As the new President and CEO of the Asthma and Allergy Foundation of America (AAFA), I am reminded daily of the burden of asthma in the U.S. Asthma is a chronic condition that costs the country more than $50 billion dollars annually. Asthma affects all populations—young and old, black and white, Hispanic and Native American, urban and rural—but it is especially a problem for families who are economically disadvantaged.
What’s “new in asthma?” It’s important first to point out what is not new. Although there is not yet a cure for asthma, very effective therapies exist—and have existed for some time. Yet, asthma continues to consume increasingly scarce healthcare resources and to limit the lives of some 25 million Americans, including more than 7 million children. A sad part of what I have to say is that, unfortunately, much is the same: We have not succeeded in achieving the results that should be achievable, given the state-of-the-science.
Is this changing? It is. While biomedical and clinical research continue to extend our understanding of the pathophysiology of the disease, and how to mitigate that through new therapies, what I see as most exciting are changes on other fronts: Changes which have the potential to make the therapies that we have more impactful. In particular, there are important changes to:
- The way healthcare is paid for:
Many have pointed out that the fee-for-service (FFS) payment model that is so prevalent in the United States drives volume but not value—and suggested that payment reform is fundamental to meaningful improvements to value. With healthcare reform, we are seeing tremendous innovation with respect to payment; models that provide for sharing of savings between providers and payers in a FFS environment (for example, Medicare’s Shared Savings Program), but also more radical innovations such as “bundled” and “global” (or “capitated”) payment. These more radical payment innovations transfer financial risk from the payer to the provider and, in so doing, create incentives for cost reduction and true efficiency gains.
At AAFA, we know that improving control of asthma leads to fewer emergency room visits and hospital admissions so that payment models that transfer risk create strong incentives is to improve clinical outcomes. While asthma has not been the central focus of payment reform, it will often be in scope as payers and providers pilot new models to address common and costly chronic illness. That said, there is one example—in Massachusetts, for Medicaid—of a bundled payment pilot specifically directed to asthma. In this pilot, providers are expected to drive much higher rates of home assessment for, and remediation of, the allergens (dust mites, mold, pet dander) that trigger asthma attacks—services which are generally not reimbursed, and, therefore, delivered at rates that are far below optimal. The promise of payment innovation is that it will encourage providers to do what is most likely to improve the health of the patient with asthma—by aligning the (important professional) incentive to do so with the incentive to maximize economic returns.
- The way “healthcare” is organized:
In parallel, we are seeing innovations with respect to the organization of healthcare providers and systems. These include the construction of “Accountable Care Organizations” (ACOs) and “Patient Centered Medical Homes.” But these also include efforts to consider more broadly how other (non-traditional healthcare) resources can be integrated into healthcare.A promising example of that is a Center for Medicare and Medicaid Innovation (CMMI) sponsored pilot in Delaware, led by the Nemours Foundation.
This broad-based innovation is directed toward improving outcomes for children with asthma, and includes enhancements to primary care that should streamline and coordinate care for children with asthma (a “family-centered medical home”) but also “integrator” and “navigator” capabilities specifically directed toward leveraging community-based services relevant to asthma care. An interesting—and potentially challenging—aspect of the work is that it is NOT linked to a payment innovation. So improvements in care (that lead to reductions in ED and hospital use) have the potential to reduce Nemours system revenue. This may be the biggest challenge facing innovators: to implement systems that drive toward the “triple aim” (better care, better health, and lower cost), at a time when innovative payment systems that align with those aims have yet to move into the mainstream.
- The number and nature of “accountability systems”:
Third, asthma care is proceeding—as is care for other conditions—in an environment in which there are more (and more sophisticated) systems both for measuring the results that healthcare providers achieve, and for creating incentives to promote improvements in those metrics. While these date back at least as far as the 1980’s—with, for example, Medicare’s release of hospital mortality data in 1987—the past decade has been marked not only by the expansion of available metrics, but the incorporation of those metrics into both private and public sector incentive programs (including “report cards” and “pay-for-performance” programs).
These systems include measures specifically related to asthma, some of which have been (or will be) included in CMS’s PQRS and EHR Incentive programs, in the set of core measures applied to the Medicaid and CHIP programs, and in health-plan-facing, and hospital-facing, private sector initiatives based on the National Committee for Quality Assurance’s (NCQA’s) and the Joint Commission’s measurement sets (HEDIS® and ORYX®), respectively. More recently, these systems are moving into individual physician practices, through the medical certifying boards’ Maintenance of Certification (MOC, part 4) programs.
The production and use of information that sheds light on the care delivered to patients with asthma have the potential to be a powerful force to accelerate improvement. As measures evolve from those that assess “process” to more directly assess outcomes—and especially as they evolve to assess the outcomes that matter to patients, through the efforts of organizations like the Patient-Centered Outcomes Research Institute (PCORI)—we can expect to see improvements in care that mean more and more to those with asthma.
- Digital data:
Finally, the digitalization of data—which has expanded data capture, greatly accelerated the speed with which data move, and created the potential for a new kind of analytics (“big data”)—has created new opportunities to improve outcomes for people with asthma, as it has already begun to affect the care of those with other conditions. For example, firms like Propeller Health, which capture and transmit data directly from the patient (in this case, when someone with asthma uses an inhaler), now make it possible for healthcare providers to monitor control—and potentially to intervene—in near real-time. And those data also permit analysis relevant not only to the care of the individual, but to the care of populations of those like that individual: For example, the potential to detect (very quickly) an “outbreak” of asthma in some area, that might signal the release of a trigger (for example, a chemical leak).
As AAFA’s new President and CEO, the question I ask is: What do these changes mean for AAFA? I think we are still working on that, but I have no doubt but it means that the validated educational programs that we have developed (www.aafa.org/education) to train patients and caregivers in asthma prevention, “healthy homes”, and guidelines-based asthma care will be more in demand, and perhaps in demand by new “customers”. I think it means as well, though, that there will be more opportunity for us to bring the voice of the patient with asthma to the national conversations that are guiding the changes that I have described, and that that voice will have more influence in those conversations. As we strive to achieve “patient-centeredness” in healthcare, there is an important set of opportunities for AAFA not only to serve as a voice for the patient, but to assure that that voice is captured and transmitted with high fidelity.