There’s a connection between one’s home environment and asthma. An array of home-related factors can trigger or worsen asthma: pests such as cockroaches and mice can cause allergic reactions, and secondhand smoke, air pollution, and mold can make it worse. In New York City, children with asthma who are exposed to pests are three times more likely to be hospitalized, and they account for more than two-thirds of asthma-related rehospitalizations annually, according to the city’s Department of Health and Mental Hygiene (DOHMH).
The department recently launched a pilot project to zero in on pest-related pediatric asthma by delivering comprehensive pest management to patients’ homes—and tapping a group of Medicaid health insurers to fund it, even though such nonmedical interventions aren’t typically covered. If the three-year Medicaid Together Improving Asthma Program pilot succeeds in reducing repeat hospitalizations, the insurers should reap returns in the form of direct health care cost savings—but if not, a $1.2 million fund is in place to mitigate any losses.
“The environment in which a person lives directly affects their health,” says DOHMH project manager Beatrice Mauger, launch lead for Medicaid Together. “Our hope is to have a win-win for the health care sector and their clients. That can be achieved if this model shows the health care sector that investing in housing-based improvements can generate sustainable financial benefits.”
Over the years, other programs have worked more generally to tackle home health hazards that could exacerbate asthma, such as the U.S. Department of Housing and Urban Development’s Healthy Homes Program and the National Institute of Food and Agriculture’s Healthy Homes Partnership. At Boston Medical Center, building in better asthma-trigger screening and outreach has reduced emergency room visits for acute asthma care. And in recent years, Medicaid insurers have been tapped to help finance affordable housing construction. But the Medicaid Together project is innovative in the way it harnesses the spending power of health insurers upfront to achieve not only health improvements, but measurable and sustainable health care cost savings.
[RELATED ARTICLE: Why Organizations Should Invest in Home Repairs to Improve Health]
Launched in September 2021, the pilot is a complex, collaborative operation overseen by DOHMH and involving multiple hospitals and Medicaid managed care organizations (MCOs) and a community-based nonprofit.
Here’s how it works: Participating hospitals (seven so far, and rising) implement new screening questions to identify young patients whose asthma flare-ups may be related to pests at home and who are insured by one of the participating MCOs. When such a patient comes in, the hospital connects the family to the nonprofit CABS Health Network, which functions as a single point of contact to both deploy pest management services to the patient’s home and to contact the patient’s health plan. CABS pays for the services and is reimbursed by the insurer. The insurer then continues engaging the family with additional case management.
The pilot will run for three years and be followed by a two-year evaluation. DOHMH will collect and analyze the data.
The five participating insurers together cover 87 percent of New York City’s Medicaid-insured children, and their contribution to Medicaid Together is proportional to their share of members. The idea is that if this carefully targeted comprehensive pest treatment, which costs about $1,000, successfully reduces repeat hospitalizations, which cost about $6,000 on average, according to DOHMH, it will easily pay for itself. The health department expects the pilot to reach 1,200 children, translating to millions of dollars saved. Even so, the commitment involves a financial risk that insurers might be leery of taking on, so the national nonprofit Enterprise Community Partners has committed $1.2 million to guarantee profitability for the insurers if the expected cost savings aren’t realized.
Elizabeth Zeldin, director of Enterprise’s neighborhood impact program, was closely involved with the health department in devising the project. She likens the setup to pay-for-success models that shift risk from government funders to new investors, though the Medicaid Together project is a bit of a reversal.
“In a way, it’s a ‘pay for failure’ model,” she says. “But if we succeed, it’s going to be so cool—a game changer.”
[The Green and Healthy Homes Initiative recently launched a somewhat similar asthma initiative for adults and children in which a mission-based investor takes on the upfront costs of things like pest management, cleaning supplies, and even carpet removal and plumbing repairs, and is paid back by a single insurer if cost savings are realized.]
Integrated pest management with allergen reduction, referred to as IPM-AR in this project, is a less toxic, more comprehensive pest control method that includes a range of preventive and remedial measures beyond just spraying chemicals or laying traps, including using HEPA-filter vacuums, sealing up holes and cracks, and improving trash management.
“There’ve been a lot of studies throughout the country about the connection between pests and asthma, and small pilots here and there. The idea of using IPM as a health intervention has been building up momentum over many years,” Zeldin says.
In her view, the real game changer will be proving that funding these health-preserving measures results in sustainable cost savings for insurers.
“This pilot ties the actual financial beneficiary to the work. That’s where it gets exciting,” Zeldin says. “It alleviates the ‘wrong pocket’ problem that we often talk about in the health and housing space.” “Wrong pocket” describes what happens when an investment produces savings but those benefits go to entities who are not paying the cost.
For Insurers, Potential Cost Savings and Enhanced Member Relationships
Claribel Blake, program director for quality management at Empire Blue Cross Blue Shield and its designated lead for the Medicaid Together partnership, says that when DOHMH reached out to insurers in 2019, it was clear that Enterprise’s funding would provide a financial guarantee, but she suggests that Empire would be interested in such preventive investments in any case.
“Over the years, we have invested in innovative asthma prevention programs and in a community health workers program. Therefore, we were excited about this opportunity to address the social drivers that impact our asthmatic children,” Blake says. “The belief is that this project could sharply reduce repeated visits and result in cost savings. These savings will allow us to continue to invest in new and ongoing programs.”
Empire has seen two referrals of member asthma patients so far. Blake cites the positive impact of not only the pest management itself, but the resulting interaction between the health plan and its members.
“When we get the info, right away we communicate with the member to make sure they are connected to our case management services and to other resources—food, housing, assistance in making doctor appointments. It could be that we have tried to contact them before, but now that there’s been a hospitalization, parents may be more receptive to receiving services.”
The MCOs provided input on the pilot project design and on tools, ongoing processes, communications materials, and billing codes, and continue to meet regularly.
“Collaborating is a good thing,” Blake says. “Although we each have our own focus and programs, we can learn from each other and share ideas and best practices.”
Nonprofit Serves as Central Point of Intake
The Brooklyn-based CABS Health Services has been working for more than 40 years to address health inequities in disenfranchised populations and jumped at DOHMH’s spring 2020 request for proposals, says Belinda Freeman, CABS project manager and point person for the Medicaid Together program.
CABS had previously participated in a pediatric asthma self-management program through a five-year Delivery System Reform Incentive Payment program that served as a foundation for the Medicaid Together pilot.
“We saw how working on the home conditions that exacerbate asthma is really effective, so we knew we wanted to be involved,” she says. “We are the central point of intake. We receive referrals. We check a database to make sure they have active insurance with the health plan. We get consent from the guardian. We let them know the pest management will be free of charge to them.”
CABS had processed referrals of around 25 asthma patients as of early May.
And if a hospitalized asthma patient is not a member of one of the participating health plans? At this point, CABS would be unable to serve the family, Freeman says.
“What makes this program sustainable is that it’s being paid for by the insurers. There’s no mechanism for us to do this as charity cases,” she says, adding that CABS is working to find other ways to provide service for those not eligible for this program.
The Pilot Does Not Involve Landlords
The Medicaid Together program bypasses landlords. Though landlords are responsible under local law for pest control, Enterprise says there often is little incentive for them to carry it out as comprehensively as integrated pest management with allergen reduction does.
DOHMH’s Mauger notes that the health plans’ continued case management may include referring families to the city’s Healthy Homes Program, which often does involve landlords. In emailed responses to questions, Mauger explains, “If they see that there is mold in the home when conducting their home environment assessment, or if there are some structural changes in the home that were too big for the IPM vendor to address, the family’s consent would then be obtained to contact the landlord in order to have that problem fixed.”
Tips for a Successful Partnership
For other cities or organizations considering similar projects, Mauger advises, “Give yourself plenty of prep time.” Beyond the two years or so of designing the project and gathering the partners, it took DOHMH an additional year to get all the contracts signed. “With the health plans, the project entailed negotiating a contract with their legal teams, though there was buy-in for the project. This ended up being a lengthier process than expected,” Mauger said.
Blake says, “For this to be successful, a lot of communication had to take place, with our members and also between the project partners. From the beginning, it’s important to come together to review workflows, and put in place expectations and a process to review outcomes on a monthly basis, between all the entities engaged. That allows an opportunity to identify gaps and make improvements.”
Freeman suggests creating a project portal that all partners can access. “That would be helpful, working with different hospitals, and different health plans. CABS doesn’t have capacity to create a new piece of technology like that. Right now it’s a lot of spreadsheets and emails. A central portal would simplify things.”
Freeman also emphasizes the importance of ensuring that partners are all in on the project’s goals.
“One lesson learned is that for a program of integrated pest management, having a success story—even just one—showing pictures of the before-and-after, is one of the most impactful pieces to get the buy-in you need from multiple players. If there’s a way to really paint the picture, it brings everyone to the same level of understanding: ‘We are here to help this child and family be healthy.’ From there, working out the details should be easier,” she says.
Buy-in must come from the families, too. “No one wants someone to come into their home,” Freeman says. “They may be mistrusting; some don’t want to admit they have pests. But when they see how it works, it really makes a difference. You need champions at every place.”
A Gateway to Other Health and Housing Targets?
The final outcomes of Medicaid Together won’t likely be known until 2026, but Zeldin envisions this pilot sparking other initiatives—from wider asthma prevention projects to eviction prevention or aging-in-place efforts—that could be funded by health insurers.
The Medicaid Together pilot intentionally targeted one concrete intervention to one narrow subset of patients. That could be important in laying groundwork for other projects.
“If we want to demonstrate something at scale, the pilot needs to be successful,” Zeldin says. “With any sort of innovation experimentation, you start with one cohort—and then if that’s successful, you figure out ways to scale it up. It’s a matter of fiddling with the box once it’s established.”
She adds, “We want insurers to say, ‘Wow, this really worked. Let’s do it more broadly, let’s do this in other markets,’ and without needing the financial guarantee. The idea here is to prove the case.”
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This is a brilliant idea and thinking outside of “this is as good as it is going to get” mentality that pervades attitudes towards low income residents by owners of properties and other people. Such a compassionate approach for our youngsters with allergies and asthma. ( adults too especially those with disabilities and seniors). As a Public Health Inspector ( retired) I saw the need for more integrated and systems involvements to create healthy living/home environments. Of course it makes monetary sense to save overall larger amounts of monies by investing some monies up front as preventive and also to remedy the problems that can have a cascading negative effect on the people(s) living with ongoing pest issues in housing issues creating which can create even further health complications. Do not forget about the psyhclogical and social impacts too that are greatly impacted in a positive way to the children and others living in these unhealthy conditions by this creative approach you have discussed in this article. I have many examples to discuss the need for this type of approach but the following one has always remained with me. I had a particular house in my inspecting territory that would continuously get reported for various violations in need of repairs and a sporatic cockroach problem off an on. The problem was not created by the current tenants plus the landlord had stop the treatment course in between tenants. The new tenants were afraid to mention anything. It was the school social worker for one of the children living in this home who was around 11 yrs old that made the complaint to the Health Department. I responded to the complaint at this particular house which also included the complaint about cockroaches. It turned out that the 11 yr old girl had had a psychiatric break down. No matter what the family was doing to protect themselves from the infestation in their living quarters it was also invading their lives outside of the home. (Remember these newer tenants had not caused this situation in the duplex unit building.) The young 11 yr old girl had gone to school and had taken her gym bag with her. When she unzipped the bag in front of all the classmates many cockroaches came running out all over. So I am sure you can imagine the uproar. The embarraasment and humiliation must have been enormous for this young girl. Plus, I am sure the meanness and teasing of the other students became to much for her to endure. So this young 11 yr old girl ended up being hospitalized on a psychiatric unit for awhile. Of course when I inspected the flat the roaches came running out from inside the drawers and cupboards etc etc. I had been to this property in the past and had known this had been a problem before which was corrected until the treatment stopped. These new tenants had´nt known this. In front of the mother and the kids (including the 11 yr old girl) I was so angry about this occurence again and neglect by the landlord. I started scooping up the live cockroaches in my bare hands to use as evidence. All they had were some ziplock baggies which I threw quite a bunch of the cockroaches that I scooped up and could catch live into the baggie. The tenants were mortified and worried about and for me. I let them know I was okay and I washed my hands. I wanted to let the young girl and the mom know that I was going to do what ever I could as a Public Health Inspector to help them and this was not their fault and they did not deserve to be living under these conditions. I told them this collection was for evidence. Especially because I was going to be issuing citations to the landlord immediately and it may come before the judge. I also discovered that the other unit was empty so this was an infestation once again of the entire property which the landlord had neglected.
After speaking with my Health Dept Director and Social Services Manager unfortunately it was prudent along with necessary for me to declare and post the property, ” Unfit for Habitation” per our Housing Health Code. The family would have to vacate the premises immediately, move out asap because of the extreme health concerns along with also the care for the youngster´s mental health. Unfortunately they temporarily had to move to a family homeless shelter but because of the circumstances and the great social service wrap-around program the family was fortunate to receive help soon there after. Plus all their belongings were treated for removal of cockroaches, and a different rental unit was found and the young girl continued to receive counseling.
I don´t remember the cost of the citations I issued to the landlord but I can tell you they were substantial. I believe the family was reimbursed for the rent they had paid while living under those conditions since the landlord stopped the treatment and also did not notify them that there was this problem. (I believe the social service care manager referred them to Legal Aid regarding the housing rental issues). I have to tell you this was one of a few of my cases that were gut wrenching unnecessary to have rent paying people who are living under these conditions due to the purposeful disregard and neglect of a landlord. Plus, the family was low income but timely on their rent, they afraid to speak up and report this situation for fear of retaliation by the landlord. Kudos for the social worker to report this. Keep in mind that this is an example of treating for pests that not only helped the physical health but there is such a huge positive effect for the occupants on their Emotional and Mental Health. Which of course permiates throughout there whole life in the moment of selfworth, confidence and living successfully. This impact also creates a brighter future for the occupants no matter what age.
I had a similar situation like this family however it was the Grandma living with the family (they also did not contribute to the pests situation) who became overwhelmed and in great distress by the pest infestation. Part of the remedy I used was a little creative but the fact that someone was willing to help them and stand up for them made a big difference also in their situation and lives. That time I just had to write an order to remedy the problem which the landlord did. I am so moved by your agencies´ creative approach to a very unfortunate common occurance that happens daily throughout our country. I have wanted some type of compassionate and with resolute remedies services for decades. I am very humbled by the agencies´ and the people that are putting this approach into the real world even if it will take a little more effort and some investment upfront. Thank you for the article.
Oh by the way… the citations did not end up in court, just pretrial. The City Attorney was grossed out by the live captured cockroaches so the landlord had to pay part of the fines and correct the situation. About several months later I went into the cabinet were my evidence was. Those dang cockroaches were still alive. Unbelievable, but true. Yuk!
Sincerely, Cathy Kunze R.S. (WI)
I got a house rent to own an my landlord didn’t tell me he left bedbugs in the house I can’t afford to get it spray I have a handicap child an I am disabled a he also has not payed his mortgage and I been paying him 1500 a month for 9 months I don’t no what to do
Bug man told I can get help medicare help me get Reid bugs I’m on Medicare and state pension . Medicaid say I make to much. My pay SSDI 1415/pen 823 month .I don’t know if I can get help here assassistan in Texas.
I am interested in this program for one of my clients. How do I get this started?
i need help for the treatment of bed bugs i am 72 on both medicare and medicaid can not afford please
Hi James, we are so sorry to hear about the bed bugs. Shelterforce is a nonprofit media organization and publication dedicated to affordable housing, housing justice, and community development. While we cannot offer aid directly, our team and a few valuable contributors have put together a list of resources you can find here: https://shelterforce.org/need-help-finding-housing/
Need to get ride of the rouchs need a government program for help
Good morning good afternoon good evening I’m in the desperate need of assistance of all the government to help get rid of these roaches in this in this building I mean it is terrible they trying to like put me out of here
Hi Yvette, we are sorry to hear about the what you are going through with your housing. Shelterforce is a nonprofit media organization and publication dedicated to reporting on affordable housing, housing justice, and community development. While we cannot help with directly, our team and a few valuable contributors have put together a list of resources that we hope you may be able to use: https://shelterforce.org/need-help-finding-housing/
Is this in Tennessee? My 82 year old Mother is disabled and has been trying to fet rid of mice for awhile.It has caused damage to health and home.I take care of her and my niece and we can’t afford a service but it is really hurting my elderly Mother.Where can we get hel
I am a DSNP navigator for United Healthcare and my member is in desperate need of pest control can you all please help my member, Its greatly appreciated
Hi Carol, we are so sorry to hear about the struggles that your member is going through with pest control. Shelterforce is a nonprofit media organization and publication dedicated to reporting on affordable housing, housing justice, and community development. While we cannot aid directly, our team and a few valuable contributors have put together a list of resources that we hope you may be able to use: https://shelterforce.org/need-help-finding-housing/
I have a rat problem and I am a senior on a fixed income of $524 per month. I need help in getting rid of these rats
I am a married separated woman who has a roach problem for awhile now the neighbors across the street had there house taken care of they emptied the house out 7 termini cars three dumpsters ever since we have had them I’m on Medicaid no income and neither my spouse I have also corranary heart disease we cannot afford the tenement we’ve sprayed used gel nothing is working please help
Hi Angela, we are so sorry to hear about the struggles you are going through. Shelterforce is a nonprofit media organization and publication dedicated to reporting on affordable housing, housing justice, and community development. While we cannot aid directly, our team and a few valuable contributors have put together a list of resources that we hope you may be able to use: https://shelterforce.org/need-help-finding-housing/
I need help with rodents in my apartment please. I cannot sleep. My cat doesn’t eat rodents. Management only gave me a couple glue traps. They don’t care… Snakes, and mice…
Hi Karen, we are so sorry to hear about the housing struggle you are facing. Shelterforce is a nonprofit media organization dedicated to affordable housing, housing justice, and community development. While we cannot offer aid directly, our team and a few valuable contributors have put together a list of resources you can find here: https://shelterforce.org/need-help-finding-housing/
I am in desperate need of an exterminator, please. It is me and my cat. My cat doesn’t kill the mice. I don’t want him getting sick, anyways… The management put traps down. They are not working. Please help. I am on disability.
Hi Karen, we are so sorry to hear about the housing struggle you are facing. Shelterforce is a nonprofit media organization dedicated to affordable housing, housing justice, and community development. While we cannot offer aid directly, our team and a few valuable contributors have put together a list of resources you can find here: https://shelterforce.org/need-help-finding-housing/
I would like to talk to somebody about Medicare pest control