Asthma in Managed Care

Abstract

The articles prior to January 2008 are part of the back file collection and are not available with a current paid subscription. To access the article, you may purchase it or purchase the complete back file collection here Paula Lozano, MD, MPH; Tracy A Lieu, MD, MPH The burden of pediatrie asthma is felt by children, families, health care providers, employers, and the health care delivery system. Managed care organizations are paying attention to asthma and are asking clinicians to invest increasing energy in asthma management. Because health care resources are organized for acute illnesses rather than chronic care, effective asthma management strategies are not consistently applied. To provide more effective chronic asthma care, four components are necessary: (1) information systems, (2) clinical expertise, (3) support for patient self- management and behavior change, and (4) practice organization with a chronic illness orientation. Several features of managed care can facilitate these chronic illness interventions, and managed care organizations have addressed the components of chronic illness care in a variety of ways. Examples of how managed care can implement these elements for asthma are presented. These examples may help clinicians and policy makers develop their own efforts to improve asthma management. WHY MANAGED CARE ORGANIZATION(S) ARE PAYING ATTENTION TO ASTHMA CARE AND HOW THIS MAY AFFECT CLINICIANS' PRACTICES Managed care organizations and organizations that measure quality have placed asthma in the spotlight of quality improvement and performance measurement. There are several reasons for this. Asthma has a significant impact on children, families, health care providers, employers, and the health care delivery system. Asthma is a major chronic illness of childhood with a prevalence of 4% to 7%.1t? Its prevalence has increased in recent decades.1 Asthma contributes substantially to days lost from play or school.3 Employers are concerned about lost work days among workers with asthma or those who are parents of children with asthma/ And, emergency department visits and hospitalizations are often preventable events.3 As growing numbers of children are cared for under Medicaid managed care programs,6 the ranks of children with asthma in managed care organizations (MCOs) are swelling. Poor urban children have a greater asthma prevalence and higher incidence of poor asthma outcomes-7 Actually, an increasing proportion of all patients seen by pediatricians are insured through managed care arrangements.8 At the same time, as asthma's burden is more widely recognized, a number of asthma management strategies are being developed and refined. The effectiveness of inhaled ami- inflammatory agents as longterm control medications has been established in individuals with persistent asthma.9·'0 The past few years have witnessed reports of studies that are reassuring about safety and the development of drugs such as nedocromil sodium, fluticasone propionate, and budesonide with improved therapeutic profiles.11 Written asthma care plans appear to be helpful in preventing emergency visits and hospital izations12 and various templates for care plans have been disseminated and promoted. Peak flow monitoring, although not of unequivocal benefit in randomized trials, is felt to have a place as an objective monitoring tool in some groups with asthma.13 Environmental control measures such as avoidance of tobacco smoke,14 dust mites,15 cockroaches,16 and molds17 show promise to decrease morbidity as well. In 1997, the National Asthma Education and Prevention Program at the National Institutes of Health put forth its second Expert Panel Report, a set of evidence-based as well as consensus-driven guidelines that encompass each of these aspects of asthma care.11 Although there seems to be general consensus about what are good practices for asthma management, there appears to be great variability in how consistently guidelines are followed.18 Variability in both process and outcomes of asthma care has led to a proliferation of quality improvement efforts, including so-called disease management programs. Beyond the need to perform well on quality measures, managed care plans are increasingly adopting organized approaches to disease management. Disease management is a process that coordinates medical resources for patients across… 10.3928/0090-4481-19990101-13