By Brie Zeltner
CLEVELAND, Ohio -- For decades, some of Cleveland's most vulnerable children -- those with severe, chronic asthma -- have been caught in an expensive cycle of fear and frustration.
They live in substandard housing surrounded by mold, cockroaches, dust, lead and secondhand smoke. They have expensive inhalers, drugs and breathing machines, but still they suffer potentially lethal asthma attacks.
They go to the emergency room for treatment. They stay in the hospital for days. They leave with a new prescription and instructions to avoid triggers.
But they always go home. And when they do, they breathe the same bad air, their lungs spasm, and they return to the hospital.
Dr. Dorr Dearborn, a pediatric lung specialist and former director of the Mary Ann Swetland Center for Environmental Health at Case Western Reserve University, was one of the first local doctors to notice the pattern – and to see a solution that saved both suffering and money.
Dearborn and a team of doctors, public health and housing experts chose to prevent asthma attacks before they begin. They did it by helping families eliminate asthma triggers at home, preventing relapses.
Over the last 15 years, using only piecemeal government funding, they cut hospitalizations among the sickest kids by more than 50 percent.
The sickest kids make up a small portion of all children with asthma. In Ohio, they may represent about 2 percent to 4 percent of asthmatics. But every year, they cost millions of dollars to treat, and even more in lost wages for parents and missed school days for children.
Prevention requires home visits by experts. Proponents say these should be standard for kids with severe asthma, just as inhalers are. And, they say, health insurers should pay for them.
In 13 other states and communities across the country, Medicaid, which pays the bulk of the bills for these kids' care, has started to respond. In California,Massachusetts and Alabama, state Medicaid programs are already studying the cost-effectiveness and feasibility of home visits. In Fresno, an innovative "pay for success" model may soon attract investors to pay for home visits in order to share in the financial savings down the road.
And in Cleveland, there are the first signs of a partnership between the state's largest Medicaid provider, CareSource, and the people who have been pushing home visits for more than a decade.
If there's a missing ingredient, it's the support of the agency with the most clout and the largest stake in children's health: Ohio's Department of Medicaid.
A safe space to breathe
Cleveland's asthma home visit program has been using federal funding, mainly from the U.S. Department of Housing and Urban Development (HUD), to help clean up breathing hazards in homes. The program has served more than 200 households over the past 10 years.
University Hospitals Rainbow Babies & Children's Hospital doctors referred most of the kids to the program, and inspectors from local non-profit Environmental Health Watch made visits to the homes to figure out what needed to be fixed.
The program is remarkably cost-effective. Average fixes cost between $800 and $3,600 depending on the severity of the problems. The team estimates the investment yields a net savings of $5,000 per patient per year.
The team's last home visit, for example, was for a toddler with severe asthma who lives in the Lee-Harvard neighborhood with his two siblings, mother and father.
For $1,500, the program provided the family with a vacuum with a HEPA filter; a HEPA room air cleaner for the toddler's bedroom; a dehumidifier, mattress and pillow covers to cut down on dust mites; pest management for mice; and leak repairs to reduce dampness in the home.
"We really make a difference in a lot of homes," said Akbar Tyler, the healthy housing manager at Environmental Health Watch, who performs many of the home inspections and repairs. "I don't think there will be funding for many programs in the future, and I think these programs are really worthwhile."
Passing the Buck
On Tuesday April 27th, Dearborn shared his team's data with fellow pediatric lung, housing and public health experts gathered in Cleveland for the Ohio Healthy Homes and Lead Conference. As he had many times before, he walked through the arguments for home intervention.
He delivered an almost identical message to another local audience in 2012, when HUD convened its first summit on asthma in an attempt to draw attention to the positive results already achieved through the Cleveland home visit program.
Since 1999, HUD had been trying to reduce asthma by expanding its lead control program to include the cleanup of multiple housing hazards.
"Pretty quickly asthma started to be one of the main focus areas, for good reason, because there's such a strong housing component to it," said Peter Ashley, director of the Policy and Standards Division in HUD's Office of Lead Hazard Control and Healthy Homes.
Researchers studying doctor-diagnosed asthma have estimated that between 39 percent and 44 percent of asthma cases could be prevented in children and adolescents by eliminating home risk factors like pets, mold and cockroaches.
Over the years, HUD funded many local efforts to eliminate home breathing hazards across the country. Since 2000, the Cleveland and Cuyahoga County health departments, Case and Environmental Health Watch have received a steady flow of these federal grants.
But then the federal money, which began at $25 million a year nationally, dropped to $10 million in 2012.
As federal funding has dwindled, local doctors and public health officials have sought out many partners to get the work done including HUD, the Environmental Protection Agency, the Centers for Disease Control and Prevention, the state health department, and local nonprofits.
HUD doesn't want to abandon these kids, said Eric Hornbuckle, the acting director of the programs division of HUD's lead office. The office is trying to be practical about its resources, though, and its mission.
Since the 2012 Cleveland summit, HUD has sponsored three more pediatric asthma summits in cities that have started pilot programs demonstrating the potential effectiveness of home visits.
What these cities and others have learned from their experience with asthma is that you either pay on the front end for prevention, or you pay more later for treatment. Ignoring the problem is simply passing the buck.
"Failing to address asthma in the home is only shifting the burden to another federal program," Hornbuckle said. "That would be Medicaid."
Medicaid is taking notice.
A glimmer of hope
Despite the city's rich history of leadership in researching asthma prevention, Cleveland has lagged behind many other cities and states in making prevention a standard part of care for kids with severe asthma.
That may soon change. There are signs of a partnership forming between the Cleveland group and Ohio's largest Medicaid provider, CareSource. Next week, the two will meet to discuss a possible pilot program to demonstrate the strategy's cost-effectiveness.
CareSource serves about 66,000 children between the ages of 2 and 17 who have asthma. Over the past few months, it has been having "active conversations" about asthma prevention with Case's Dearborn and Dr. Heidi Gullett, a Case family physician who specializes in reducing health disparities among Medicaid recipients.
Dr. Craig Thiele, medical director at CareSource, said the Dayton-based health insurer has yet to make a formal commitment, but "we see a lot of promise in what they're doing... They had good results.
"I'm intrigued by this and I think there's an opportunity here," he said.
If CareSource and the Cleveland group were to move forward, they'd likely follow a plan like the one four New England states have been using in order to foster cooperation between Medicaid providers and doctors across the region. The New England Asthma Innovations Collaborative is funded by a Centers for Medicare and Medicaid Services (CMS) innovation grant. It's designed to evaluate the cost-effectiveness of home visits for Medicaid payers.
Over the past two years, the collaborative has conducted home visits for 1,100 children between the ages of 2 and 17 with poorly controlled asthma. So far, they've drastically reduced the number of kids with poorly controlled asthma and increased the percentage of kids whose asthma was well-controlled. In a subset of children they polled six months after the intervention, emergency medical visits dropped by more than half.
The collaborative is gathering economic data now, and has early indications from two states that the project is financially worthwhile, said Stacey Chacker, director of the Asthma Regional Council of New England.
"Everything is trending in the right direction," she said.
Chacker said that by the time the team gathers the complete evidence from claims data, it will know whether investing in home visits saves money.
"The sad thing is that a lot of these programs will fall apart due to lack of funding before we can do it," she said.
In Fresno, California, a similar collaborative is trying a different approach and also seeing early positive results.
The non-profit Central California Asthma Collaborative offers home visits to high-risk kids. If the prevention efforts show a positive return, the plan is to let investors provide the up-front financing, then share in the Medicaid savings down the line. This "pay for success" model is already used as a solution to other social ills such as homelessness and prisoner recidivism.
Rick Brush's Connecticut-based social enterprise company Collective Health is overseeing the project.
"We're seeing a very, very positive impact on health outcomes like improvement in asthma control symptoms, daily functioning and other quality of life measures," Brush said, as well as more than a 50 percent reduction in healthcare use.
The group is waiting on Medicaid claims data to confirm these self-reported early results, which come from the first 39 home interventions, he said.
He's not surprised Cleveland is considering a partnership with Medicaid to fund the home visits.
"They've been measuring outcomes for a long time, and there are significant health improvements," he said. "If you add the financial outcomes and partnering with a Medicaid provider in Ohio from the beginning of this, that's a great way to move forward."
After the April 27th Healthy Homes and Lead Conference, officials from the CDC and the Ohio Department of Health approached Dearborn to offer their support for the home visit model.
Absent from the conference were state Medicaid officials. Dearborn and his team have been gently lobbying Ohio Medicaid for an endorsement of their program for years, with little effect.
Dr. Mary Applegate, Ohio Medicaid's medical director, said the state is having some "holistic discussions" about what it takes to keep kids healthy, but its asthma strategy is based on existing state health department and CDC-funded programs. These programs promote school-based interventions and some education about home triggers, but focus on making sure kids with asthma can see a doctor and take their medications faithfully.
"What we notice in the state is that we're spending more but the health status of children in the state is actually going down," Applegate told The Plain Dealer. "So it's about a lot of things — exercise, making good personal choices, making good food choices, whether or not you smoke and drink and use drugs, and a whole number of other things — we definitely have our eye on the cultural competencies and some of the supports for some of those choices as well."
Applegate said the state is open to new ideas, but fixing housing problems would not be a solution for these kids.
"Even if you fixed all of the housing that wouldn't get rid of all the asthma," she said. "It's a much more complex problem that requires a more holistic solution."
John Corlett, the former state Medicaid director and current president of the Center for Community Solutions, understands Applegate's hesitation, to a certain extent.
"I was always mildly skeptical when people came to me to tell me they had a plan to save money that required me to spend more money," he said. "But I think there's a way to do this; it just requires some focus."
"I think there's evidence that's really clear that supporting these home interventions could reduce Medicaid expenditures."
Next week, Dearborn and his team will meet with CareSource. They are still seeking the state's endorsement, but, he said, are ready to move forward without it.
For more Cleveland area and Ohio health news and discussion, follow this reporter on Facebook @BrieZeltner