Promote Institutional Change for Sustainability
Partnering with ANWM is vital to Priority Health's ability to sustain comprehensive asthma care for members. When ANWM had to discontinue services to one of Priority Health's high-need markets for financial reasons, Priority Health saw a dramatic increase in hospitalizations and ED visits for members who no longer had access to ANWM's services. After learning that related costs for the increased utilization amounted to more than $70,000, Priority Health managers approved an increased reimbursement that enabled ANWM to reinstate crucial activities in targeted markets to help members manage their asthma and avoid acute care services.
In the late 1990s, Priority Health recognized the need for home-based asthma care that includes environmental trigger management. To deliver effective home-based care, Priority Health formed a first-of-its-kind partnership with the Asthma Network of West Michigan (ANWM). Priority Health uses ANWM's case managers and social workers to increase its ability to effectively assess and educate its members. Today, all of the plan's members with high asthma risk within ANWM's service area receive intensive case management that integrates patient education, home-based environmental interventions and evidence-based clinical care as part of Priority Health's Asthma Management Program. Priority Health also works with providers, pharmacists, case managers, employers, schools and day care centers to offer comprehensive asthma management for its members.
Home-based environmental assessments are offered to all members who reside within the ANWM service area. Assessments include comprehensive education on asthma and an environmental assessment. Priority Health emphasizes reduced exposure to secondhand tobacco smoke in the home by aligning their benefits structures to incorporate multidisciplinary community and pharmacological initiatives.
Collaborate to Build a System that Will Last
Although Priority Health was educating providers through regular mailings and using case managers to assess and educate members about asthma via mail and phone, Priority Health leaders realized that they could not manage all aspects of the disease through these methods. By partnering with ANWM, Priority Health can provide comprehensive asthma management services to members. 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.
Align Incentives with Goals
Priority Health established the Physician Incentive Program (PIP) to offer incentives to their providers to ensure that members use asthma medications appropriately and to implement the Planned Care Model for asthma. With the goal of encouraging evidence-based practice among physicians, the program offers a financial incentive (per member per month) to physicians whose asthma patients meet a specified ratio of long-term controller medication to short-acting medication.
COMMITTED LEADERS & CHAMPIONS-- INSTITUTIONALIZE THE FOCUS ON OUTCOMES
A dedicated Asthma Workgroup comprised of Priority Health leaders with diverse experience meets monthly to oversee the Asthma Health Management Program and employ improvement strategies. The workgroup is committed to continually improving activities such as identification of the member population, risk stratification, directed member education, physician registries, incentives, clinical practices guidelines and employer support.
INTEGRATED HEALTH CARE SERVICES--EDUCATE AND SUPPORT CLINICAL CARE TEAMS
Priority Health case managers communicate regularly with providers to emphasize the importance of asthma education and appropriate use of medications based on national guidelines. This critical educational information is reinforced through regular mailings to providers.
Evaluate Program Implementation
In order to help providers manage patient information and track progress toward goals, Priority Health created the interactive Patient Profile tool. The tool allows providers to look at the record of an individual member with asthma or to sort for care opportunities such as suboptimal medication management, missed services and ED utilization.
One of Priority Health's strategies to help providers reach targeted goals is the Pacesetter's Initiative. In this initiative, Priority Health and provider office staff team up to implement the Planned Care Model to improve processes for managing asthma patients and, ultimately, improving health outcomes. When Priority Health met with Alger Pediatrics to discuss improved compliance on asthma measures, the team identified specific strategies for improvement, including partial reimbursements for provider staff to attend an asthma education course and using the Michigan Asthma Resource Kit. The case manager assigned to this provider became an integral part of the team, facilitating referral of the provider's asthma patients to the Priority Health case management program. After identifying and implementing key improvement strategies, Alger Pediatrics increased their asthma PIP score from 67% in 2004 to 82% in 2005.
Use Evaluation Data to Demonstrate the Business Case
Senior managers at Priority Health have continued to support the Asthma Management Program because of the progress made to reduce the burden of asthma, decrease ED visits and hospitalizations and gain a return on the plan's investment. As a result of Priority Health's interventions, medical costs incurred by members with asthma were reduced by approximately $1.7 million in 2007. The long-term return on investment for the Priority Health was 2.1-to-1.