It’s not just a money-saver.
When Kaufman pediatrician C. Turner Lewis, MD, found a way to dramatically drop his allergy and asthmatic patients’ emergency department visits in less than a year, he achieved more than one of medicine’s aims. He also found a route by which patients can remarkably transform themselves and do things they could never do before.
“I had a 15-year-old male who is going to go into the service academies. And his dad said, ‘We’ve got to get him cleared of these allergies, because when he applies at age 18, he can’t have that on his record.’ He hasn’t ever been able to breathe through his nose since he was 5 years old,” Dr. Lewis told Texas Medicine.
That patient was one of dozens who began a new treatment regimen tailored to their specific allergy triggers, thanks to a pilot program Dr. Lewis developed that demonstrates a successful path to value-based care.
“He’s been on it for 10 months, and he came in just last week and he [said], ‘Dr. Lewis, I ran a mile and a half cross-country, and I was able to breathe through my nose for the first time.’ So when you see that you’re changing people’s lives, it’s not just about what is saving the health care industry [money]. You’re making a huge impact.”
Value-based care generally refers to programs or approaches that result in better care, lower costs, and higher physician payments. Examples include pay-for-performance models and shared savings or risk, in which physicians keep the money saved from meeting cost-of-care targets – and take a loss if they’re unsuccessful.
As medicine continues to transition away from fee-for-service, Dr. Lewis’ pilot program is one example of how even a small practice can make value-based principles work.
Getting data
The genesis of the pilot began with data Dr. Lewis received from the Parkland Center for Clinical Innovation (PCCI), a Dallas-based independent health care analytics organization. Children’s Medical Clinics of East Texas, which Dr. Lewis founded 26 years ago, had been using PCCI data since 2016 to improve its clinical outcomes.
PCCI pulls its data from multiple sources, including electronic health records (EHRs) and insurance claims, says Donna Persaud, MD, vice president of clinical leadership. Dr. Lewis, through PCCI, received data from Parkland Community Health Plan, Parkland Hospital’s Medicaid managed care plan.
“Those children are seen in multiple provider offices,” Dr. Persaud said. “We use their claims data to develop a predictive risk model – a strong one. Every month, the children are risked, and they’re risked into very high, high, medium, and low probability of going into the emergency room in the next 90 months. The providers that look after them, they get workable reports of who’s in that ‘very high’ and ‘high’ zone.”
In Dr. Lewis’ case, PCCI had been “monitoring the asthma medication ratio (AMR) as a predictive indicator of whether or not an asthmatic is under control and whether an asthmatic is at risk for going to the emergency room,” he said. “They were trying to improve their asthma quality management and also decrease their ER utilization.” AMR is the ratio of prescription asthma controller medications to total asthma medications; the fewer rescue inhalers people are on, for example, the higher and better their ratio will be.
For a while, Dr. Lewis says, PCCI’s data and recommendations helped Children’s Medical Clinics decrease its hospitalizations. “But then once I started identifying more asthmatics, that number went back up,” he recalled. “Parkland came back and said, ‘We have 9,000 asthmatics. What do you think would be a better way to try and manage these people?’”
Dr. Lewis said identifying triggers for asthma was key, but there was another angle to consider that he thought was even more important.
“It’s patient education and understanding, [and] parent education and understanding,” he said. “Figuring out some way to have better compliance with using the medicines and teaching the patients and parents what symptoms are asthmatic symptoms, so they can intervene ahead of time before they actually have an asthmatic attack.”
Putting electronic tools to work
Dr. Lewis also partnered with Advantage Allergy Services (AAS) to gain new capabilities beyond those of his own EHR system, such as gathering information on skin testing results, injection schedules, and asthma symptoms. AAS develops software for allergy and asthma control during immunotherapy, as well as food and environmental allergy testing. The company provided a board-certified allergist to help Dr. Lewis with his program.
“Their allergist had worked with them to help develop the software to begin with, and that software then was able to basically provide the information that my [EHR] could not provide,” Dr. Lewis said.
His office was then able to use its EHR system to generate more detailed reports, which the practice used to call patients in for more testing to identify their allergy and asthma triggers, and to identify whether those patients may be candidates for immunotherapy. The software also provided spirometry readings to measure lung function, allergic inflammation, and scores on tests that track improvement in allergy and asthma settings.
Testing revealed new candidates for immunotherapy, but also key was identifying whether patients had an allergy trigger.
“It let me know how better to customize a treatment plan for them, as well as educate them about their signs and symptoms,” Dr. Lewis said.
In just 10 months, after testing almost 500 patients, Dr. Lewis’ emergency department visits and hospitalizations for asthma collectively dropped by 75%. Also, the clinic’s standing in that key asthma metric, AMR, improved dramatically.
“In the last two months of our program we have had no emergency department visits,” Dr. Lewis said in late July. He says that’s an amazing transformation from just three years ago, when one insurer’s data showed he had 112 patients making four or more visits to the ED per year.
Constant education
Sean Puype, owner and CEO of Advantage Allergy Solutions, says using the new approach, Dr. Lewis added a significant number of new patients to his existing asthma control efforts – patients who previously hadn’t been correctly categorized or diagnosed.
“He is way above everybody else in their results [for asthma management],” Mr. Puype said.
Dr. Lewis credits patient education for much of that success. For example, a mother might tell Dr. Lewis that her child coughs whenever he exercises. But because she never sees her son struggle to breathe, she may not understand that can be a sign of asthma.
“All these things they didn’t understand were actually asthmatic symptoms,” he said. “By … making them come in for these follow-up appointments, we were able to identify these things as well as identify the triggers.”
And that success has gone beyond asthma to other allergy disorders.
Thanks to the program, for example, Dr. Lewis was able to identify a new treatment plan for a patient who had recurring hives. That patient, after previously going to the ED six times in a year, had gone eight months without a recurrence, he said.
Dr. Lewis also has met with several different organizations interested in setting up pilot programs or related initiatives, including hospital systems and health plans. Although Dr. Lewis operates his pilot on a fee-for-service basis right now, he says the program is a stepping stone to value-based care.
While there’s no hard-and-fast definition for what a value-based model is, he says his experience showed “that a practice can partner with an insurer or a health care system and achieve a reduction in overall cost for a patient population and, at the same time, improve the health of that [population].”
Dr. Persaud of PCCI says physicians’ most likely pathway into a similar program is through payers that cover most of their patients, versus being expected to create one on their own.
Predictive analytics, she said, “is really fast becoming the standard of care for population health.”
Tex Med.
2019;115(9):30-33
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