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A number of studies demonstrate widespread improvements in asthma patients’ health and quality of life when a team of providers supplement primary and specialist health care with home assessments, in-home education, and reduction of home-based triggers. The literature on the financial benefits of these interventions is also beginning to make a compelling business case for the health sector to invest in home-based environmental interventions and education, targeted to patients whose asthma is not well controlled.
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Asthma is a chronic lung disease which strikes nearly 11% of Americans at some point during their lives. The burden is most severe among populations with lower socio-economic status, those living in low-income neighborhoods, and certain racial/ethnic minority groups. In addition, there is a growing body of evidence concerning the connection between housing conditions and asthma. In 2006, 22.9 million Americans had asthma, and an estimated 12.4 million of them (54%) suffered an asthma attack. Emerging data suggests that asthma is poorly controlled in most adults and children. Asthma symptoms, when uncontrolled, result in preventable hospital visits, missed days of school and work, and many other societal costs.
Controlling and managing asthma is extremely costly. In 2007, the U.S. paid $14.7 billion in direct health care costs and another $5 billion in indirect costs (lost productivity) for a total of $19.7 billion. Asthma represents a significant drain on the time and resources of the health care sector.
There are a number of environmental asthma triggers in the home. Triggers are conditions or substances that can cause airways to constrict or become inflamed, resulting in respiratory problems. They fall into two categories—allergens and irritants.
Common Allergens or Sources
Mice
Molds/Mildew
Cockroaches
Rats
Household Pets
Outdoor Allergens
Common Irritants or Sources
Cleaning chemicals
Environmental Tobacco Smoke (ETS)
Sprays/Scents
Indoor/Outdoor Fumes (gas/wood burning stoves, diesel engines)
Patients face several significant—but not insurmountable—challenges to accessing programs to address environmental asthma triggers in the home. The two biggest barriers are: 1) lack of payment for services and 2) insufficient service delivery capacity. Currently, most home-based environmental intervention programs are paid for by federal and private grants. Thus, they tend to come and go.
Where insurance reimbursements are available, the infrastructure often does not exist to accommodate referrals to environmental assessment and remediation programs. Moreover, many insurance payers will not reimburse for providers other than physicians and nurses. For example, the culturally competent and less expensive outreach services provided by Community Health Workers (CHWs), and other unlicensed professionals, are rarely reimbursed. Yet by using CHWs who live nearby and may share cultural or ethnic backgrounds, another barrier can be overcome: the hesitation of some people in allowing professional providers - sometimes perceived as outsiders - to enter their homes.
The Health Care Sector Can Transform Asthma Disease Management
Traditionally, the health care sector has delivered, and paid for, the management of chronic diseases using a medical model. For asthma, that has meant measuring lung function and using medications for symptom control. Rarely has the health sector been called upon to deliver, or reimburse for, environmental strategies as part of a disease management regimen.
In 2007, the widely respected National Asthma Education and Prevention Program’s (NAEPP) Expert Panel produced updated Guidelines for the Diagnosis and Management of Asthma, considered the “gold standard” for clinical practice. NAEPP evaluated the scientific literature on environmental strategies designed to reduce home asthma triggers, and found that multi-faceted environmental control measures, when tailored to the patient’s allergen and irritant sensitivities, are a vital component of effective asthma management. The Centers for Disease Control and Prevention’s Task Force on Community Preventive Services and the National Center for Healthy Housing recently completed similar reviews and came to virtually identical conclusions.
This multi-pronged approach usually includes:
- A home assessment,
- Basic asthma education and trigger avoidance education, and
- Provision of materials/supplies that help manage pests (closed containers or traps for rodents), protect against dust-mites (mattress/pillow encasements), and reduce exposure to contaminants in the air (HEPA filters for vacuums), among others.
A Business Case for the Health Sector Investing in Home-based Environmental Interventions
In the health care sector, a business case for a particular service exists if there are documented cost savings realized by investing in the intervention, or if a program is considered “reasonable” relative to the costs of standard services, given the health benefits realized by the intervention (cost effective).
A number of studies have evaluated the cost effectiveness of multi-faceted in-home environmental interventions for asthma. These studies demonstrate that the costs of providing a combination of environmental education and home assessments, services, and supplies as part of an asthma management treatment plan, are reasonable and cost effective given the improvement in health as compared to the cost and benefit of other standard interventions, such as medications.
In 1997, an NAEPP working group recommended using symptom-free day as the principal outcome measure for cost-effectiveness. A symptom-free day is defined as a night and day with no asthma symptoms and no nighttime awakenings. Two recent studies estimate that each symptom-free day gained from standard medications cost $7.50 in adult patients with mild to moderate asthma and $11.30 in patients 5-66 years old with mild persistent asthma. Medications such as Xolair, which is prescribed to patients with moderate-severe, uncontrolled allergic asthma, cost a whopping $523 per symptom-free day gained.
When looking across the spectrum of standard asthma management treatments, in home environmental interventions - which cost $2-$28 per symptom-free day gained during approximately the same time period - are clearly within the range of what payer organizations have deemed “reasonable” to improve similar asthma outcomes, and may produce net cost savings if the more costly treatment options are avoided. Research suggests that patients classified as high risk (have moderate or severe persistent asthma, and/or had recent unscheduled urgent care visits), and those who have been sensitized to certain allergens through allergy testing, will benefit most from more intensive and tailored interventions. We do not suggest replacing medications with environmental interventions, rather, we recommend pursuing such strategies should symptoms remain uncontrolled, and/or if specific allergies are confirmed.
Delivering Home-Based Environmental Interventions
Effective home-based programs have used a variety of staffing models including nurses, community health workers/environmental counselors, respiratory therapists, and social workers. The literature suggests that these non-physician providers can effectively provide asthma education and environmental interventions, often at a lower cost, given appropriate training, supervision, and reimbursement, depending on the mix of services needed by a given patient.
A variety of organizations and agencies have designed and delivered such programs including:
- Local health departments, in several states including Connecticut, Oregon, Washington, and Massachusetts (both Cambridge and Boston).
- Numerous large hospitals and health care systems, including Children’s Hospitals of Boston and Philadelphia, and MaineHealth).
- Non-profits and coalitions in western Michigan and Boston.
- Health plans serving primarily low-income populations in Virginia Beach, VA; Medford and Boston, MA; and Rochester, NY.
Community health centers are a promising source of service delivery as well.
Our Challenge: Agreeing on Policy Change We Might Pursue Collaboratively
Here are several federal policy options to consider and discuss:
1. Housing Sector: Given the important role that environmental tobacco smoke (ETS), pests, mold, and dust mites play in triggering asthma attacks, the housing sector should prioritize the following steps:
o Adopt policies and practices that limit exposures to ETS and pests through adoption of smoke-free housing policies and integrated pest management practices.
o Adopt green and healthy building standards to help prevent asthma triggers from developing.
o At the time of unit turnover and scheduled maintenance of housing units, implement asthma-friendly housing maintenance protocols which include remedying moisture and pest intrusion, addressing mold, removing carpeting in bedrooms and bathrooms, maximizing cleanable surfaces, using non-toxic cleaners, and providing garbage receptacles and containers for food.
2. Health Sector: In light of the robust evidence demonstrating the effectiveness of home-based services, providers, health systems, payers, and public agencies all have important roles to play in ensuring that people with asthma have access to trigger reduction services:
o The health sector should facilitate the delivery and financing of integrated home-based education and environmental services for patients whose asthma is not well controlled. This should include payment and reimbursement for:
- A range of staffing approaches that have been shown to be cost effective in the literature (e.g. community health workers);
- A home environmental assessment;
- Supplies needed for environmental trigger reduction; and
- More intensive environmental services based on a patient’s allergy profile and/or whether conditions warrant the service (e.g. professional pest control services). The latter two might be reimbursable for those particularly in financial need.
Source: National Center for Healthy Housing (NCHH) and Briefing Paper for the National Healthy Housing Policy Summit, May 2009
Prepared on behalf of the Asthma Regional Council by: Laurie Stillman, MM, Health Resources in Action; Polly Hoppin, ScD and Molly Jacobs, MPH, University of Massachusetts Lowell.
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