HMO gives its doctors a D for asthma management

Steps taken promptly to improve care

Question: What happens when a major health care provider learns its primary care physicians are, frankly, doing a lousy job of following the guidelines for asthma management?

Answer: A lot.

Health Net, California’s second largest health plan, with 1.3 million members in California alone, released a ground-breaking report card on itself in early December.

In what is believed to be the first chronic disease-specific report card, the HMO found a disturbing bottom line:

• Only 72% of Health Net’s patients with severe asthma reported having a steroid inhaler and, of those, only 54% used it daily.

• In addition, only 26% of patients with severe asthma reported having a peak flow meter and of those, only 16% of them reported using it daily.

"Although the National Asthma Education Program guidelines were published seven years ago, compliance with the guidelines was low," says Antonio P. Legorreta, MD, MPH, vice president of the quality initiatives division of Foundation Health Systems, Health Net’s parent company in Woodland Hills, CA.

In addition, older patients who had been diagnosed for a longer period of time with increasing severity of the disease under treatment by a specialist were more likely to be using inhaled steroids daily. Those who were under the care of specialists had better outcomes than those seeing primary care physicians.

Those least likely to be using inhaled steroids were African-American patients, which resulted in more emergency room visits and hospital admissions for asthma.

Interestingly, Legorreta says, researchers discovered there was an overuse of beta-agonist metered-dose inhalers, "directly related to the fact that members think bronchodilation is the backbone of asthma management." Legorreta says.

What did Health Net do with this information?

First of all, post haste, the HMO sent a peak flow meter and educational material to each of its 5,000 severe asthmatics.

Then, Legorreta says, "We identified the most severe cohort of asthmatics and we added a nurse educator call to them weekly, among other things to help them learn how and when to use the peak flow meter."

The report card wasn’t all bad. Of Health Net’s 47 medical groups, nine groups were rated above-average, 32 were rated average and six were rated below average.

The HMO’s experience does not apply exclusively to California. An eight-state study of Foundation’s patients produced "similar results," in terms of compliance with the NAEP guidelines for patients across the nation, Legorreta says. Those results are expected to be published soon.

Health Net surveyed 5,580 patients enrolled for a year or more identified through the HMO’s pharmacy database as having received prescriptions for inhaled corticosteroids, beta-agonists, or theophylline. Patients who received prescriptions for those medications who answered the questionnaire saying they were not being treated for asthma were screened out.

The questionnaire asked a series of questions about symptoms, treatment, knowledge of disease self-management, use of medical care (emergency department visits and hospital admissions), medical history, and satisfaction with care.

The questionnaire measured eight areas of function on a scale of 0 to 100:

• general health perception;

• physical functioning;

• social functioning;

• limitations due to:

— physical conditions;

— emotional conditions;

— bodily pain;

— mental health;

— energy or fatigue.

Primary care physicians are once again bearing the brunt of the responsibility for the lack of compliance.

Health Net has addressed that problem by sharing the results of the survey with doctors face-to-face. Doctors are getting guidelines from Health Net as well as personal report cards showing how they compare with their peers.

In addition, the company has sent individual profiles to incorporate into the patients’ medical records that include an assessment of functional status.

The California study was published in the Archives of Internal Medicine, which was also part of Health Net’s strategy to get the attention of physicians.

"Quite honestly," Legorreta says, "if we just sent out a report in a slick folder with some charts, it probably would have wound up in the garbage. By publishing in a peer journal, we let them know this material has been scrutinized. It’s a way of getting them to read it."

Other California HMOs have had their own experiences with compliance in asthma management. and have somewhat different methods of approaching the same problem.

Mike Ralston, MD, director of quality demonstration at Kaiser-Permanente Northern California in Oakland says informal internal surveys in recent years have showed that "we had room for improvement."

While being less specific about it, Ralston says Kaiser employed a slightly different methodology from Health Net by asking providers which of the NAEP guidelines were most relevant and pushing compliance in those areas.

"We created an asthma registry and it’s based on looking at pharmacy data to see who’s had a prescription for an asthma medication, who’s had an asthma-coded visit in the medical office, who’s been in the emergency room, and hospitalization discharge codes," Ralston says.

Those patients are coded and matched to pharmacy files to see who’s not appropriately been medicated.

That list of names is linked to providers and the provider is sent a list of the patients.

"It seems to be working," Ralston says. "What our providers are really crying for is they want to do the right thing, but they need the right information to do it.

"So we send them a list of something they have preliminarily agreed to, such as, Yeah, I agree that moderate to severe asthmatics ought to be taking inhaled steroids.’ If we send them a list of the patients who are not, they say, Great, this is just what I need.’ And they’ll get the nurse to call them in and maybe just automatically get a prescription or get them into an education program."

"It’s been very successful with the providers," he adds.

Kaiser did not study use of peak flow meters, an area the NAEP says is crucial to effective asthma management. Ralston says Kaiser has the same experience at Health Net in terms of better outcomes for patients seeing specialists.

[Editor’s note: Antonio Legorreta of Foundation Health System in Woodland Hills, CA, can be reached at (818) 676-7912.]