimated Medicaid spending on asthma for the three age groups and list them in the first column below. Calculate the cost per person by dividing the estimated expense by the estimated Medicaid population with asthma. Make the same type of comparisons for the Medicaid population between your State and the two States you used in question 2b above.

   Note: Do you have estimates for asthma care costs from your State health department or Medicaid program office that are better than those listed in Table 1.4? If so, use them here. Your own State estimates for spending on asthma care would be more accurate than these derived through national studies and more generalized assumptions.

   Medicaid population	Your State	State A	State B
   Age 0-18
   Population with asthma
   Estimated expense
   Average cost per person (divide expense by population)
   Age 19-64
   Population with asthma
   Estimated expense
   Average cost per person (divide expense by population)
   Age 65 and older
   Population with asthma
   Estimated expense
   Average cost per person (divide expense by population)

   
   

4. Go to Appendix B, Tables B.1-B.6 in the Resource Guide. These tables show estimated numbers of people in racial/ethnic subgroups of the Medicaid population with asthma by age group and estimated Medicaid spending for asthma for these groups. Fill in the blanks in the following table below with figures for your State and two comparable States.

   Population group	Medicaid eligibles with asthma
   	Age 0-18	Age 19-64	Age 65 and older	Estimated Medicaid spending
   Your State:
   White
   Black
   American Indian/    Alaska Native
   Asian
   Hispanic
   Other
   State A:
   White
   Black
   American Indian/    Alaska Native
   Asian
   Hispanic
   Other
   State B:
   White
   Black
   American Indian/    Alaska Native
   Asian
   Hispanic
   Other

   
   

   1. Does your State have large numbers of these subgroups with asthma? How much of your Medicaid spending is devoted to asthma care for these groups?
      
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   2. Can you use the figures in Appendix Tables B.1-B.6 to help make the case for asthma care quality improvement in your State?
      
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3. Estimate a State's Potential Cost Savings by Using Targeted Disease Management and Reducing Pediatric Hospitalizations for Asthma

1. Go to Estimating potential Medicaid savings from asthma disease management—a Virginia example of the Resource Guide to see the results from a calculation of potential Medicaid savings from an asthma disease management program based on the Virginia Health Outcomes Partnership (VHOP) experiment.

   1. Call your Medicaid program office to find your State's spending for emergency department visits for Medicaid (step 1), the number of Medicaid claims for emergency department visits (step 2), and the number of physicians participating in primary care case management who might accept training in asthma management (step 6). Use your State data to fill in the blanks to develop a "ballpark" estimate of how much might be saved in Medicaid costs with a similar asthma disease management intervention.

      Note: These estimates assume that you would have results similar to those of Virginia and that your State has not already implemented a training program for physicians treating Medicaid recipients with asthma. Your results will vary depending on the size of your Medicaid program and the scale of the intervention your State might undertake.

      Steps for Estimating Potential Medicaid Savings From an Asthma Disease Management Program

      Step	Your State
      1. Total annual spending for emergency department visits for asthma pre-intervention for Medicaid recipients
      2. Total annual number of Medicaid claims for emergency department visits
      3. Payment per claim: Divide step 1 by step 2
      4. Emergency visit reduction factor: Adjusted to four quarters and to exclude added costs per physician and added drug prescribing (both included below; see steps 7 and 8)	0.06
      5. Emergency care visit annual saving after training physicians: Multiply step 1 by step 4
      6. Number of physicians participating in primary care case management who might accept training in asthma management
      7. Asthma drug cost: Multiply step 6 by $180 per physician per year
      8. Program training costs: Multiply step 6 by $235 per physician
      9. Total drug and training costs: Add steps 7 and 8
      10. Total Medicaid savings: Subtract step 9 from step 5
      11. Savings per Medicaid claim: Divide step 10 by step 2

      Source: Estimates derived from Rossiter LF, Whitehurst-Cook MY, Small RE, et al. The impact of disease management on outcomes and cost of care: a study of low-income asthma patients. Inquiry 2000;37:188-202.

      Note: Based on the VHOP experiment, for purposes of step 6, assume that one-third of Medicaid participating physicians in any disease management program would accept training in asthma management. See Rossiter, et al., for further detail on derivation of the emergency visit reduction factor, asthma drug cost, and program training cost. In addition, percent savings per claim can be calculated by dividing step 11 by step 3.

   2. How do these potential Medicaid savings for asthma care compare with other disease management programs in your State? Do these figures help make a case for asthma care quality improvement for your Medicaid program?
      
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2. Go to Estimating potential cost savings from reducing excess hospitalizations for pediatric asthma—a Massachusetts validation in the Resource Guide to see results from a calculation of potential savings for Massachusetts from reducing avoidable hospitalizations for pediatric asthma.

   1. Follow the steps below to develop a "ballpark" estimate of how much your State might save by reducing excess hospitalizations for pediatric asthma.

      Note: These estimates assume that you would have results similar to those of Massachusetts. Your results may vary. In addition, the cost of implementing a quality improvement program to reduce hospitalizations is not included in the calculation below.

      Steps for Estimating Potential Savings From Reducing Excess Pediatric Asthma Hospitalizations

      Step	Your State
      1. Hospital admission rate for pediatric asthma per 100,000 population under age 18 (Table 1.2 in the Resource Guide)
      2. Estimated population under age 18 in State (Census, 2000; available at http://www.census.gov/popest/states/asrh/SC-est2004-02.html)
      3. Number of pediatric asthma hospital admissions: Multiply step 1 by step 2
      4. Percent of pediatric asthma hospital admissions to be reduced to achieve best-in-class (Table 1.2 in the Resource Guide)
      5. Number of hospital admissions for pediatric asthma to reduce (excess hospitalizations): Multiply step 3 by step 4
      6. Mean cost for pediatric asthma hospitalization*	$2,590.72
      7. Total cost of all pediatric asthma hospitalizations in State: Multiply step 3 by step 6
      8. Total cost of excess pediatric asthma hospitalizations in State: Multiply step 5 by step 6
      9. Potential cost savings from reducing excess hospitalizations: Subtract step 8 from step 7

      * Step 6 was calculated by multiplying the national mean charge per pediatric asthma hospitalization ($5,888) by the national cost-to-charge ratio for these hospitalizations (0.44) using data from the 2001 HCUP Nationwide Inpatient Sample. Information on HCUP data and tools is available on the HCUP Web site at http://www.hcup-us.ahrq.gov or via E-mail at hcup@ahrq.gov.

   2. Look at your potential cost savings from reducing excess hospitalizations. Can these potential savings help to make a case for asthma care quality improvement in your State?
      
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