(Chest. 1999;116:173S-178S.)
© 1999
American College of Chest Physicians
A Survey of Asthma Care in Managed Care Organizations*
Results From the Chicago Asthma Surveillance Initiative
Sandra G. Nelson, MA;
Evalyn N. Grant, MD;
Mitchell J. Trubitt, MD, FCCP;
Michael B. Foggs, MD, FCCP;
Kevin B. Weiss, MD, and
for the
Chicago Asthma Surveillance Initiative Project
Team
*
From the Center for Health Services Research, Rush Primary Care Institute (Mrs. Nelson and Dr. Weiss), Department of Immunology/Microbiology (Dr. Grant), Rush-Presbyterian-St. Luke's Medical Center, Chicago, IL; United Health Care of Illinois Inc (Dr. Trubitt), Chicago, IL; and Advocate Health Care (Dr. Foggs), Chicago, IL.
See Appendix for other members of the CASI Project Team.
Correspondence to: Kevin B. Weiss, MD, Center for Health Services Research, Rush Primary Care Institute, Rush-Presbyterian-St. Luke's Medical Center, 1653 W Congress Pkwy, Chicago, IL 60612
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Abstract
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Introduction:
Managed care, both via staff model health maintenance plans and
nonstaff model plans, has become a major source of health-care funding
in the United States. However, very little is known about the
asthma-specific products and services offered by these plans. The
purpose of this study is to examine the asthma-specific products and
services offered by managed care within the Chicago area.
Methods: Between December 1997 and February 1998, a
self-administered survey was mailed to the medical directors of the 19
managed care organizations (MCOs) in the Chicago area. The survey
covered the following content areas: general characteristics of the
MCOs, asthma-related services, monitoring of asthma care, and
asthma-related quality improvement efforts. The medical directors were
asked to respond separately for staff model capitated plans, nonstaff
model capitated plans, and noncapitated plans.
Results: Responses were received from 13 of the 19 eligible
Chicago-area MCOs (a response rate of 68.4%). Three of the responding
MCOs (23.1%) offered a staff model plan, 11 (84.6%) offered a
nonstaff model capitated plan, and 6 offered some type of noncapitated
plan. Asthma education programs, although available in all plan types,
were offered much less frequently in the nonstaff model capitated and
noncapitated plans, 36.4% and 33.3%, respectively. Asthma case
management programs were also available in some, but not all of the
health plans. Only 54.5% of the nonstaff model capitated health plans
promoted the use of asthma practice guidelines. Among the responding
MCOs, asthma quality improvement efforts related to National Committee
on Quality Assurance accreditation were infrequent in 1995. Sixty-one
percent of the MCOs reported that program development for improving
asthma care was a very high priority relative to programs for other
health conditions.
Conclusion: The results of this
study suggest that many, but not all, of the basic elements of asthma
care services are offered by the MCOs in the Chicago area. Findings
from this study also suggest ways in which asthma-related product and
service delivery might be changed to improve outcomes for asthma in
this community.
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Introduction
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The partnership between a person with
asthma and their health-care provider is a core component of what is
commonly thought to be necessary for high-quality asthma
care.1
However, it is becoming increasingly evident that
the health systems surrounding this partnership are key to making this
relationship possible.2
In 1996, the National Asthma
Education and Prevention Program published a report of findings from
their Task Force on the Cost-effectiveness, Quality of Care, and
Financing of Asthma Care. In this report, the task force emphasized the
importance of adequate health-care financing for optimal asthma
management and stressed the importance of finding out how different
types of financing mechanisms may lead to more effective
care.3
Managed care products—both staff model health maintenance plans and
nonstaff model plans—have become a major source of health-care finance
in the United States during the past decade. Although there are some
published data about asthma care practices in managed care, the data
are limited and mostly relate to selected asthma care characteristics
of individual plans4
5
6
7
or groups of plans drawn from
opportunistic samplings of differing geographic areas.8
9
These studies focused on very specific performance measures without
exploring the many factors, such as health plan services; providers'
knowledge, attitudes, and beliefs about asthma; and community factors,
that may also influence asthma care and asthma outcomes.
Little is known about how managed care organizations (MCOs) organize
care within their plans. There are no published studies comparing the
products and services offered for asthma care among the various plans
within a single community. Therefore, the purpose of this study is to
examine asthma care services among the MCOs of Chicago—a large urban
community known to have disproportionately unfavorable asthma
outcomes.10
11
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Materials and Methods
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Overview of Study Design
A cross-sectional study of asthma care products and services in
the managed care environment was conducted, using a self-administered
survey mailed to the medical directors of the MCOs in the Chicago area.
The survey was administered between December 1997 and February 1998.
Survey Instrument
Because of a lack of existing instruments specific to managed
care, a new self-administered survey instrument was constructed for the
purposes of this study. Two senior medical administrators of
Chicago-area MCOs served as consultants to inform the initial content
of the survey. Once a draft of the survey was complete, it was
circulated to several local MCO medical directors for review and
comment. The survey underwent two subsequent revisions on the basis of
the feedback of the reviewers and consultants.
The final survey instrument contained 84 items in the following content
areas: general characteristics of the MCOs, asthma-related services,
monitoring of asthma care, and asthma-related quality improvement
efforts. Because many MCOs offer more than one type of health plan, the
medical directors were asked to respond separately for staff model
capitated plans, nonstaff model capitated plans, and noncapitated
plans.
Study Population
Twenty MCOs were initially identified from a list provided by
the Illinois Association of Managed Care Organizations. Eighteen of
these MCOs were either staff model health maintenance organizations or
had nonstaff model capitated care network products or services; one
health plan provided only noncaptitated care. One health plan no longer
served the Chicago area at the time of the survey and was therefore
considered ineligible.
Survey Administration
In December 1997, the survey, along with a cover letter and
postage-paid return envelope, was mailed to the medical directors of
the Chicago-area MCOs. The medical directors were requested to return
their surveys by mail or fax. Telephone follow-up was conducted, and
the potential respondents were notified that they would be given early
access to a report of the findings to encourage completion of the
survey. Survey administration ended in February 1998.
Statistical Analysis
Descriptive statistics are presented. Because of the small
number of actual responses, no inferential statistics were assessed.
For the purpose of this report, the term "very few" is used to
describe responses reported by < 20% of the respondents,
"minority" refers to 20 to 49%, "majority" refers to 50 to
79%, and "nearly all" refers to 80 to 100% of the respondents.
Although information on all three types of insurance products is
presented, this report will primarily focus on responses for the two
types of capitated care, staff model and nonstaff model plans. All
analyses were conducted using computer software (SAS Version 6.12; SAS
Institute; Cary, NC).
The study was conducted under the approval of the Institutional Review
Board serving Rush-Presbyterian-St. Luke's Medical Center.
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Results
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Selected General Health Plan Characteristics
Of the 19 eligible MCOs, 13 responded, for a response rate of
68.4%. It is estimated that these 13 MCOs accounted for 83.0% of the
capitated care in the region (estimates based on 1997 Illinois state
enrollment of the surveyed MCOs; data provided by the Illinois Medical
Society). All but one of the respondents was the medical
director of the organization. Regarding the differing plans within the
overall organization, 3 of the responding MCOs (23.1%) had a staff
model plan, 11 (84.6%) had a nonstaff model capitated plan, and 6
(46.2%) had some type of noncapitated plan.
Table 1
describes some of the characteristics of the plans within the MCOs. At
the time of the survey, two of the three staff model plans had an
enrollment of > 50,000 members, whereas nearly 64% of the nonstaff
model capitated plans had < 50,000 members. Only one of the three
staff model plans enrolled Medicaid recipients, vs 9.1% of the
nonstaff model plans; in contrast, all three of the staff model plans
enrolled Medicare recipients vs 27.3% of the nonstaff model plans.
Characteristics of Asthma-Specific Services and Covered Benefits
Table 2
provides insights to some key aspects of asthma-related services and
covered benefits. All of the staff model plans offered some type of
asthma education program. These patient education programs were offered
much less frequently in both the nonstaff model plans (36.4%) and
noncapitated plans (33.3%). Asthma case management programs were also
available in some, but not all of the health plans: 33.3% of the staff
model plans, 45.5% of the nonstaff model capitated plans, and 33.3%
of the noncapitated plans. Comprehensive, population-based asthma
management strategies (eg, asthma disease state management
programs) were offered infrequently in all types of plans.
The data revealed some important variations in benefit coverage for
asthma-related medications and services. Among the staff model and
nonstaff model capitated plans, overall coverage of asthma medications
and peak flowmeters was high; these plans covered spacer devices less
frequently (Table 2)
. All plans offered coverage of some type of asthma
education, although the exact content of this coverage was not
characterized and may have varied from plan to plan. Very few plans
covered allergen reduction materials such as pillow and mattress
covers. Similarly, very few plans covered smoking cessation programs
and smoking cessation medications. Of note, 45.5% of the nonstaff
model capitated plans covered environmental home assessment for persons
with asthma. In contrast, none of the staff model plans covered
environmental home assessments.
Characteristics of Asthma-Specific Quality Improvement Activities
Monitoring and improving quality of care are important goals of
MCO operations. As part of this survey, the MCOs were asked about
asthma-specific quality improvement activities within their plans. Only
54.5% of the nonstaff model capitated plans promoted the use of
practice guidelines for asthma care (Table 3 ). Use of asthma guidelines in the staff model plans and noncapitated
plans was even less frequent.
The respondents reported conducting asthma drug utilization reviews in
a majority of the nonstaff model capitated plans and noncapitated
plans, 54.5% and 66.7%, respectively. The most common reviews were
for use of inhaled anti-inflammatory medications (85.7% of nonstaff
model and noncapitated plans) and short acting ß-agonists (71.4% of
nonstaff model and noncapitated plans). This type of review was not
conducted in the staff model plans.
The respondents indicated that a majority of the capitated health plans
had made an effort to estimate the number of covered lives diagnosed
with asthma (Table 3)
. Approximately 83.3% of the capitated plans used
asthma hospitalizations as the identifier for these estimates, and
66.7% of the capitated plans used emergency department visits or
prescriptions as the identifier. Patient identification via urgent care
visits, routine office visits, or patient survey were less common
(Table 4
).
During both 1995 and 1996, approximately one third of the plans in each
category were tracking the Health Employers Data Information Set
(HEDIS) measure for asthma. Asthma-related quality improvement efforts
in response to National Committee for Quality Assurance (NCQA)
accreditation was rare in 1995. However, by 1996, nearly one third of
the capitated insurance plans were conducting some type of asthma
improvement project.
The respondents indicated that, for 61.5% of the plans, program
development in asthma care improvement was a high-priority goal
relative to programs for other conditions. In addition, the respondents
indicated all three staff model plans as well as 81.8% of the nonstaff
model capitated plans intended to implement an asthma care improvement
program in the next year. A majority of the respondents indicated their
plans would be interested in participating in a collaborative asthma
care improvement activity with other MCOs.
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Discussion
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As the results from this survey demonstrate, many of the managed
care plans in the Chicago community have an interest in providing
comprehensive asthma care and have identified asthma as a priority for
quality improvement efforts. According to the survey, benefit coverage
for essential items such as asthma medications, peak flowmeters, and
spacer devices is generally high. Most of the health plans offer some
type of asthma education, and some of the plans appear to be adopting
more formal asthma education programs as well as asthma case management
plans or more comprehensive disease management programs. However, there
are other important issues in asthma care that the MCOs in Chicago have
not fully embraced. For example, very few plans cover allergen
avoidance materials such as pillow and mattress covers or environmental
control measures such as air purifiers or devices for humidity
management. Similarly, there is very little coverage for programs or
medications targeting smoking cessation. Many of the health plans have
not formally adopted any guidelines for asthma care.
There also appear to be differences in some of the asthma-specific
services offered in staff model vs nonstaff model capitated health
plans. For example, coverage of environmental home assessments was only
reported among the nonstaff model plans. All the respondents indicated
that they covered some type of asthma education, and all three of the
staff model plans offered a formal asthma education program. However,
nearly two thirds of the nonstaff model plans did not offer any formal
asthma education program to their enrollees.
During 1995 and 1996, HEDIS included an asthma
indicator.12
Although it is unclear how much impact this
indicator had on how various plans chose to focus on asthma, this
survey found that approximately one third of the plans were conducting
some type of asthma quality improvement activity in response to HEDIS
and NCQA.
Although it was evident that some plans sought to engage in performance
monitoring for purposes of reporting to NCQA and HEDIS, a larger number
of plans appeared to be examining health-care utilization for asthma
via hospitalization, emergency care, or pharmacy records. However, the
plans did not appear to have a uniform approach to identifying persons
with asthma, and this survey did not query how the plans were using the
information on asthma care utilization to affect quality improvement.
The 1996 National Asthma Education and Prevention Program's Task Force
on Cost-effectiveness, Quality of Care, and Financing of Asthma Care
found that whereas MCOs may provide optimal access to most
asthma-related services, co-payments and partial coverage of some
services often create financial barriers for patients.3
Several studies have demonstrated how changing the systems for
delivering asthma care can lead to better patient
outcomes.13
14
However, these few studies do not represent
a substantive body of literature on this subject to suggest optimal
ways by which to improve care in managed care environments.
There are numerous limitations to this study. Perhaps most apparent is
the small number of observations. Only 13 MCOs participated in this
survey, and information on the nonrespondents is not available to
assess bias. Yet, as noted above, the MCOs that responded to the survey
represent most of the managed care services delivered in the Chicago
area. A larger study would, perhaps, make these findings more
generalizable. Also, the findings of this study are based on
self-reported data; respondents may report what they believe to be
acceptable instead of actual practice. Therefore, many of the estimates
may be optimistically high. The cross-sectional study design also
limits interpretation to reflect a single point in time. A repeated
cross-sectional or longitudinal cohort design would provide information
on the changes in asthma care over time.
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Conclusions
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Given the many limitations, the information from this survey best
serves as a starting point for generating ideas, concepts, and perhaps
more formal hypotheses about the asthma care delivered by managed care
plans. More important, this study provides some new insights into the
variations in asthma care among health plans serving a community known
to be at risk for unfavorable asthma outcomes.
Many of the plans offer competing services in the areas of asthma
education, case management, and population-based management programs.
Each plan sends providers and patients different materials and messages
about optimal asthma care strategies, and many of the health plans do
not have practice guidelines on which to base these strategies. Perhaps
a first step for Chicago-area MCOs would be to design a process by
which the health plans would adopt common asthma materials
(eg, practice guidelines, patient education) so as to give a
consistent message to health-care providers and patients. The Chicago
Asthma Consortium15
would be one possible vehicle for
facilitating this process. From this beginning, further efforts could
be initiated to improve asthma care performance of individual health
plans and the overall quality of managed care for persons with asthma
living in Chicago.
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Appendix 1
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Other members of the CASI team include (in alphabetical order):
Claudia Baier, MPH, Steven Daugherty, PhD, Edward Eckenfels, Tao Li,
PhD, Christopher Lyttle, MA, Anita Malone, MPH, and Karen Turner-Roan,
MPH, of Rush-Presbyterian-St. Luke's Medical Center, Chicago, IL; and
Michael McDermott, MD, and James Moy, MD, of Cook County Hospital,
Chicago, IL.
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Acknowledgements
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The authors would like to thank the Illinois
Association of Health Maintenance Organizations for providing the
mailing list for this study and Ms. Robin Wagner for her assistance in
manuscript preparation.
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Footnotes
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The Chicago Asthma Surveillance Initiative is funded by a grant from
the Otho S.A. Sprague Memorial Institute.
Abbreviations:
CASI = Chicago Asthma Surveillance Initia-tive;
HEDIS = Health Employers Data Information Set; MCO = managed care
organization; NCQA = National Committee for Quality Assurance
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References
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TOP
Abstract
Introduction
