Mattress and mold release: Medi-Cal will offer unconventional treatments for asthmatics

MADERA, CALIFORNIA – Growing up among the dusty farm fields of the Central Valley, Ruby Marentes-Cabrera can’t remember a time when it was not difficult to breathe.

Diagnosed with asthma at a young age, the ninth grade student came to hate the pistachio trees that surround her house because the dust, pesticides and other allergens that fly from orchards often trigger an attack. asthma, even infiltrating one’s home so that simple tasks like vacuuming can be dangerous.

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

Ruby is one of more than 2 million low-income Californians who have health insurance coverage from Medi-Cal, the state’s Medicaid program, and who have been diagnosed with asthma, a chronic and costly disease. that costs California billions of dollars a year in health care costs, missed jobs 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 hardest. Medi-Cal patients accounted for half of emergency and urgent asthma-related care visits in the state in 2016, even though they made up about a third of the population, according to data cited (PDF) by state health officials.

From 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 at-home “treatments” that aren’t traditionally considered healthcare: removing mold, installing air purifiers, and even replacing rugs, blinds and mattresses. .

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These New Asthma Benefits (PDF) are just a small part of Governor Gavin Newsom’s $ 6 billion initiative to transform the nation’s largest Medicaid program. The initiative, known as CalAIM, will target the sickest and most expensive patients in the state 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 curb the surge in Medi-Cal spending – which has reached an astronomical $ 124 billion this fiscal year – by preventing expensive care such as emergency room visits. But state health officials recognize that the new benefits of asthma may not save taxpayer dollars.

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

With just two weeks of the start of the program, many insurers are scrambling to establish networks of nonprofit organizations and private contractors specializing in the provision of asthma home services and home repairs.

In San Bernardino and Riverside counties, for example, approximately 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 the first year, in large part because the insurer only identified one organization equipped to take responsibility.

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

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Fajardo said El Sol is frantically preparing. While her organization has experience in asthma training, she lacks expertise in medical billing, patient privacy regulation, and managed care contracts.

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

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

“We have to really be creative and have some leeway because this is brand 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 increase capacity over the initiative’s five years. The state offers 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 Care Services, which administers Medi-Cal, could not say how many low-income Californians will benefit from new asthma home services because they are voluntary and, therefore, cannot predict future costs. . But Anthony Cava, a spokesperson for the department, cited data (PDF) showing that more than 220,000 Medi-Cal beneficiaries 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 hospital stay, department officials said.

Agency officials could not confirm that the benefits of asthma will save money, saying the costs will be at or below the costs of traditional medical treatments.

As part of 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 purchasing non-toxic cleaning products and pillow covers, within limits. lifetime limit of $ 7,500 (PDF) for each Medi-Cal beneficiary. Services will be offered to tenants and owners.

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

Fresno and Madera counties have one of the worst air qualities in the state. They also have the highest rates of childhood asthma-related emergency room visits in California, with Imperial County on the Mexican border, according to 2019 state public health data.

Ruby and her family, who live in Madera, Calif., Appear to be ideal candidates for state-funded asthma benefits, said Joel Ervice, associate director of regional asthma management and prevention, who lobbied for the new services. Ruby and her 20-year-old sister Yesenia suffer from asthma and were frequent emergency room visits as children.

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

“I’m taking 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 be good at school activities outdoors. “I have a hard time running the mile at school, so being able to run would be so good for me and my health. “

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

That organization, the Central California Asthma Collaborative, hopes to serve up to 500 people in seven counties next year. Unlike other nonprofits who are still evaluating how to deliver 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.

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CalViva Health CEO Jeffrey Nkansah said asthma is one of the leading causes of hospitalizations among the insurer’s members.

“But at the moment, these conversations around identifying partners to provide these asthma treatment services are flowing,” Nkansah said. “We’re still working hard to make sure we can get these services up and running by January 1st.”

For the Marentes-Cabreras, the relentless clouds of dust and other toxins from the orchards, combined with the seasonal smoke from forest fires, are the biggest problem. The particles seep into their lungs and into their homes, coating surfaces and clumping together carpet they would like to replace. But they don’t have the money.

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

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

This story was produced by KHN, which publishes California Healthline, an independent editorial service of the California Health Care Foundation.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health issues. Along with policy analysis and polls, KHN is one of the three main operational programs of the KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization that provides information on health issues to the nation.

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