Health Policy Brief (Analysis)

To: Bill de Blasio

From: Daniel V. DeMarco

Date: January 18, 2018

Re: NYC Measure for Asthma Treatment Coverage

Statement of Issue: Statistics reported by the CDC indicate that the 3rd-highest cause of hospitalizations among children <15 years old is Asthma. Additionally, they estimate that approximately $56 billion dollars/year is spent due to Asthma (including medications, office visits, hospitalizations, etc.). It is also estimated that that are >1.1 million asthmatic adults in New York State alone. Children residing in NYC were almost 2x as likely to be hospitalized for asthma as children in the United States as a whole in the calendar year 2000. Statistics from the CDC indicate the large differences in Asthma prevalence, as well as Asthma deaths, that exist between race/ethnicities. An understanding of the fact that Asthma is multifactorial (genetic and environmental) is critical to justifying altering current policies regarding care for asthmatics.

  • From years 2001 to 2009, 4.3 million people were diagnosed with Asthma in the United States. If Asthma prevalence is increasing, how long must the population suffer before some effective health policy is implemented? Policy implemented, even at the local level, can have far-reaching, trend-setting effects.
  • Individuals of lower socioeconomic status, many times living in impoverished areas with the potential for greater air pollution and poor environmental conditions (nearer to factories, etc.), account for a large portion of asthmatics. This puts undue financial and emotional strain on individuals whom may not be able to afford (with or without insurance) an office visit, asthma medications, etc. To reiterate, the environment is greatly exacerbating a medical condition that may otherwise have been controlled and now the individual suffering from the condition (patient) is required to pay for its treatment.
  • In 2012, Medicaid spent nearly $60 per member on Asthma medications. Dispensing of these medications increased 6.2%, though ER visits did not decrease. Express Scripts cites this to be the result of medication nonadherence. The issue of nonadherence comprises various barriers like Age, Health Literacy, and Complexity of Therapy.

Landscape

Factors Description
Political Depending on the approach to solving the issue at hand, political conservatives may be likely to resist this effort. For example, if the solution to this issue involves increasing taxes, it is likely to be resisted. The attitude surrounding the measure may also be one of “Why should I pay for someone else to receive healthcare?”
Social This issue disproportionately affects non-Whites. As a result, gaining momentum and support for this issue may be made more difficult, as minority race/ethnicities are affected.
Economic Solving the issue at hand will result in imminent increases in local healthcare spending, though in hopes that long-term spending would be greatly reduced. Allocating funding for a measure, such as that which will be later discussed, may be complicated by the fact that there are many other needs of New York City communities that are currently unmet (including those related to education, etc.)
Practical Coupled with the support of organizations such as the New York City Asthma Partnership (NYCAP) and various other state or community-level organizations, combatting the “Asthma Epidemic” is pragmatic. Seeing as though organizations have been pushing for action within the Public Health realm pertaining to Asthma, they will likely support a variety of potential policies targeting the issue.
Legal Legislation will likely need to be introduced depending on what approach or policy is adopted. In the event that policy aims at targeting insurers, the potential for litigation must be considered.
Quality-of-Care The solution to this issue not only encompasses a solution to quality-of-care issues, but also issues related to access to care.


Policy Options

  • Creation of a NYC Optional Asthma Registry open to all those diagnosed with Asthma located in Asthma Prevalent locations (These locations could be determined through assessment of Asthma Prevalence and other research that may be conducted by organizations such as the Department of Health, Department of Environmental Protection, etc.). This includes individuals with or without insurance. These individuals would receive a card with an ID number, similar to an insurance card, that could be used for the following related to their asthma care:

a. One annual office visit

b. One home visit to aid in identification of asthma triggers

c. No-Copayment prescriptions for pharmacologic therapy (asthma medication)

d. No-Cost Emergency Department Visits if the Diagnosis is Asthma Exacerbation

    • Advantages: Increases access to critically-needed asthma care by addressing the financial barrier. Management of these asthmatics may lead to lower asthma-related ED visits (which are costly). Rather than impose legislature on insurers, creation of an Asthma Registry may be more acceptable (through the eyes of insurers). The issue of medication nonadherence can be successfully combatted through the services provided above. For example, it is possible that a user interface (similar to a patient portal) could be developed specifically for the asthmatic patients where they can log on and review details related to their care like how to take their medication. In the event that they do not have access to these tools (as we mentioned, a great deal of the population affected may be suffering financially), then simple printouts or flyers distributed at the office can help patients stay in control of their asthma. Being aware of health literacy-related aspects of medication nonadherence can make them easier to identify and rectify accordingly.
    • Disadvantages: Financing this project would be costly. Potential sources for financing might include taxation (either locally, state-wide, or even on businesses). This could stir up resentment for the plan by those being taxed and possibly quash it while it is in its birthing stage. The decision of what locations are considered Asthma Prevalent, though measures could be outlined by the aforementioned organizations, may still be “grey” and leave many that require asthma care unable to attain it.
  • Creating financial incentives for private insurance companies to cover a more extensive range of asthma care services (like those mentioned above). Perhaps this can occur based on the number of members that “opt-in” to these extra services. The member themselves (patient) would not have to pay higher premiums to the insurance company, which instead would receive finances from the local government (city government).
    • Advantages: Rather than creating an Asthma Registry, this option would likely be much cheaper. It would not create as much of an “uproar” from the public because taxes would not increase too much, if at all. Additionally, insurance companies, now receiving finances from the city government, would be satisfied with this policy.
    • Disadvantages: This does not help those who remain uninsured. The question of the percentage of, or the amount, at which providers and other staff should be reimbursed for their services is up for debate. Should providers be reimbursed at a lower rate for these services (visits for Asthma care?) so as not to drive up taxes to fund such programs?
  • NYC/NYS mandate that private and public insurance companies cover the aforementioned asthma care services (one annual office visit, one home visit, no-copayment prescriptions, no-cost ED visits…). Uninsured individuals that qualify (with a diagnosis of asthma) can still sign up for an Asthma Registry-like option where they can access these services.
    • Advantages: Those with and without insurance will be covered for asthma care. Access to care increases and financial burdens decrease. This approach is a practice of “health equity,” and may serve to potentiate change in other locales or states and regarding other health conditions.
    • Disadvantages: Will likely receive a negative response from insurers who may use this to justify increasing premiums for their beneficiaries. Especially through public insurance companies, it is difficult to justify this change in only one state. For example, if Medicare patients are getting prescription asthma medications and they are completely covered in New York, why shouldn’t they be covered elsewhere? May be perceived as “over-stepping” regarding political “control” of insurance companies. Possibility of litigation.

Policy Recommendation: Evidence shows that Asthma prevalence is rising rapidly in New York City. The disproportionate manner that characterizes Asthma prevalence and the alarming numbers of children suffering all serve as “calls to action.” These particularly vulnerable populations should not suffer financially, medically, nor emotionally as a result of a condition which is exacerbated due both to their socioeconomic status and environment. There are many organizations and proponents of Asthma Awareness but there is, disgracefully, no action. It is important to be mindful that any of the aforementioned “Policy Options” will likely result in short-term costs, and to understand that costs are much easier to calculate than benefits. Of the options proposed, the first option (Asthma Registry) overwhelmingly exceeds others in scope and breadth. Individuals will be afforded the access to care that they deserve, and will not be constrained by financial barriers. This option, however, will be expensive for whomever (taxpayers, businesses, etc.) is taxed; this fact will not be ignored. The long-term benefits would include reducing ED visits related to asthma because these individuals will have better control over their condition (the issue of medication nonadherence would specifically be targeted as mentioned above). Long-term, this could save a great deal of money. Going further, it could leave more hospital beds open to (and shorten hospital wait times) more complicated medical emergencies.

Sources:

https://ephtracking.cdc.gov/showAsthmaAndEnv

https://www.cdc.gov/policy/hst/statestrategies/asthma/index.html

https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/14/11/30/reducing-the-rising-rates-of-asthma

https://www.health.ny.gov/diseases/asthma/

Asthma Facts: Second Edition, by New York City Childhood Asthma Initiative

https://www.cdc.gov/asthma/stateprofiles/asthma_in_nys.pdf

https://www.cdc.gov/asthma/asthma_stats/insurance_coverage.htm

http://lab.express-scripts.com/lab/insights/government-programs/asthma-hits-medicaid-hardest

http://www.asthma.partners.org/NewFiles/BoFAChapter37.html

https://www.cdc.gov/vitalsigns/asthma/index.html

https://www1.nyc.gov/site/doh/providers/health-topics/asthma-provider-partners.page