Medi-Cal will offer unconventional treatments for asthmatics

Growing up among the dusty fields of the Central Valley, Ruby Marentes-Cabrera can’t remember a time when it wasn’t hard to breathe.

Diagnosed with asthma at an early age, the ninth grader has come to hate the pistachio trees that surround her home because the dust, pesticides and other allergens that fly from the orchards often trigger an asthma attack – even in infiltrating his home for simple tasks like vacuuming can be dangerous.

“We live so close to the fields – I breathe in dust and chemicals,” said Ruby, 14, describing bouts of coughing and wheezing subsided by puffs from her emergency inhaler or respiratory treatments from a nebulizer. “It’s getting so bad that my back hurts, my head hurts, my lungs hurt. I get sick and really have trouble breathing.”

Ruby is one of approximately 2 million low-income Californians who have health insurance coverage from Medi-Cal, the state’s Medicaid program, and has been diagnosed with asthma, a chronic and costly condition that costs California. billions dollars per year in health expenses, missed work for parents and lost school days for children.

The disease – exacerbated by air pollution and indoor threats such as harsh cleaning products, cockroach infestations, dust and mold – hits low-income communities the hardest. Medi-Cal patients accounted for half of the state’s asthma emergency and urgent care visits in 2016, even though they made up about a third of the population, according to quoted data by state health authorities.

Starting in January, California will embark on an ambitious experiment to control asthma in its most vulnerable patients. Medi-Cal will provide recipients like Ruby with unconventional home “treatments” that aren’t traditionally considered health care: removing mold, installing air purifiers and even replacing carpeting, blinds and mattresses.

these new benefits for asthma are just a small part of Governor Gavin Newsom’s sweep $6 billion initiative to transform the nation’s largest Medicaid program. initiative, known as CalAIM, will target the state’s sickest and most expensive patients and cover a range of new social services, including healthy meals delivered to homes; help with groceries, laundry and money management; and security deposits for homeless people looking for housing.

Newsom’s goal is to reduce soaring Medi-Cal spending — which reached a staggering $124 billion this fiscal year — by avoiding costly care such as emergency room visits. But state health officials acknowledge that the new asthma benefits may not save taxpayers money.

The benefits will also not be evenly distributed: since Medi-Cal managed care insurance plans have immense power to decide what new services to offer and to whom, the initiative will create a patchwork of haves and have-nots. destitute. Of the 25 participating insurance companies, 11 will offer home asthma services beginning in January in 36 of the state’s 58 counties. In these counties, some Medi-Cal beneficiaries will qualify; some don’t.

With just two weeks to go before the program launches, many insurers are working to establish networks of non-profit organizations and private contractors specializing in providing home asthma services and home repairs.

In San Bernardino and Riverside counties, for example, about 400 patients served by the Inland Empire health plan — out of nearly 1.4 million Medi-Cal plan members — will have access to asthma services over the course of of the first year, largely because the insurer has only identified an organization equipped to take on the liability.

“If we don’t do it right, this dream can turn into a nightmare,” said Alexander Fajardo, executive director of the El Sol neighborhood educational center in San Bernardino, who is negotiating a contract with the insurer.

Fajardo said El Sol was frantically preparing. While her organization has experience in asthma education, it lacks expertise in medical billing, patient confidentiality regulations, and managed care contracts.

“It’s new, so we still have to learn,” Fajardo said.

Jeanna Kendrick, senior director of care integration for the Inland Empire Health Plan, called the experience of developing new social services “probably the hardest thing we’ve ever done.” This pushes the plans into uncharted territory, she said, contracting with community organizations and teaching them how to handle medical billing, for example.

“We really need to be creative and have some breathing room because this is all new to all of us,” Kendrick said.

Jacey Cooper, director of Medicaid in California, argued earlier this year that health plans will start small but grow in capacity over the five years of the initiative. The state is offering incentive payments to help plans launch new services and has set aside $300 million for the first half of 2022 alone.

The Department of Health Services, which administers Medi-Cal, could not say how many low-income Californians will receive new at-home asthma services because they are voluntary and therefore could not predict costs. future. But Anthony Cava, spokesman for the department,quoted data showing that more than 220,000 Medi-Cal recipients have poorly controlled asthma. The state pays $200 to $350 for a typical asthma-related emergency room visit and $2,000 to $4,000 a day for a typical hospitalization, department officials said.

Agency officials could not confirm that the asthma benefits will save money, saying the costs will be equal to or lower than the costs of traditional medical treatments.

Under the program, health insurers will send contractors to homes and apartments to assess risks and educate patients about conditions that can trigger asthma attacks. Insurance executives say they will consider approving any service that could help asthma patients – from replacing ragged carpets to buying non-toxic cleaning supplies and pillow dust covers – as part of the Lifetime cap of $7,500 for each Medi-Cal beneficiary. Services will be offered to tenants and landlords.

“It’s not that someone can just say they just want a brand new $3,000 mattress,” said Dr. Takashi Wada, chief medical officer of the Inland Empire Health Plan. “But we believe that many of these asthma attacks are preventable, and by avoiding the disease you also avoid unnecessary hospital and emergency room visits.”

Fresno and Madera counties have some of the worse air quality in the state. They also have the highest rates of childhood asthma-related ER visits in California, with Imperial County bordering Mexico, according to 2019 State Public Health Data.

Ruby and her family, who live in Madera, Calif., seem like ideal candidates for state-funded asthma benefits, said Joel Ervice, associate director of Regional Asthma Management and Prevention, which lobbies for new services. Ruby and her sister Yesenia, 20, suffer from asthma and frequently visited the emergency room as children.

But as in the Inland Empire, only a small portion of asthma patients in Central Valley will initially benefit from the new services. Ruby and her family hope they will be among the lucky ones, but realize they may still have to rely on conventional treatments such as emergency inhalers – and hospital if necessary.

“I’m on my meds a lot right now – it would be nice if my asthma got better,” said Ruby, who wants to be able to play outside of her home and excel at outdoor school activities. “I struggle to run the mile at school, so being able to run would be so good for me and my health.”

CalViva Health, a major insurer serving Central Valley patients, including the Marentes-Cabrera family, has so far identified a nonprofit to provide services and is negotiating with others.

That organization, the Central California Asthma Collaborative, expects to be able to serve up to 500 people in seven counties next year. Unlike other non-profit groups that are still evaluating how to provide services, the collaboration has already identified private contractors to remove mold, install bathroom or kitchen ventilation, and provide other services, said co-director Kevin Hamilton.

CalViva Health CEO Jeffrey Nkansah said asthma is a leading cause of hospitalization among the insurer’s policyholders.

“But right now, these conversations around identifying partners to provide these asthma treatment services are fluid,” Nkansah said. “We’re still working hard to make sure we can get these services in place for January 1.”

For the Marentes-Cabreras, the relentless clouds of dust and other toxins from orchards, combined with seasonal smoke from wildfires, are the biggest problem. The particles seep into their lungs and their home, coating surfaces and encrusting carpeting they would like to replace. But they have no money.

For now, Sandra Cabrera uses non-toxic cleaning products and her daughters Ruby and Yesenia monitor their lung capacity with oxygen meters.

“I try to control what’s in the house to keep them from getting sick, cleaning a lot and using different cleaners,” Cabrera said in Spanish. “We could use help to do more, but it’s really difficult.”

This story was produced by KHNwho publishes California Healthlinean editorially independent service California Health Care Foundation.