Hospitals find asthma hot spots more profitable to neglect than fix

and Kaiser Health News and Capital News Service

Keyonta Parnell has had asthma most of his young life, but it wasn’t until his family moved to a 140-year-old house in southwest Baltimore two years ago that he became one of the health-care system’s frequent customers.

“I call 911 so much since I’ve been living here, they know my name,” said the 9-year-old’s mother, Darlene Summerville, who calls the emergency medical system her “best friend.”

Summerville and her family live in the worst asthma hot spot in Baltimore: Zip code 21223, where decrepit houses, rodents and bugs trigger the disease and where few community doctors work to prevent asthma emergencies.

Residents of this area visit hospitals for asthma flare-ups at more than four times the rate of people from the city’s wealthier neighborhoods, according to data analyzed by Kaiser Health News and the University of Maryland’s Capital News Service.

Baltimore paramedic crews make more asthma-related visits per capita in 21223 than anywhere else in the city, according to Fire Department records. It is the second-most-common ZIP code among patients hospitalized for asthma, which, when addressed properly, should never require emergency visits or hospitalization.

The supreme irony of the localized epidemic is that Keyonta’s Carrollton Ridge neighborhood is not far from prestigious medical centers — the University of Maryland Medical Center and Johns Hopkins, whose researchers are international experts on asthma prevention.

As nonprofits, both receive massive tax breaks for providing “community benefit,” a poorly defined federal requirement that they serve their neighborhoods. Under Maryland’s ambitious effort to control medical costs, both are supposed to try to improve the health of residents outside the hospital and prevent admissions.

But like hospitals across the country, the institutions have done little to address the root causes of asthma. The incentives of the health-care payment system have long made it far more lucrative to treat severe, dangerous asthma attacks than to prevent them.

Hopkins, UMMC and other hospitals collected $84 million over the three years ending in 2015 to treat acutely ill Baltimore asthma patients as inpatients or in emergency rooms, according to an analysis of statewide hospital data. Hopkins and a sister hospital received $31 million of that.

Executives at Hopkins and UMMC acknowledge that they should do more about asthma in the community but note that there are many competing problems: diabetes, drug overdoses, infant mortality and mental illness among the homeless.

Science has shown it’s relatively easy and inexpensive to reduce asthma attacks: Remove rodents, carpets, bugs, cigarette smoke and other triggers. Deploy community doctors to prescribe preventive medicine and health workers to teach patients to use it.

Ben Carson, secretary of the Department of Housing and Urban Development, who saw hundreds of asthmatic children from low-income Baltimore during his decades as a Hopkins neurosurgeon, said that the research on asthma triggers is unequivocal.

“It’s the environment — the moist environments that encourage the mold, the ticks, the fleas, the mice, the roaches,” he said in an interview.

As the leader of HUD, he says he favors reducing asthma risks in public housing as a way of cutting expensive hospital visits. The agency is discussing ways to finance pest removal, moisture control and other remediation in places asthma patients live, a HUD spokesman said.

“The cost of not taking care of people is probably greater than the cost of taking care of them” by removing triggers, said Carson, adding, “It depends on whether you take the short-term view or the long-term view.”

The long view

Asthma is the most common childhood medical condition, with rates 50 percent higher in families below the poverty line, who often live in run-down homes, than among kids in wealthier households. The disease causes nearly half a million hospital admissions a year in the United States, about 2 million visits to the emergency room and thousands of deaths annually.

That drives the total annual cost of asthma care, including medicine and office visits, to well over $50 billion.

Keyonta lives in a two-bedroom rowhouse on the 1900 block of Lemmon St., which some residents call the “Forgetabout Neighborhood,” about a mile from UMMC and three miles from Hopkins.

It is a multi­racial community where the average household income of $38,911 is lower than in all but two other Zip codes in Maryland.

To uncover the impact of asthma, Kaiser Health News and Capital News Service analyzed every Maryland inpatient and emergency room case over more than three years through a special agreement with the state commission that sets hospital rates and collects such data. The records did not include identifying personal information.

For each emergency room visit to treat Baltimore residents for asthma, according to the data, hospitals were paid $871, on average. For each inpatient case, the average revenue was $8,698. The 50 most expensive patients, each of whom visited the hospital at least 10 times, accounted for $6.1 million collected by the hospitals between 2013 and 2015.

Hopkins’s own research shows that shifting dollars from hospitals to Lemmon Street and other asthma hot spots could more than pay for itself. Half the cost of one admission — a few thousand dollars — could buy air purifiers, pest control, visits by community health workers and other measures proven to slash asthma attacks and hospital visits by frequent users.

“We love” these ideas, and “we think it’s the right thing to do,” said Patricia Brown, a senior vice president at Hopkins in charge of managed care and population health. “We know who these people are. . . . This is doable, and somebody should do it.”

But converting ideas to action hasn’t happened at Hopkins or much of anywhere else.

The close-up view

Half of the 32 rowhouses on Summerville’s block are boarded up. Late last year at least 10 people on the block had asthma, according to interviews with residents.

All three of Summerville’s kids have asthma. Before moving to Lemmon Street two years ago, she remembered, Keyonta’s asthma attacks rarely required medical attention.

But the Lemmon Street house contained a clinical catalogue of asthma triggers. The moldy basement has a dirt floor. Piles of garbage in nearby vacant lots draw vermin: mice, which are one of the worst asthma triggers, along with rats. Summerville kept a census of invading insects: gnats, flies, spiders, ants, grasshoppers, “little teeny black bugs.”

Often she smokes inside the house.

The state hospital data show that about 25 Marylanders die annually from acute asthma, their airways so constricted and blocked by mucus that they suffocate.

Keyonta missed dozens of school days last year because of his illness, staying home so often that Summerville had to quit her cooking job to care for him. Without that income, the family nearly got evicted last fall and again in January. The rent is $750.

About a third of Baltimore high school students report they have had asthma, causing frequent absences and missed learning, said Dr. Leana Wen, Baltimore’s health commissioner.

With numbers like that, West Baltimore’s primary-care clinics, which treat a wide range of illnesses, are insufficient, as is the city health department’s asthma program, whose three employees visit homes of asthmatic children to demonstrate how to take medication and reduce triggers.

The program, which an analysis by Wen’s office showed cut asthma symptoms by 89 percent, “is chronically underfunded,” she said. “We’re serving 200 children [a year,] and there are thousands that we could expand the program to.”

We’re a business’

The federal government paid for $1.3 billion in asthma-related research over the past decade, of which $205 million went to Hopkins, records show. The money supports basic science as well as many studies showing that modest investments in community care and home remediation can improve lives and save money.

“Getting health care providers to pay for home-based interventions is going to be necessary if we want to make a dent in the asthma problem,” said Patrick Breysse, a former Hopkins official, who as director of the National Center for Environmental Health at the Centers for Disease Control and Prevention is one of the country’s top public health officials.

Other factors can trigger asthma: outdoor air pollution and pollen, in particular. But eliminating home-based triggers could reduce asthma flare-ups by 44 percent, one study showed.

Perhaps no better place exists to try community asthma prevention than Maryland. By guaranteeing hospitals’ revenue each year, the state’s unique rate-setting system encourages them to cut admissions with preventive care, policy authorities say.

But Hopkins, UMMC and their corporate parents, whose four main Baltimore hospitals together collect some $5 billion in revenue a year, have so far limited their community asthma prevention to small, often temporary efforts, often financed by somebody else’s money.

UMMC’s Breathmobile program, which visits Baltimore schools dispensing asthma treatment and education, depends on outside grants and easily could be expanded with the proper resources, said its medical director, Mary Bollinger.

“The need is there, absolutely,” she said.

Hopkins runs Camp Superkids, a week-long, sleep-away summer session for children with asthma that costs participants $400, although it awards scholarships to low-income families. It’s also conducting yet another study — testing referral to follow-up care for emergency-room asthma patients.

But no hospital has invested substantially in home remediation to eliminate triggers, a proven strategy supported by the HUD secretary and promoted by Green and Healthy Homes Initiative, a Baltimore nonprofit that works to reduce asthma and lead poisoning.

“We either go forward to do what has been empirically shown to work or we continue to bury our heads in the sand and kids will continue to go to the hospital instead of the classroom,” said Ruth Ann Norton, the nonprofit’s CEO.

Hopkins and UMMC say they do plenty to earn their community benefit tax breaks.

“It’s always a challenge to say, ‘Where do we start first?’ ” said Dana Farrakhan, a UMMC senior vice president whose duties include community health improvement.

Among other initiatives, UMMC takes credit for working with city officials to sharply reduce infant mortality by working with expectant mothers. A new outpatient center will include health workers to help people reduce home asthma triggers, Farrakhan said.

Hopkins officials point to their health fairs and charity care as well as work in school and neighborhood clinics to help ­low-income families prevent asthma attacks.

“What we do is perhaps not sufficiently focused,” Hopkins’ Brown said. At the same time, “we have to have revenue,” she said. “We’re a business.”

After months of waiting, Summerville considered herself lucky to get an appointment with the city health department’s asthma program.

One of its workers came to the house late last year, bearing mousetraps and mattress and pillow covers to control mites and other triggers. She helped force Summerville’s landlord to fix holes in the ceiling and floor.

She urged Summerville to stop smoking inside and gave medication lessons, which uncovered that Summerville had mixed up a preventive inhaler with the medicine used for Keyonta’s flaring symptoms.

“The asthma lady taught me what I needed to know to keep them healthy,” Summerville said of her family. That was late in 2016. Since then, Summerville said last month, she hasn’t needed her emergency medical friends.

Naema Ahmed, Douglas Birch, Helen Lyons and Talia Richman contributed to this report.

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