Key Health and Cost Information

Payers

Payers can continue to emphasize key components of the NAEPP in clinical practice guidelines.¹³

The use of ED and hospital claims data has been shown to improve the use of the NAEPP Guidelines have shown that those patients who have been treated according to NAEPP Guidelines recommendations have proportionately fewer ED visits and are hospitalized less often.¹⁴

Using claims data to improve asthma disease case management (for example, through directed provider training, audit, or feedback) has been shown to reduce asthma-related ED visits by up to 55% and hospitalizations by up to 56%. , Return on investment has been reported as between $2.40–$4.00 per $1.00 spent.^17,18,19

Providing ongoing NAEPP Guidelines-based medical education to primary care physicians has been shown to increase dispensing of asthma controller medication by 25%.²⁰

Providers

Studies of health care providers who follow the NAEPP Guidelines for medical management have shown that their patients had up to a 45% decrease in asthma-related ED visits, up to a 56% decrease in asthma-related hospitalizations, a 19% decrease in asthma-related outpatient visits, and up to a 59% reduction in asthma symptom days compared with non-intervention groups.^{21,22,23,24,25,26,27,28} Return on investment has been reported as $2.40–$4.00 per $1.00 spent.^29,30,31

Payers

Higher costs may result from better patient adherence to asthma medication regimens and device use, but these can be offset by savings from fewer asthma-related ED visits or hospitalizations.^41,42 Payers are providing feedback to health care providers from pharmacy claims data on controller or rescue inhaler dispensing to identify patients who frequently use rescue inhalers or do not adhere to controller medication regimens. Payers are permitting patients to obtain asthma devices such as spacers from pharmacies instead of durable medical equipment facilities, as well as reducing out-of-pocket medication costs for patients.^{44, 45,46}

Providers
Evidence-based strategies to increase adherence to asthma medication regimens include shared decision making and asthma self-management education.^46,47 Providers can continue incorporating these strategies when developing treatment plans for patients with asthma.

Payers

Intensive asthma self-management education can improve adherence to medication regimens, reduce ED visits or hospitalizations, and yield a positive return on investment.^66,67 National standards for asthma self-management education exist.^68, Physicians, nurses, respiratory therapists, certified asthma educators, and trained lay health workers, among others, can deliver asthma self-management education.⁶⁹ Certified asthma educators typically are licensed health care professionals with an additional certification in asthma education, but non-health care professionals can also become certified if they have at least 1,000 hours of relevant experience and pass the National Asthma Educator Certification Board Exam.⁷⁰

State Medicaid programs are considering several strategies for advancing reimbursement of asthma self-management education services or expanding the types of providers that can deliver such services (e.g., trained lay health workers). Strategies include “activating” relevant CPT codes (see CPT code list on page 9) and encouraging Medicaid managed care organizations through contractual agreements or quality-improvement projects to promote delivery of asthma self-management education (through trained in-house staff or contracts with external clinic or community educators).⁷¹

State Medicaid programs that are operating in a fee-for-service environment have obtained a Medicaid waiver or state plan amendment (SPA) from CMS to expand the types of providers (e.g., non-health care professionals) that can be reimbursed for providing asthma self-management education. This flexibility results from a CMS 2014 rule change that permits payment for preventive services to Medicaid/Children’s Health Insurance Program beneficiaries for services initially recommended by a physician or other licensed healthcare professional. ⁷²

Health plans are using several strategies for improving access to intensive self-management education for patients whose asthma is not well-controlled with the medical management approach outlined in the NAEPP Guidelines. These strategies include employing certified asthma educators or trained lay health workers for their asthma disease management programs, training existing staff members to become certified asthma educators, and contracting with community organizations to provide asthma self-management education services.^73,74,75,76 Medicaid managed care plans are also working with state Medicaid programs to establish individual provider rates and reimbursable billing codes.^77,78

Providers
Health care providers are investigating and considering payment mechanisms available to them to support their or their staff’s delivery of asthma self-management education. CPT codes to consider include the following:

• CPT codes for individual patient education
  • 98960 — Education and training for patient self-management by a qualified, non-physician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family); individual patient
    99401 — Patient counseling and/or risk factor reduction intervention services; individual patient follow-up visit
    99402 — Patient counseling and/or risk factor reduction intervention services; individual patient initial visit
    94664 — Inhalation instructions – Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler, or intermittent positive pressure breathing (IPPB) device
• CPT codes for group education
  • 98961 — Education and training for patient self-management by a qualified, non-physician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family); 2–4 patients, initial or follow-up visit
    98962 — Education and training for patient self-management by a qualified, non-physician healthcare professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family); 5–8 patients, initial or follow-up visit

Health care providers can investigate and consider advising patients on existing asthma self-management education programs available through local health care systems, community organizations, or patients’ health plans.^79,80

Home visits for asthma that target removal of asthma triggers and provide asthma self-management education can improve adherence to medication regimens, reduce ED visits or hospitalizations, and yield a positive return on investment, particularly in urban areas.^{93,94,95,96,97} Many non-physician health care providers, including nurses, respiratory therapists, certified asthma educators, and trained lay health workers, are utilizing asthma home visit services to reduce home asthma triggers and provide asthma self-management education.⁹⁸ Certified asthma educators typically are licensed health care professionals with an additional certification in asthma education, but non-healthcare professionals (e.g., trained lay health workers) can also become certified asthma educators if they have at least 1,000 hours of relevant experience and pass the National Asthma Educator Certification Board Exam.⁹⁹

Payers

State Medicaid programs are utilizing several strategies for advancing reimbursement of asthma self-management education services or expanding the types of providers that can deliver such services (e.g., trained lay health workers or non-health care professionals who are certified asthma educators). Strategies include encouraging Medicaid managed care organizations through contractual agreements or quality improvement projects to promote delivery of home visit services for asthma, either by trained in-house staff or contracts with external clinic or community providers.¹⁰⁰

State Medicaid programs that are operating in a fee-for-service environment have obtained a Medicaid waiver or SPA from CMS to establish reimbursement for asthma-related home visits or expand the types of providers (e.g., trained lay health workers or non-health care professionals who are certified asthma educators) that can be reimbursed for providing home visits for asthma self-management education and asthma trigger reduction. This flexibility results from a CMS 2014 rule change that permits reimbursement for preventive services to Medicaid/Children’s Health Insurance Program beneficiaries for services initially recommended by a physician or other licensed healthcare professional.

Health plans are using several strategies for expanding access to asthma home visit services or the types of providers that can deliver such services. Strategies include hiring or training staff members (health care professionals or lay health workers) to provide asthma home visit services or contracting with community organizations to provide such services.^102,103,104

Providers

Providers can continue to refer patients to asthma home visit programs available through local health care systems, community organizations, or patients’ health plans.^105,106