BALTIMORE 鈥 Keyonta Parnell has had asthma most of his young life, but it wasn鈥檛 until his family moved to the 140-year-old house here on Lemmon Street two years ago that he became one of the health care system鈥檚 frequent customers.
鈥淚 call 911 so much since I鈥檝e been living here, they know my name,鈥 said the 9-year-old鈥檚 mother, Darlene Summerville, who calls the emergency medical system her 鈥渂est friend.鈥
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. One mom there wields a BB gun to keep rats from her asthmatic child.
Residents of this area visit hospitals for asthma flare-ups at more than four times the rate of people from the city鈥檚 wealthier聽neighborhoods, according to data analyzed by Kaiser Health News and the University of Maryland鈥檚 Capital News Service.
The supreme irony of the localized epidemic is that Keyonta鈥檚 neighborhood in southwest Baltimore is in the shadow of prestigious medical centers 鈥 Johns Hopkins, whose researchers are international experts on asthma prevention, and the University of Maryland Medical Center.
Both receive massive tax breaks in return for providing 鈥渃ommunity benefit,鈥 a poorly defined federal requirement that they serve their neighborhoods. Under Maryland鈥檚 ambitious effort to control medical costs, both are supposed to try to improve residents鈥 health 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 perverse 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 the news organizations鈥 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鈥檚 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. 鈥淚t鈥檚 the environment 鈥 the moist environments that encourage the mold, the ticks, the fleas, the mice, the roaches,鈥 he said in an interview.
Research showing that removing household triggers reduces asthma attacks 鈥渋s unequivocal,鈥 says Ben Carson, a former Johns Hopkins neurosurgeon and now secretary of the Department of Housing and Urban Development. 鈥淭he cost of not taking care of people is probably greater than the cost of taking care of them.鈥 (Katherine Gilyard/KHN)
As the leader of HUD, he says he favors reducing asthma risks in public housing as a way of cutting expensive hospital visits.聽The agency is discussing ways to finance pest removal, moisture control and other remediation in places asthma patients live, a spokeswoman said.
鈥淭he cost of not taking care of people is probably greater than the cost of taking care of them鈥 by removing triggers, Carson said, adding, 鈥淚t depends on whether you take the short-term view or the long-term view.鈥
The Long View
Asthma is the most common childhood medical condition, with rates who often live in run-down homes, than among kids in wealthier households. The disease causes聽nearly in the United States a year,聽about and聽thousands of deaths annually.
That drives the total annual cost of asthma care,聽including medicine and office visits, .
Keyonta lives in a two-bedroom row house on the 1900 block of Lemmon Street, which some residents call the 鈥淔orgetabout Neighborhood,鈥 about a mile from UMMC and 3 miles from Hopkins.
Reporters spent months interviewing patients and parents and visiting homes in 21223, a multiracial community where the average household income of $38,911聽is lower than in all but two other ZIP codes in Maryland.
To uncover the impact of asthma, the news organizations 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. In one recent three-year period, hospitals collected $6.1 million for treating just 50 inpatients, the ones most frequently ill with asthma, each of whom visited the hospital at least 10 times.
Lemmon Street鈥檚 trash piles and vacant homes harbor rodents and insects that can set off asthma flare-ups. (Doug Kapustin for KHN)
Darlene Summerville partly blames a moldy dirt basement for triggering her children鈥檚 asthma flare-ups. (Doug Kapustin for KHN)
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 鈥 a few thousand dollars 鈥 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.
鈥淲e love鈥 these ideas, and 鈥渨e think it鈥檚 the right thing to do,鈥 said Patricia Brown, a senior vice president at Hopkins in charge of managed care and population health. 鈥淲e know who these people are. .鈥.鈥. This is doable, and somebody should do it.鈥
But converting ideas to action hasn鈥檛 happened at Hopkins or much of anywhere else.
One of the few hospitals making a substantial effort, Children鈥檚 National Health System in Washington, D.C., has found that its good work comes at a price to its bottom line.
Children鈥檚 sends asthma patients treated in the emergency room to聽 that teaches them and their families how to take medication properly and remove home triggers. The program, begun in the early 2000s, cut emergency room use and other unscheduled visits聽by those patients by 40 percent, a study showed.
While recognizing that it decreases potential revenue, hospital managers fully support the program, said Dr. Stephen Teach, the pediatrics chief who runs it.
鈥溾楢sthma visits and admissions are down again, and it鈥檚 all your fault!鈥欌 Children鈥檚 chief executive likes to tease him, Teach said. 鈥淎nd half his brain is actually serious, but the other half of his brain is celebrating the fact that the health of the children of the District of Columbia is better.鈥
I call 911 so much since I鈥檝e been living here, they know my name.
鈥淟iving with people that got asthma 鈥 it鈥檚 really scary,鈥 said Darlene Summerville, here with son Keyonta and daughter Ka-niya. (Doug Kapustin for KHN)
The Close-Up View
Half of the 32 row houses on Summerville鈥檚 block of Lemmon Street are boarded up, occupied only by the occasional heroin user. At least 10 people on the block had asthma late last year, according to interviews with residents then.
鈥淲e have mold in our house鈥 and a leaky roof, said Tracy Oates, 42, who lived across the street from Summerville. 鈥淭hat is really big trouble as far as triggering asthma.鈥
Two of her children have the disease. 鈥淚 don鈥檛 even want to stay here,鈥 she said. 鈥淚鈥檓 looking for a place.鈥
Shadawnna Fews, 30, lived with her asthmatic toddler on Stricker Street, a few blocks east. She kept a BB gun to pick off rats that doctors said can set off her son鈥檚 wheezing.
Delores Jackson, 56, who lived on Wilkens Avenue, a few blocks south of Lemmon Street, said she had been to the hospital for asthma three times in the previous month.
All three of Summerville鈥檚 kids have asthma. Before moving to Lemmon Street two years ago, she remembers, Keyonta鈥檚 asthma attacks rarely required medical attention.
But their new house contained a clinical catalog of asthma triggers.
The moldy basement has a dirt floor. Piles of garbage in nearby vacant lots draw vermin: mice, which are聽, along with rats. Summerville, 37, kept a census of invading insects: gnats, flies, spiders, ants, grasshoppers, 鈥渓ittle teeny black bugs,鈥 she laughed.
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鈥檚 health commissioner.
With numbers like that, West Baltimore鈥檚 primary care clinics, which treat a wide range of illnesses, as is the city health department鈥檚 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鈥檚 office showed cut asthma symptoms by 89 percent, 鈥渋s chronically underfunded,鈥 she said. 鈥淲e鈥檙e serving 200 children [a year], and there are thousands that we could expand the program to.鈥
鈥楾he Hospital Instead Of The Classroom鈥
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.
鈥淕etting 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,鈥 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鈥檚 top public health officials.
Other factors can trigger asthma: outdoor air pollution and pollen, in particular. But eliminating home-based triggers could ,聽one study showed.
Perhaps no better place exists to try community asthma prevention than Maryland. By guaranteeing hospitals鈥 revenue each year, the state鈥檚聽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鈥檚 money.
UMMC鈥檚 Breathmobile program, which聽visits Baltimore schools dispensing asthma treatment and education, depends on outside grants and could easily be expanded with the proper resources, said its medical director, Dr. Mary Bollinger.聽鈥淭he need is there, absolutely,鈥 she said.
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.
鈥淲e 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,鈥 said Ruth Ann Norton, the nonprofit鈥檚 chief executive.
Hopkins and UMMC say they do plenty to earn their community benefit tax breaks.
鈥淚t鈥檚 always a challenge to say, 鈥榃here do we start first?鈥欌 said Dana Farrakhan, a senior vice president at UMMC whose duties include community health improvement.
Among other initiatives, UMMC聽takes credit for working with city officials聽to sharply reduce infant mortality by working with expectant mothers. The organization鈥檚 planned outpatient center will include health workers to help people reduce home asthma triggers, Farrakhan said.
鈥淲hat we do is perhaps not sufficiently focused,鈥 Brown of Hopkins said. At the same time, 鈥渨e have to have revenue,鈥 she said. 鈥淲e鈥檙e a business.鈥
After months of waiting, Summerville considered herself lucky to get an appointment with the city health department鈥檚 asthma program.
One of its聽health workers came to the house late last year. She supplied mousetraps and mattress and pillow covers to control mites and other triggers. She helped force Summerville鈥檚 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鈥檚 flaring symptoms.
鈥淭he asthma lady taught me what I needed to know to keep them healthy,鈥 Summerville聽said of her family.
That was late in 2016. Since then, Summerville said last month, she hasn鈥檛 called an ambulance.
METHODOLOGY:
Kaiser Health News and the University of Maryland鈥檚 Capital News Service obtained data held by the Maryland Health Services Cost Review Commission on every hospital inpatient and emergency room case in the state from mid-2012 to mid-2016 鈥 some 10 million cases. The anonymized data did not include identifying personal information.
The news organizations measured asthma costs by calculating total charges for cases in which asthma was the principal diagnosis. Maryland鈥檚 hospital rate-setting system ensures that such listed charges are very close to equaling the payments collected.
To determine asthma prevalence, reporters calculated the per capita rate of hospital visits with asthma as a principal diagnosis 鈥 a method frequently used by health departments and researchers. This may exaggerate asthma prevalence in low-income ZIP codes such as 21223, because of those communities鈥 tendency to use hospital services at greater rates.
However, the data also point to high asthma rates in 21223 and other low-income Baltimore communities 鈥 for example, asthma prevalence within the population of all hospital patients in a ZIP code.
黑料吃瓜网 News鈥 coverage of health disparities in east Baltimore is supported by .