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Volume 2: Special Issue, November 2005
COMMUNITY CASE STUDY
Collaboration Between
Oregon’s Chronic Disease Programs and Medicaid to Decrease Smoking Among
Medicaid-Insured Oregonians With Asthma
R. David Rebanal, MPH, Richard Leman, MD
Suggested citation for this article: Rebanal RD, Leman R.
Collaboration between Oregon’s chronic disease programs and Medicaid to
decrease smoking among Medicaid-insured Oregonians with asthma. Prev
Chronic Dis [serial online] 2005 Nov [date cited]. Available from:
URL: http://www.cdc.gov/pcd/issues/2005/
nov/05_0083.htm.
PEER REVIEWED
Abstract
Background
Environmental tobacco smoke is a leading environmental asthma trigger and
has been linked to the development of asthma in children and adults. Smoking
cessation and reduced exposure to secondhand tobacco smoke are key components
of asthma management. We describe a partnership involving two state agencies and
14 health plans; the goal of the partnership was to decrease smoking and
exposure to environmental tobacco smoke among
Medicaid-insured Oregonians with asthma.
Context
Oregon’s asthma rate is higher than that of the national population, and
approximately one third of Oregonians with asthma smoke. The Health Promotion
and Chronic Disease Prevention Program (HPCDP) in the Oregon Department of
Human Services has collaborated with the Office of Medical Assistance Programs
(OMAP) to promote preventive care at the population level.
Methods
Two HPCDP programs — the Oregon Asthma Program and the Oregon Tobacco
Prevention and Education Program — worked with OMAP to launch the statewide
Asthma–Tobacco Integration Project in 2003. A primary focus of the project is
the development of partnerships among health plans, health care providers, and
large health care organizations to integrate asthma management and smoking
control through systems innovations and provider education. OMAP and its
participating health plans also decided to focus cessation efforts on its
members with chronic diseases. In addition, HPCDP has collaborated with OMAP
to distribute educational tools and information about tobacco’s impact on
asthma morbidity to Oregon’s health care providers who serve
low-income Oregonians.
Consequences
The partnership between OMAP and HPCDP program staff members has allowed
them to discuss problems, leverage resources, and obtain support for many
public health initiatives. In addition, OMAP–HPCDP collaboration on
educational workshops and outreach to health care providers has helped
convince quality improvement specialists and administrators about the
importance of addressing smoking among patients with asthma. The Asthma–Tobacco
Integration Project has also led to formative research aimed at increasing
community involvement in promoting tobacco-free environments.
Interpretation
Collaboration between HPCDP and OMAP has been an important factor in Oregon’s
successful smoking cessation efforts in general and in recent efforts to
address tobacco use among Oregonians with asthma.
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Background
Asthma is one of the most common chronic diseases in the United States and
has a major impact on the quality of life of the individuals who have it, as
well as on their families, their friends, and society as a whole. Although no
cure for asthma exists, it can be controlled with high-quality medical care and a
good self-management plan, including awareness of asthma triggers and how to
avoid them. Environmental tobacco smoke is a leading environmental asthma
trigger and has been linked to the development of asthma in children and
adults (1,2). Among people with asthma, cigarette smoking decreases lung
functioning, increases the risk for asthma-related hospital admissions,
increases asthma-related health care use, and increases the risk of death from
asthma (3,4). Cigarette smoking has also been associated with an impaired
therapeutic response to corticosteroids among people with chronic asthma (5).
Smoking cessation and reduced exposure to secondhand tobacco smoke are key
components of asthma management.
Many state Medicaid programs shifted from fee-for-service systems to
predominantly managed care systems in the 1990s, which presented unique
opportunities to improve the public’s health by integrating disease
prevention and public health goals into the health care system (6). In many
situations, managed care led to increased monitoring of quality of care and in
some systems made reimbursement dependent on performance (7). The Centers for
Disease Control and Prevention (CDC) recognized the potential role of managed
care in implementing population-level disease prevention activities. The CDC
recommended that public health agencies develop partnerships with Medicaid
programs to identify cost-effective preventive services for Medicaid
populations and hold managed care plans accountable for the delivery of these
services (8,9).
We describe a partnership involving two state agencies and 14 health plans.
The goal of the partnership was to decrease smoking and exposure to
environmental tobacco smoke among Oregonians with
asthma who had Medicaid coverage.
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Context
Asthma and smoking among Medicaid-insured individuals
In Oregon, 9.2% of the adult population has asthma, higher than the
national rate of 7.5% (10,11). Approximately 7.3% of Oregon children have
asthma, and approximately 2500 asthma-related hospitalizations occur in Oregon
each year. Almost 12% of the state’s population lives on an income less than
the poverty threshold, and 442,000 Oregonians (13%) qualify for Medicaid
(12). Among Oregon’s population insured by Medicaid, approximately 17% of
adults report having asthma (13).
Despite the solid evidence that tobacco smoke is detrimental to the health
of people with asthma, data show that 31% of Oregon adults with asthma smoke
cigarettes, whereas 23% of Oregon adults without asthma
smoke cigarettes (14). Among Oregonians insured by Medicaid, the rate of
smoking among adults with asthma is 43% (13). Oregonians who smoke and have
asthma report more severe asthma symptoms than Oregonians with asthma who do not
smoke. They have more activity limitations, miss more work and school, and
seek urgent medical care more often (14).
Collaboration between Oregon’s chronic disease programs and
Medicaid
In 1995, the Health Promotion and Chronic Disease Prevention Program
(HPCDP) in the Oregon Department of Human Services began working with the
Office of Medical Assistance Programs (OMAP), the agency responsible for
administering Oregon’s Medicaid programs. OMAP is the largest purchaser of
managed care in Oregon and has contracts to administer Medicaid with almost
all of the major managed care plans in Oregon. Collaboration between HPCDP and
OMAP helped the agencies promote preventive care at the population level.
Preventive care interventions developed by HPCDP and OMAP were offered
to Medicaid-insured patients in managed care settings, which in 1995
comprised 85% of the population on Medicaid and more than a third of Oregon’s
overall population. In addition, because most health care providers treated at
least some Medicaid patients and belonged to one of these major health plans,
joint OMAP–HPCDP initiatives had the potential to reach almost all of the
primary care physicians in Oregon.
In 1996, HPCDP created a staff position dedicated to exploring potential
areas of collaboration between the agency’s chronic disease programs and
major Oregon health systems. The person in this position works with health
system administrators and data personnel to develop standardized measures of
asthma care that can be compared across health systems. HPCDP
also provided partial funding for an OMAP staff position dedicated to
developing and
coordinating chronic disease prevention projects of mutual interest.
The coordinated efforts of the people in the two previously described
positions contributed to the establishment of a monthly meeting known as the
Quality Performance and Improvement Workgroup. Through this workgroup,
representatives from all the contracted Medicaid health plans collaborate on
prevention activities as part of their OMAP contract. Activities include
implementing physician trainings, developing quality performance measures and
quality improvement interventions, implementing tracking systems, developing
population-based guidelines, and developing health care policy and service
reforms. This collaboration helped catalyze a public–private partnership and
a public-health–medical partnership that led to coordinated
initiatives promoting chronic disease prevention.
One such initiative was the Tobacco Intervention Project, a partnership
involving HPCDP, OMAP, and the Tobacco-Free Coalition of Oregon (15). The
project was designed to integrate tobacco-use prevention and treatment into
routine health care. It resulted in the statewide implementation of a tobacco-cessation program by all Medicaid health plans. The program included
counseling and pharmacotherapy, as well as systematic referral to the Oregon
Tobacco Quit Line. The program also included an evaluation component so that
health plans could conduct patient satisfaction surveys and chart audits,
review relevant administrative claims data to assess the program’s effects,
and obtain data on numbers of Oregon Tobacco Quit Line calls received from their
members. Health plan staff
members conducted training and outreach programs for their physicians and
provided education and outreach programs to members through mass mailings and
other forms of communication (15). These initial collaborative projects have
led to several more recent joint OMAP–HPCDP initiatives focusing on tobacco
and asthma.
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Methods
Asthma–Tobacco Integration Project
Two HPCDP programs — the Oregon Asthma Program and the Oregon Tobacco
Prevention and Education Program — began the statewide Asthma–Tobacco
Integration Project in 2003. The goal of the project is to reduce smoking
prevalence and secondhand smoke exposure among people with asthma. A primary
focus of the project is the development of partnerships among health plans,
health care providers, and large health care organizations to integrate asthma
management and smoking control through systems innovations and provider
education.
One of the strategies for implementing the Asthma–Tobacco Integration
Project was to leverage OMAP’s investment in tobacco cessation by dedicating
HPCDP staff to support OMAP–HPCDP cooperation on asthma management projects,
a strategy that had been used previously to promote tobacco cessation.
However, because of budget constraints and a hiring freeze, HPCDP was not able
to hire new employees. Instead, the state asthma and tobacco programs
successfully applied to the CDC’s Public Health Prevention Service for a staff
member to fill this role. The program sends master’s-level, CDC-trained prevention specialists with
backgrounds in program management and epidemiology to state and local health
departments. This new staff person’s duties involve coordination not only
between HPCDP’s asthma program and tobacco program but also between HPCDP
and OMAP.
Discussions between HPCDP and OMAP produced additional tobacco-cessation
initiatives at the health systems level. Building on the infrastructure
established by the Tobacco Intervention Project, OMAP and its participating
health plans decided to target cessation efforts toward its members with
chronic diseases. In addition, the health plans in OMAP chose asthma
management as a key performance measure for the 2004–2005 fiscal year, partly
because of the existence of asthma quality performance indicators developed
through a cooperative effort between HPCDP and Oregon’s major health plans.
As part of the Asthma–Tobacco Integration Project, HPCDP and OMAP have distributed educational tools and information about
tobacco’s impact on asthma morbidity to almost all of Oregon’s health care
providers who serve low-income Oregonians. In April 2004, HPCDP distributed a
report on tobacco and asthma in the CD Summary, an epidemiology
newsletter that is produced semimonthly by the Oregon Department of Human
Services and sent to all physicians and nurse practitioners in Oregon. The
report, “Tobacco and Asthma — Enough to Take Your Breath Away,”
discussed the epidemiology of tobacco use among adults with asthma and
provided effective clinical interventions and resources for clinicians (16).
As part of another Asthma–Tobacco Integration Project
activity, HPCDP and OMAP staff collaborated to plan and conduct a statewide
workshop on asthma management issues for medical directors and quality improvement managers from Medicaid health plans. Such workshops are held twice
a year by OMAP. Topics are
selected by the OMAP Quality Performance and Improvement Workgroup
participants with the purpose of enhancing health plan initiatives. The
day-long statewide workshop was called “What Does Good Asthma Care Look Like?
The Roles of Health Plans and Providers.” Topics included best practices and
guidelines that promote high-quality asthma care and the roles of providers, health
plans, and the public health field in improving population-level asthma care.
The workshop included a speech from a national expert on health system
strategies to promote effective asthma management, as well as an expert panel
comprised of proponents of asthma-related disease registries, disease
management, and other successful asthma-related interventions at the health
systems level. The importance of systematically assessing and treating tobacco
use in clinical settings was emphasized throughout. Clinical asthma and
tobacco tools were provided to medical directors and quality improvement
coordinators.
Additional performance improvement interventions
The activities described have led to additional collaborative initiatives
to educate and empower health providers and health systems about tobacco
control and asthma care. In July 2005, 14 health plans began using an asthma
registry (created through a joint effort between HPCDP and the participating health systems) to conduct smoking-cessation activities for members
with asthma. The outreach effort involves distribution of materials
(previously tested by focus groups) to encourage members who smoke and have
asthma to quit, as well as to encourage quitting among plan members who smoke
and care for a household member with asthma. The distributed materials contain
information about the effects of tobacco smoke on people with asthma, tobacco-cessation assistance, and information about the Oregon Tobacco Quit Line.
Health plans are also promoting the Oregon Asthma Resource Bank, a clinically
accurate, patient-tested Web site that contains free, easy-to-read, and
culturally appropriate asthma education and clinical management tools
developed by asthma experts in Oregon.
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Consequences
The partnership between OMAP and HPCDP program staff members has allowed
them to discuss problems, leverage resources, and obtain support for many
public health initiatives. Despite competing priorities and limited resources,
collaboration between the two agencies has allowed each of them to accomplish
more in the area of smoking and asthma than either could have alone. Initial
partnerships promoting smoking cessation served as a model for the Asthma–Tobacco
Integration Project.
Partly as a result of the Asthma–Tobacco Integration Project and other
initial programs, 80% of the Oregon Medicaid plans have implemented
tobacco-related policy and planning, quality improvement programs,
communication initiatives, and clinical delivery systems; 50% of the dental
care organizations have done the same.
OMAP–HPCDP collaboration on educational workshops and outreach to health
care providers has helped convince quality improvement specialists and
administrators about the importance of addressing smoking among patients with
asthma. More than 60 people attended the statewide Quality Improvement
Workgroup on asthma. All 14 Medicaid health plans were represented, including
two
Medicaid dental health plans. In previous years, such workshops were attended
primarily by
quality improvement managers and medical directors, but because of OMAP’s
collaboration with HPCDP’s asthma program, the workshop’s participants
also included local public health specialists, clinicians,
pharmacists, and education specialists. Survey results from the
workshop revealed that more than 95% of the respondents either strongly agreed
or agreed that the information presented would be useful in their work.
Furthermore, 90% of the respondents appreciated the opportunity to network
with members of other health plans and public health programs, share best
practices, and learn about other interventions to improve the quality of
asthma care.
Direct distribution of Asthma–Tobacco Integration Project information to
clinicians has had positive results. After HPCDP released its CD Summary
newsletter on tobacco’s impact on people with asthma, several health plans used
information from the publication in their own health plan newsletters (16).
The Asthma–Tobacco Integration Project has also led to formative research
aimed at increasing community involvement in promoting tobacco-free
environments. HPCDP has conducted a series of focus groups among populations
with a high smoking prevalence (including various racial and ethnic groups and
low socioeconomic status groups) to identify smoking-cessation messages that
motivate and are relevant to these populations. Additional populations
considered priorities for focus groups include people with asthma who smoke
and people who smoke and have a child with asthma. Several health plans helped
recruit their members to become focus group participants. The information will
be used in targeted media campaigns and other interventions to generate
grassroots support for tobacco-cessation and prevention programs.
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Interpretation
Collaboration between HPCDP and OMAP has been an important factor in Oregon’s
successful smoking cessation efforts in general and in recent efforts to
address tobacco use among Oregonians with asthma. Initiatives have been
greatly enhanced by the staff positions that were developed to establish and
expand collaboration between HPCDP and OMAP and between HPCDP and major health
plans. In addition, the collaboration between the two agencies has been driven
by a clear common interest: for humanitarian and economic reasons, OMAP has
been motivated to decrease smoking prevalence among people with asthma and
other chronic diseases — one of the core missions of HPCDP.
The partnership between public health professionals and the administrators
and directors of Oregon’s Medicaid plans has helped maintain the Medicaid
program’s focus on chronic disease prevention. In addition, cooperation
between public health professionals and OMAP provides an extensive network
through which HPCDP can distribute educational tools and messages regarding
smoking cessation and chronic disease management to physicians and nurse
practitioners throughout Oregon. Additional process and outcome evaluations to
assess the effectiveness of recent partnership activities addressing tobacco
use and asthma are currently in progress.
The monthly OMAP Quality Performance and Improvement Workgroup has been an
effective forum through which HPCDP and OMAP can collaborate with health plans
and optimize use of resources and staff time. Public health professionals
provide expert information on epidemiology, surveillance, and health promotion
program planning. OMAP and the participating health plans serve as leaders and
provide the practical knowledge that makes it possible to translate the
objectives of an intervention such as the Asthma–Tobacco Integration Project
into functional clinical systems. In addition, OMAP encourages health plans
and health care practitioners to be accountable for promoting high-quality care.
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Acknowledgments
The authors thank Judith Van Osdol of the Oregon Medical Assistance
Programs and Nancy Clarke, Jane Moore, and Karen Main of the Health Promotion
and Chronic Disease Prevention Section, Oregon Department of Human Services,
for sharing their historical perspectives. We also acknowledge the staff of
the Oregon Asthma Program and the Oregon Tobacco Prevention and Education Program and the members
of the Quality Performance and Improvement Workgroup for their ongoing efforts
to address tobacco and asthma issues among Oregonians.
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Author Information
Corresponding Author: R. David Rebanal, MPH, Oregon Health Services,
Health Promotion and Chronic Disease Prevention Program, 800 NE Oregon St,
Suite 730, Portland, OR 97232. Telephone: 503-731-4273. E-mail:
David.Rebanal@state.or.us. Mr.
Rebanal is also affiliated with the Centers for Disease Control and
Prevention, Atlanta, Ga, and was affiliated with the Oregon Health Services,
Health Promotion and Chronic Disease Prevention Program, Portland, Ore, when
this research was conducted.
Author Affiliations: Richard Leman, MD, Oregon Department of Human
Services, Office of Disease Prevention and Epidemiology, Health Promotion and
Chronic Disease Prevention Program, Portland, Ore.
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