Asthma Consensus Statement

1. Asthma Consensus Statement A Health Care Provider Perspective on Working with Payers, Health Organizations, and Government to Improve Asthma Outcomes Coordinated by: Polly Hoppin, UMass Lowell Laurie Stillman, Asthma Regional Council Presented by: Shari Nethersole, MD and Matthew Sadof, MD

2. Problem Statement Asthma: a disease that can be nearly fully controlled, yet� Too many children with asthma still using urgent care, unable to play or attend school Too many adults with asthma unable to work, exposed to asthmagens, and limited in activities of daily life Disproportionate burden on low income communities. Lack of targeted resources to address burden. Too many providers not delivering best practices Too many families unable to pay for, or self-manage, their care. Low patient expectations.

3. Purpose of Consensus Statement We can do better; we must do better. The research on best practices is clear; the translation into the real world is challenging. Current policies and programs not aligned with best practices. Payers and Policy Makers listen to Providers of care who do the work everyday. Payers and Policy Makers need and want to hear their priorities so they can effectively target limited resources. The priorities have to be clear and realistic.

4. What will the Consensus Statement Look Like? Will be short and to the point�focus on recommendations Will provide provider-offered solutions to barriers and problems in the field and in the literature Will tailor solutions to payers, health care providers, policy makers and govt. officials: all have a role to play Will be signed by providers across the Commonwealth

5. Who Crafted It? Organized by UMass Lowell and Asthma Regional Council: Polly Hoppin, ScD & Laurie Stillman, MM Drafting Committee: Polly Hoppin and Laurie Stillman, Stephanie Chalupka, Francis Duda, Lisa Mannix, Shari Nethersole, Margaret Reid, Elaine Rosenberg, Matthew Sadof, Megan Sandel.* Input Solicited From: 18 adult and child physicians and nurses in Framingham meeting; governmental and NGO reps. included. Payer reactions sought. *Physicians, Nurses and Policy Experts in the field of asthma.*Physicians, Nurses and Policy Experts in the field of asthma.

6. Overall Recommendations We call on payers, health systems, our provider colleagues and public health agencies to take the following steps to improve asthma outcomes in Massachusetts: Align policies and programs with best practices (NAEPP EPR3) Target and deliver appropriate care and services to those most in need Address and integrate 3 areas: -Clinical Care -Patient and Provider Education -Work, home, community environments

7. What are the Recommendations? Payers Align Reimbursements/Provide Incentives for providers and patients to follow Best Practices promoted by NAEPP EPR3 *� Payers should provide incentives for�providers and patients to follow the NAEPP guidelines.�Currently there are�financial barriers for patients to receive proper care to control their disease, including�unaffordable medications and lack of consistent reimbursement policies and practices that would allow for clinicians to directly or via referral provide needed specialty consultation, case management, educational and environmental services in a variety of settings. * There are four main components to NAEPP guidelines, and the following slides take each of the four components and prioritizes ways of meeting each of them.*� Payers should provide incentives for�providers and patients to follow the NAEPP guidelines.�Currently there are�financial barriers for patients to receive proper care to control their disease, including�unaffordable medications and lack of consistent reimbursement policies and practices that would allow for clinicians to directly or via referral provide needed specialty consultation, case management, educational and environmental services in a variety of settings. * There are four main components to NAEPP guidelines, and the following slides take each of the four components and prioritizes ways of meeting each of them.

8. Payers Pharmacologic therapy. To enable people with asthma to secure needed medications, payers should: Reduce or eliminate co-pays, and/or redesign drug formularies, to ensure that brand name drugs for which there are no generic alternatives are placed in a lower-cost category. Reimburse for multiple prescriptions for inhalers, so patients can have them at school, at work, and at more than one home�if that�s their situation. 1. Cost of therapy is way to expensive, especially since many families have multiple family members with the disease, have to have two sets of meds�one for school or work. We need to at least focus on the controller meds for secondary prevention.1. Cost of therapy is way to expensive, especially since many families have multiple family members with the disease, have to have two sets of meds�one for school or work. We need to at least focus on the controller meds for secondary prevention.

9. Payers Measures of assessment and monitoring. To ensure correct diagnosis and monitoring of symptoms, payers should reimburse sufficiently for: Pulmonary function testing, conducted in laboratories and/or in clinical office setting - Peak flow meters for patients for whom this is a reliable indicator of asthma control.

10. Payers Education for a partnership in asthma care. Payers should provide and/or reimburse for asthma education, including: - Longer office visits with primary care providers - Reinforcement Sessions with asthma educators in the clinic, home and/or community, as appropriate and needed.

11. Payers Control of environmental factors and co-morbid conditions that affect asthma. - Payers should reimburse for environmental services and supplies for the home, as appropriate and needed * - Payers should promote coordination and collaboration among providers caring for patients with asthma and other conditions that affect asthma, such as obesity and sinusitis. * e.g., smoking cessation programs and associated pharmacotherapy; mattress/pillow covers; HEPA air and vaccum TYPO filters; home assessments; integrated pest management supplies and, where needed, professional services.

12. Payers Reimburse and facilitate billing for multiple kinds of providers most appropriate for a given setting. Work with health systems to establish robust disease management programs that may include: - Asthma Registries - Electronic Provider Decision Support (feedback) Mechanisms for benchmarking care - Case Managers that coordinate and follow care.

13. Payers Help finance and support organizations that provide comprehensive asthma management services to ensure sufficient supply. As first step: Support and participate in pilot projects (NGOs or health agencies) that deliver comprehensive asthma management; track costs and health benefits to inform decision-making about longer-term investments.

14. What are the Recommendations? Providers/Health Systems Providers & health systems need to work collaboratively to ensure that high quality services are being offered in their communities

15. Providers/Systems Ensure full understanding among providers of the NAEPP Guidelines and the literature on promising interventions. Primary care and other providers should take advantage of CME/CEU opportunities for keeping current on the latest science on best practices - diagnosis criteria; - pulmonary function testing and interpretation of results; - Prescribing and monitoring appropriate medications; - delivering asthma education; - the potential for home visits to benefit patients whose asthma is out of control - the role of workplace exposures in asthma onset and exacerbation, and the importance of public health reporting of workplace-induced asthma. - diagnosis criteria; - pulmonary function testing and interpretation of results; - Prescribing and monitoring appropriate medications; - delivering asthma education; - the potential for home visits to benefit patients whose asthma is out of control - the role of workplace exposures in asthma onset and exacerbation, and the importance of public health reporting of workplace-induced asthma.

16. Providers/Systems Promote quality improvement, in particular: Establish and/or link with disease management tools including asthma registries and provider feedback/decision support mechanisms Via referrals, connect patients with case managers and community services Use written asthma action plans* Ensure that staff or referrals are appropriately trained and culturally competent Communicate with school nurses and employers about your patients� asthmas and their needs Seek patient and family input on quality improvement initiatives *AAP Order Forms are in everyone�s packets (they are free)*AAP Order Forms are in everyone�s packets (they are free)

17. Providers/Systems Facilitate patients� access to asthma education and environmental intervention services and supplies as appropriate and needed. On behalf of patients who could benefit, request insurance coverage of services, materials and supplies that are not routinely reimbursed by payers. Inquire about workplace explosures, help workers minimize these exposures, and report them to the MDPH as required. - diagnosis criteria; - pulmonary function testing and interpretation of results; - Prescribing appropriate medications; - the benefits of asthma education; - the potential for home visits to benefit patients whose asthma is out of control - the role of workplace exposures in asthma onset and exacerbation, and the importance of public health reporting of workplace-induced asthma. - diagnosis criteria; - pulmonary function testing and interpretation of results; - Prescribing appropriate medications; - the benefits of asthma education; - the potential for home visits to benefit patients whose asthma is out of control - the role of workplace exposures in asthma onset and exacerbation, and the importance of public health reporting of workplace-induced asthma.

18. What are the Recommendations? Public Agencies State Public Agencies are uniquely capable of supporting systems change, increasing capacity for service delivery, and delivering safety net interventions. The recommendations that follow envision partnerships between public agencies, payers, providers/health systems and community organizations.

19. Public Agencies Build capacity for focused and coordinated chronic disease prevention and management. Utilize data in asthma registries, claims data and surveillance systems to inform program planning and monitor trends in quality of services provided. Institutionalize communication between public health and coordinators of care. Work with MassHealth and Legislators to articulate minimum services needed to provide effective asthma management, and minimum insurance benefits necessary to access these services. Work with legislature to resource school nurses to maximize their role in controlling students� asthma and provide guidelines on asthma management in schools. Empower and resource local public health depts., through promoting regionalization and training, to track and fill gaps in services. Help establish capacity for delivering asthma education and environmental interventions and providing appropriate materials and supplies. Increase awareness of work-related asthma among providers, employees and employers - Develop agenda for primary prevention of asthma through research and policy, and promoting alternatives to identifiable asthmagens. 1. State after topic sentence �, akin to that used to control and eradicate communicable diseases�1. State after topic sentence �, akin to that used to control and eradicate communicable diseases�

20. Public Agencies Identify, strengthen and enforce laws and regulations aimed at preventing exposures and improving social and environmental conditions. - State agencies should provide guidance to cities and towns in enforcing sanitary codes in housing to address triggers - OSHA should ensure workers receive info. on asthmagens in workplace and employers should address them in the workplace. Public workers should be covered by OSHA rules as well.* - EPA should ensure that all communities in MA. meet national ambient air quality standards, and enhance clean transportation programs, such as diesel prevention/anti-idling *Public sector workers, such as teachers and nurses are not covered by OSHA, yet have high rates of asthma.*Public sector workers, such as teachers and nurses are not covered by OSHA, yet have high rates of asthma.

21. What Do You Think? Do these suggestions ring true to you? Is there anything important that we�re missing? Is there anything inaccurate in these observations and suggestions?

22. What Do You Think? From your experience, which of these recommendations would be most helpful or important to you? Would you be willing to support their implementation?