In a valley wedged between the Mississippi and Missouri rivers, St. Louis often finds itself beset by a stationary air mass that only a severe storm of some kind can dislodge. St. Louis is also an industrial city with high humidity, so it’s no wonder it usually makes the list of worst places for asthmatics to live.
But the state has also pioneered advances in addressing asthma treatment and costs. Two years ago, the Missouri legislature became the first to allow schools to stock quick-relief asthma medications for emergencies. Missouri also became the first state to permit school nurses and other trained staff to administer that medication to any child suffering an asthmatic attack while at school, whether or not the child has an asthma diagnosis or a prescription at the school.
Now the state is poised to register another advance in its campaign against the respiratory disease. The House passed an appropriations bill late last month that would allow Medicaid reimbursement for specialists to visit the homes of low-income patients with severe asthma to identify asthma triggers in those homes. Medicaid would also provide reimbursement for face-to-face sessions to educate severe asthmatics in the disease and ways to manage it. The Senate is now considering the measure.
If approved, Missouri would join a very small number of states, including Massachusetts, Minnesota and New York, that either provide Medicaid reimbursement for asthma education or home assessments or both.
“Missouri is doing the most innovative policy interventions on asthma at this time,” said Charlotte Collins, senior vice president for policy and programs at the Asthma and Allergy Foundation of America (AAFA).
“There is lots of buzz inside the national asthma advocacy community about Missouri.”
Super-Utilizers
The latest legislation would define eligible patients as those identified as frequent users of emergency rooms for asthma, frequently hospitalized as a result of asthma or frequently prescribed oral steroids for asthmatic emergencies.
What prompted Missouri to act was an informational bulletin from the Centers for Medicare and Medicaid Services last month that encouraged states to look for ways to cut down on health care cost by the so-called “super-utilizers,” or those patients who consume a disproportionately high share of health care costs because of chronic conditions or acute illness or trauma.
According to CMS, this 1 percent of the U.S. population accounts for 22 percent of total annual health care expenditures. The CMS encourages states to find ways to treat those patients more effectively and less expensively.
The new legislation would cost Missouri $524,033 in the first year with the federal government chipping in another $4.7 million in Medicaid dollars. Not exactly cheap, the measure is anticipated to save far more by reducing the number of paramedic calls and visits to emergency rooms. A study published in the American Journal of Preventive Medicine and other research have shown that home assessments are effective in reducing emergency room visits and health care costs.
“Without a doubt, we’ll be able to save the state money,” said John Kraemer, founder of the Institute for Environmental Health Assessment and Patient-Centered Outcomes at Southeast Missouri State University. The institute provides asthma training and assists with home assessments.
One in Five Children
A chronic inflammatory disease of the airways characterized by breathing disorders, asthma afflicts 18.7 million adults and 7 million children in the U.S., according to the Centers for Disease Control and Prevention (CDC). And the numbers are going up.
The CDC says the number of Americans diagnosed with asthma increased by 4.3 million from 2001 to 2009, most steeply among black children, who are more likely to live in areas with greater pollution and environmental toxins. There were nearly 480,000 asthma-related hospitalizations in 2009, 1.2 million outpatient visits, 1.9 million emergency room visits, and 3,388 asthma-associated deaths. The CDC estimated health care costs related to those asthma incidents at $56 billion.
Nationwide, one in 10 children has asthma. In St. Louis, the rate for children is nearly one in five, according to the Missouri Department of Health and Senior Services.
Respiratory illness is the leading cause of hospitalizations for children between 1 and 10, according to the federal Health Resources and Services Administration.
Asthma ranked behind only mental illness in expenditures for childhood diseases, a 2011 survey by the U.S. Department of Health and Human Services found. Expenditures for treating asthma and chronic obstructive pulmonary disease in children totaled $11.9 billion. More than 12 million children were treated for asthma in 2011, and Medicaid paid about half the treatment costs. Hospitalizations accounted for 29.4 percent of these asthma expenditures.
The St. Louis chapter of AAFA pushed hard for the asthma-related legislation in 2012 and is also behind this year’s proposal, according to Joy Krieger, the chapter’s executive director. The organization already provides to the uninsured and underinsured asthma medications and nebulizers, which are drug delivery devices that transform liquid medicine into inhalable mist.
“Elbow Grease”
Krieger also regards home assessments as key to improving the health of asthma sufferers and reducing health care costs.
“For too long, people have treated this as a crisis rather than as a chronic condition,” she said. In other words, many crises can be avoided if people can eliminate or reduce the asthma triggers in their homes, she said. They include tobacco smoke, dust, cockroaches, mites, mold, pets, fragrances, fireplaces and certain paints.
“A lot of this you can just get rid of with elbow grease,” Krieger said. It’s a matter of education, she added.
Despite the state’s policies addressing asthma, the Asthma and Allergy Foundation of America still does not consider Missouri one of the states doing the best job in schools. It didn’t include Missouri in the honor roll of states with the most comprehensive and preferred statewide public policies supporting people with asthma, food allergies, anaphylaxis risk and related allergic diseases in schools.
The organization grades states on whether they have adopted 18 specific policies related to medication, reporting, tobacco use and indoor quality. By those standards, only seven states made the foundation’s honor roll: Washington, Indiana, Vermont, New Jersey, Rhode Island, Connecticut and Massachusetts. (The District of Columbia also made the list).
While Collins, of the national office, said Missouri was deficient in school-related air quality and tobacco policies, its innovations in accessibility to medications in schools had gotten the attention of advocates across the country.