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An Action Agenda To Eliminate Asthma Disparities
Supplement ELIMINATING ASTHMA DISPARITIES
An Action Agenda To Eliminate Asthma Disparities* Results From the Workgroups of the National Workshop to Eliminate Asthma Disparities Kevin B. Weiss, MD
(CHEST 2007; 132:853S– 855S) Key words: action agenda; asthma; disparities; health policy; public health Abbreviations: CDC ⫽ Centers for Disease Control and Prevention; EPA ⫽ Environmental Protection Agency; NAEPP ⫽ National Asthma Education Prevention Program; SCHIP ⫽ State Children’s Health Insurance Program
objective of this workshop was to develop a T heparsimonious set of recommendations that can
serve as “next steps” for the research, clinical, policy, and consumer communities to use in reducing asthma disparities. Workshop participants met in small groups and plenary discussion sessions structured around each theme to elicit actionable tasks thought to be instrumental in eliminating asthma disparities. Each group was asked to develop up to three actions. Reported below are the priority actions for each theme, as well as a brief description of the key task related to each action. Epidemiology/Risk Factors Critical Gap It is necessary to increase the amount of local data on asthma risk factors and health-care use available to states and communities for public accountability. Using this data, efforts should be launched to improve asthma outcomes for high-risk communities.
*From the Institute for Healthcare Studies, Northwestern Feinberg School of Medicine, Chicago, IL. The author has no conflict of interest to disclose. Manuscript received December 20, 2006; revision accepted August 2, 2007. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: Kevin Weiss, MD, Institute for Healthcare Studies, 676 N St. Clair St, Suite 200, Chicago, IL 60611; e-mail: [email protected] DOI: 10.1378/chest.07-1928 www.chestjournal.org
Solution Behavioral Risk Factor Surveillance System asthma modules should be enhanced, and methods should be developed so that communities can conduct local asthma surveys to guide community action. Also, the National Committee on Quality Assurance, the Joint Commission on Accreditation of Healthcare Organizations, and other performance measure developers should be involved to improve public reporting of asthma care at a community level. Examples of areas of reporting in need of improvement include community profile data and physician performance measurement data. Community profile data can be provided by private and public insurers that use the Health Employers Data Information Set, and physician performance measurement data are collected by regional coalition efforts such as the Massachusetts Health Quality Partnership. Action Plan The Centers for Disease Control and Prevention (CDC) should work with states and city health departments to engage health plans, both public (specifically Medicaid) and private. This activity might be advanced through state-supported asthma programs or more general regional health-care quality coalitions. Genetics and Molecular Sciences Critical Gap There is a lack of policy related to the management of new information on complex traits in minority populations, with respect to ethical, legal, and social implications. Solution A policy report that attempts to define the ethics, legal, and social issues regarding the genetics of CHEST / 132 / 5 / NOVEMBER, 2007 SUPPLEMENT
853S
asthma should be developed, with particular emphasis on minority and culturally diverse populations. Action Plan The National Asthma Education Prevention Program (NAEPP) should urge the Institute of Medicine (alternatively a panel of the National Institutes of Health) to convene a working group to address these issues. Although this is a systemic issue, considering an asthma-specific set of solutions may be useful. Environmental Impact Critical Gap There is a need to generalize and improve on Inner-city Asthma Study intervention.
with health plans and with private industry firms (health insurance plans) or foundations. A set of common educational messages should be developed collaboratively around the new guidelines and integrated with public and private education efforts. A good example of this has been the recent national asthma campaign partnership between the EPA and the Ad Council. This could also be integrated into the dissemination plans for the updated asthma guidelines.
Health-Care Communications and Cultural Competency Critical Gap There is a lack of cultural competencies at many sites of asthma care.
Solution
Solution
A multisite demonstration project based on community capacity is needed to implement such a home-based program.
A “toolkit” focused on cultural competency in asthma care should be developed on the basis of upcoming asthma guidelines. The toolkit would include training modules related to known common communication issues that interfere with guidelinebased care. The toolkit would also include patient directed materials to support providers that care for culturally diverse populations.
Action Plan The CDC, US Environmental Protection Agency (EPA), Bureau of Maternal and Child Health, private foundations (such as the Robert Wood Johnson Foundation), private industry (eg, health insurance plans), and health-care payors (large employers) should be brought together for testing. Most importantly, it will be necessary to enlist Medicaid programs to move this plan forward. Behavioral Health and Family/Social Function
Action Plan Each key consumer or professional organization should begin to work with NAEPP as soon as possible in developing this toolkit.
Health-Care Access, Delivery, and Quality of Care
Critical Gap
Critical Gap
Minority and low-income populations may have low expectations for optimal asthma outcomes. Lack of community assets may negatively impact asthma outcomes.
Medicaid reimbursement is not supportive of preventive visits, self-management, and care coordination. New models of reimbursement based on newer models of long-term care delivery are needed.
Solution
Solution
A public awareness campaign for minority communities should be launched to change perceptions of optimal asthma outcomes, which are alternatively referred to as “asthma control” (eg, sleep throughout the night, active lifestyle, and patient empowerment).
Medicaid should modify reimbursement for asthma to be more responsive to evidence-based asthma management. Particularly, demonstration projects on new models of long-term care delivery are needed.
Action Plan
Action Plan
Consumer organizations and professional organizations concerned with asthma control need to cooperate
The NAEPP should convene leadership from several state Medicaid programs along with key asthma
854S
Eliminating Asthma Disparities
stakeholders to forge a partnership. The primary purpose of this partnership will be to develop plans for 1115 waivers (or the equivalent) to demonstrate new models of care. Ideally, this will happen in most of the states. Role of Private Insurance and Medicaid/ State Children’s Health Insurance Program, and Safety Net Care Providers Critical Gap Care for children in near poverty by means of State Children’s Health Insurance Program (SCHIP) programs and private insurers needs to be addressed more effectively.
Action Plan Program directors of relevant asthma programs should convene with the CDC, the EPA, leadership from a couple of State Health Departments, state social services programs (eg, the Department of Labor and Department of Education), and community leadership from high-risk inner-city neighborhoods. Testable models for community empowerment with respect to asthma should be developed, and public health or private funds to test models should be sought.
State and Local Policy Critical Gap
Solution SCHIP programs in 2007 should be reauthorized and expanded to provide accessible, affordable, quality asthma care and support for self-management training. This may require working with state policy leadership for reauthorization. Also, it will require working with health benefit managers to develop best practices in health benefit design for asthma care, particularly care for minority populations and persons of lower socioeconomic status. Action Plan Consumer groups focused on asthma and professional groups concerned with children with asthma should begin working to educate key members of health-care plan leadership. Partners in this effort might include state Medicaid programs or other SCHIP service providers. Inner-city Asthma and the Role of the Community Critical Gap There is a lack of community infrastructure, trust, and empowerment with respect to asthma-care issues. Solution Asthma “chronic care empowerment zones” should be developed.
www.chestjournal.org
Health plans vary in their benefit designs in ways that may negatively impact medication access and adherence, continuity of care, and preventative care, therefore creating barriers to access of specialty services. This variability in benefit design creates confusion for families with asthma, particularly vulnerable populations who are underinsured. Solution State-based legislation or policy that can be used to improve asthma-related health benefits for insured persons should be promoted. Action Plan In collaboration with other voluntary health organizations, leading insurers, state Medicaid program directors, and the American Lung Association should be enlisted to draft a series of model state bills to be introduced to improve asthma care in targeted communities. In addition, voluntary health organizations such as the American Lung Association, the Asthma and Allergy Foundation of American, and the Allergy and Asthma Network Mothers of Asthmatics should be enlisted to work with university-based policy researchers to develop model state and local policies aimed at eliminating asthma disparities. Voluntary health organizations could then use these model policies to educate state and local governments on best practices.
CHEST / 132 / 5 / NOVEMBER, 2007 SUPPLEMENT
855S
An Action Agenda To Eliminate Asthma Disparities* Results From the Workgroups of the National Workshop to Eliminate Asthma Disparities Kevin B. Weiss, MD
(CHEST 2007; 132:853S– 855S) Key words: action agenda; asthma; disparities; health policy; public health Abbreviations: CDC ⫽ Centers for Disease Control and Prevention; EPA ⫽ Environmental Protection Agency; NAEPP ⫽ National Asthma Education Prevention Program; SCHIP ⫽ State Children’s Health Insurance Program
objective of this workshop was to develop a T heparsimonious set of recommendations that can
serve as “next steps” for the research, clinical, policy, and consumer communities to use in reducing asthma disparities. Workshop participants met in small groups and plenary discussion sessions structured around each theme to elicit actionable tasks thought to be instrumental in eliminating asthma disparities. Each group was asked to develop up to three actions. Reported below are the priority actions for each theme, as well as a brief description of the key task related to each action. Epidemiology/Risk Factors Critical Gap It is necessary to increase the amount of local data on asthma risk factors and health-care use available to states and communities for public accountability. Using this data, efforts should be launched to improve asthma outcomes for high-risk communities.
*From the Institute for Healthcare Studies, Northwestern Feinberg School of Medicine, Chicago, IL. The author has no conflict of interest to disclose. Manuscript received December 20, 2006; revision accepted August 2, 2007. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: Kevin Weiss, MD, Institute for Healthcare Studies, 676 N St. Clair St, Suite 200, Chicago, IL 60611; e-mail: [email protected] DOI: 10.1378/chest.07-1928 www.chestjournal.org
Solution Behavioral Risk Factor Surveillance System asthma modules should be enhanced, and methods should be developed so that communities can conduct local asthma surveys to guide community action. Also, the National Committee on Quality Assurance, the Joint Commission on Accreditation of Healthcare Organizations, and other performance measure developers should be involved to improve public reporting of asthma care at a community level. Examples of areas of reporting in need of improvement include community profile data and physician performance measurement data. Community profile data can be provided by private and public insurers that use the Health Employers Data Information Set, and physician performance measurement data are collected by regional coalition efforts such as the Massachusetts Health Quality Partnership. Action Plan The Centers for Disease Control and Prevention (CDC) should work with states and city health departments to engage health plans, both public (specifically Medicaid) and private. This activity might be advanced through state-supported asthma programs or more general regional health-care quality coalitions. Genetics and Molecular Sciences Critical Gap There is a lack of policy related to the management of new information on complex traits in minority populations, with respect to ethical, legal, and social implications. Solution A policy report that attempts to define the ethics, legal, and social issues regarding the genetics of CHEST / 132 / 5 / NOVEMBER, 2007 SUPPLEMENT
853S
asthma should be developed, with particular emphasis on minority and culturally diverse populations. Action Plan The National Asthma Education Prevention Program (NAEPP) should urge the Institute of Medicine (alternatively a panel of the National Institutes of Health) to convene a working group to address these issues. Although this is a systemic issue, considering an asthma-specific set of solutions may be useful. Environmental Impact Critical Gap There is a need to generalize and improve on Inner-city Asthma Study intervention.
with health plans and with private industry firms (health insurance plans) or foundations. A set of common educational messages should be developed collaboratively around the new guidelines and integrated with public and private education efforts. A good example of this has been the recent national asthma campaign partnership between the EPA and the Ad Council. This could also be integrated into the dissemination plans for the updated asthma guidelines.
Health-Care Communications and Cultural Competency Critical Gap There is a lack of cultural competencies at many sites of asthma care.
Solution
Solution
A multisite demonstration project based on community capacity is needed to implement such a home-based program.
A “toolkit” focused on cultural competency in asthma care should be developed on the basis of upcoming asthma guidelines. The toolkit would include training modules related to known common communication issues that interfere with guidelinebased care. The toolkit would also include patient directed materials to support providers that care for culturally diverse populations.
Action Plan The CDC, US Environmental Protection Agency (EPA), Bureau of Maternal and Child Health, private foundations (such as the Robert Wood Johnson Foundation), private industry (eg, health insurance plans), and health-care payors (large employers) should be brought together for testing. Most importantly, it will be necessary to enlist Medicaid programs to move this plan forward. Behavioral Health and Family/Social Function
Action Plan Each key consumer or professional organization should begin to work with NAEPP as soon as possible in developing this toolkit.
Health-Care Access, Delivery, and Quality of Care
Critical Gap
Critical Gap
Minority and low-income populations may have low expectations for optimal asthma outcomes. Lack of community assets may negatively impact asthma outcomes.
Medicaid reimbursement is not supportive of preventive visits, self-management, and care coordination. New models of reimbursement based on newer models of long-term care delivery are needed.
Solution
Solution
A public awareness campaign for minority communities should be launched to change perceptions of optimal asthma outcomes, which are alternatively referred to as “asthma control” (eg, sleep throughout the night, active lifestyle, and patient empowerment).
Medicaid should modify reimbursement for asthma to be more responsive to evidence-based asthma management. Particularly, demonstration projects on new models of long-term care delivery are needed.
Action Plan
Action Plan
Consumer organizations and professional organizations concerned with asthma control need to cooperate
The NAEPP should convene leadership from several state Medicaid programs along with key asthma
854S
Eliminating Asthma Disparities
stakeholders to forge a partnership. The primary purpose of this partnership will be to develop plans for 1115 waivers (or the equivalent) to demonstrate new models of care. Ideally, this will happen in most of the states. Role of Private Insurance and Medicaid/ State Children’s Health Insurance Program, and Safety Net Care Providers Critical Gap Care for children in near poverty by means of State Children’s Health Insurance Program (SCHIP) programs and private insurers needs to be addressed more effectively.
Action Plan Program directors of relevant asthma programs should convene with the CDC, the EPA, leadership from a couple of State Health Departments, state social services programs (eg, the Department of Labor and Department of Education), and community leadership from high-risk inner-city neighborhoods. Testable models for community empowerment with respect to asthma should be developed, and public health or private funds to test models should be sought.
State and Local Policy Critical Gap
Solution SCHIP programs in 2007 should be reauthorized and expanded to provide accessible, affordable, quality asthma care and support for self-management training. This may require working with state policy leadership for reauthorization. Also, it will require working with health benefit managers to develop best practices in health benefit design for asthma care, particularly care for minority populations and persons of lower socioeconomic status. Action Plan Consumer groups focused on asthma and professional groups concerned with children with asthma should begin working to educate key members of health-care plan leadership. Partners in this effort might include state Medicaid programs or other SCHIP service providers. Inner-city Asthma and the Role of the Community Critical Gap There is a lack of community infrastructure, trust, and empowerment with respect to asthma-care issues. Solution Asthma “chronic care empowerment zones” should be developed.
www.chestjournal.org
Health plans vary in their benefit designs in ways that may negatively impact medication access and adherence, continuity of care, and preventative care, therefore creating barriers to access of specialty services. This variability in benefit design creates confusion for families with asthma, particularly vulnerable populations who are underinsured. Solution State-based legislation or policy that can be used to improve asthma-related health benefits for insured persons should be promoted. Action Plan In collaboration with other voluntary health organizations, leading insurers, state Medicaid program directors, and the American Lung Association should be enlisted to draft a series of model state bills to be introduced to improve asthma care in targeted communities. In addition, voluntary health organizations such as the American Lung Association, the Asthma and Allergy Foundation of American, and the Allergy and Asthma Network Mothers of Asthmatics should be enlisted to work with university-based policy researchers to develop model state and local policies aimed at eliminating asthma disparities. Voluntary health organizations could then use these model policies to educate state and local governments on best practices.
CHEST / 132 / 5 / NOVEMBER, 2007 SUPPLEMENT
855S