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Claims Management News

How One Health Payer Partnership Reduced Hospitalizations

Among children participating in the health payer partnership program but have not seen a reduction in hospitalizations, home visits will become part of the solution.

By Vera Gruessner

- Recently, the health payer Blue Cross and Blue Shield of Illinois (BCBSIL) announced in a press release that it will be extending its partnership with the American Lung Association of the Upper Midwest over the next two years. The specific partnership revolves around the Enhancing Care for Children with Asthma program, which has already decreased hospitalizations by 60 percent and emergency room visits by 53 percent in 16 clinics over the course of two years.

Health Payer Partnership

The program is looking at using community-based interventions to assist high-risk asthma patients in pediatric care offices and school-based clinics. Currently, 12.5 percent of the population in Illinois has been diagnosed with asthma with children’s rates hitting higher than the national average at 13 percent, which is why this health payer partnership program is so important to addressing the needs of this particular patient population.

“BCBSIL reviewed its claims data to identify the Illinois providers representing areas with the highest rates of hospitalizations and emergency-related visits for children with asthma,” Opella Ernest, MD, Senior Vice President and Chief Medical Officer for BCBSIL , stated in the press release.

“Teaming up with the American Lung Association in Illinois to recruit primary care clinics was then a logical choice to try to make a difference for these kids. The American Lung Association signed up the clinics to participate in year-long training cohorts based on National Heart, Lung and Blood Institute guidelines to enhance asthma treatment for children.”

Health care clinicians and staff are provided in-depth training sessions to ensure the health of asthma patients is better controlled and managed. It is meant to reduce hospitalizations due to complications of asthma. The program is expected to advance among 10 new primary care clinics over the next two years.

“What continues to make this quality improvement initiative with BCBSIL invaluable is we have not only reduced emergency department visits and hospitalizations among those children in participating clinics, but it has provided participating clinics with technical assistance and resources that may have unfortunately been out of their reach,” Felicia Fuller, Dr.PH, Director of Lung Health and Community Health Services at the American Lung Association, said in a public statement.

“This partnership has helped hundreds of children in Illinois with controlling their asthma so they can do everyday activities like sleep all night, go to school, and play sports. It has also made a positive impact on their parents, providing additional education and resources, allowing them to miss fewer days of work and improving their quality of life and peace of mind.”

Among children and their families who are participating in the health payer partnership program but have not seen a reduction in emergency department visits or hospitalizations, home visits will become part of their solution in order to determine if there are any stimulants that could be causing their poor outcomes.

The American Lung Association of Illinois has set up specific quality improvement steps for medical professionals who are participating in the program. The steps are as follows:

1.       Buy-in

2.      Rooming process

3.      Documentation process (opportunity to pilot electronic DDS)

4.      Self-assessment process

5.      Controller meds

6.      Albuterol refill protocol

7.      Asthma action plan

8.     Spirometry

9.      Tobacco dependence

10.  Self-management/Patient education

11.   ED follow-up

12.  Planned visit

Felicia Fuller of the American Lung Association spoke to to offer her perspective on the Enhancing Care for Children with Asthma program.

When asked about some of the best health outcomes that came about due to the partnership between Blue Cross and Blue Shield of Illinois (BCBSIL) and the American Lung Association, Fuller responded, “We saw over 50 percent reduction in hospitalizations as well as emergency room visits in both Illinois and the other states that were a part of this collaboration. That was probably the main findings that our data has found so far.”

When it comes to cost savings within the Enhancing Care for Children with Asthma program, Fuller explained that, “We found specific numbers and we did find cost savings – savings to the insurer.”

When asked about the biggest achievements that this health payer partnership brought to providers, the payer, and asthma patients, Fuller mentioned, “Beyond the lower hospitalizations and the emergency room visits – which is grand – and the money savings, probably some of the best outcomes were that many providers and healthcare workers had been trained in asthma management.”

“Part of the training included seminars, trainings and webinars that they didn’t have access to in the past,” Fuller continued. “Also, many did not know about spirometry or other guideline based tools associated with good asthma care. Since many clinic staff members needed more education regarding asthma care, the American Lung Association assisted clinicians through the process and educated staff on guideline-based care.”

When asked about the methods the American Lung Association used to improve patient care and reduce hospitalization rates along with emergency room visits, Fuller answered, “What we did was we formed a partnership aimed at assisting clinics and enhancing asthma care for children in Illinois.”

“We cover topics including the use of asthma action plans, asthma control tests, documentation processes, and basic asthma health education” she continued. “We cover about 12 areas over a one-year period through four to five meetings over the course of the year. These five meetings last about three to four hours each. We have key staff go back to their clinic to share important details with the rest of the team. This information and education is meant to help clinics improve their methods and way of providing care to children with asthma,” she concluded. 


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