1. ROI Communities of Practice November 1, 2015 Public Health Finance Roundtable American Public Health Association Annual Meeting Lacy Fehrenbach, Director of Programs lfehrenbach@amchp.org | 202-266-3039

2. Who is AMCHP? AMCHP is a national resource, partner and advocate for state public health leaders and others working to improve the health of women, children, youth and families, including those with special health care needs.

3. AMCHP Mission and Vision Vision: AMCHP envisions a society where healthy children and healthy families live in healthy communities Mission: AMCHP supports state maternal and child health programs and provides national leadership on issues affecting women and children

4. Caroline Stampfel Associate Director Krista Granger Program Manager Data and Assessment Jen Farfalla Program Analyst QI and Life Course The Epidemiology and Evaluation Team

5. Why Economic Analysis? Health CarePrevention/Public Health

6. Why is AMCHP supporting ROI analysis? Strong interest of foundation and government funders Most health departments do not employ a health economist Epidemiologists in the field are not typically trained in economic analysis Epidemiology is the foundation for demonstrating return on investment

7. Economic Analysis in Public Health Cost-benefit analysis: comparison of total benefits (in monetary terms) of an investment relative to the total costs Expressed as a dollar value capturing net economic benefit Cost-effectiveness analysis: improvement investment costs divided by effectiveness Often expressed as estimated costs per quality adjusted life year (QALY) Return on investment analysis (ROI): financial gains divided by improvement investment costs; captures net financial cost to a single stakeholder (health department, health plan, hospital) Expressed as return, in dollars, for every dollar invested

8. Notes on Cost Economic Costs – Resources used up that cannot be used elsewhere (opportunity or resource cost) Financial Costs – Outlays by payers Direct – Cost of providing a service Medical; Non-medical (education, justice, etc) Indirect – Lost output for person affected Mortality; Disability Parental time cost – Direct cost by US guidelines Intangible costs - Pain and suffering; loss of well-being

9. Effectiveness First: The Role of Epi

10. Activities to Support Economic Analyses Connections to Health Economists Scott Grosse Mac McCullough Ricardo Basurto-Davila Sheri Eisert Tools and resources Roadmap LARC Examples Trainings Communities of Practice Learning Collaboratives

11. AMCHP Activities to Support ROI Return on Investment Community of Practice (CoP) Return on Investment Analytic Action Learning Collaborative (ALC) – Round 2 Who can participate: Anyone interested in calculating return on investment, including teams that have participated in AMCHP-sponsored ROI training Teams that applied to the RFA and were accepted Key elements: -SharePoint site to post and share materials with others -Participant-driven with AMCHP support -Monthly learning events -Monthly check-in with AMCHP -Peer-to-peer support with ALC teams -1-1 Expert consultation -Private SharePoint site Expected outputs: -Increased knowledge of ROI methods -Learning from peers -Completed ROI analysis -Communications product that suits needs of team, to include fact sheet, issue brief, white paper, or some other product TimeframeOngoingDeliverables by Feb 2016

12. AMCHP ALC ROI Projects – Round 1 Michigan: Preterm Birth and Home Visiting Programs New Mexico: Cesarean Delivery, Low Birth Weight and Doulas Wyoming: Preterm Birth and Nurse Family Partnership Home Visiting Program Kansas: Cost-effectiveness of the Cerebral Palsy Research Foundation Seating Clinics vs. Wichita clinic for Title V Children with Special Health Care Needs (CSHCN) program

13. Michigan Intervention: The Maternal Infant Health Program (MIHP) benefit for Medicaid-eligible mothers, care coordination and intervention services for mom + baby; 9 visits for each, additional visits for substance-exposed infants. AVERAGE COST: $51,757.76 per 100 infants Outcome: Preterm birth (<=36 weeks gestation). AVERAGE COST: $24,612.94 per infant Program Effectiveness: Comparing MIHP-enrolled mothers who gave birth in 2010 (registered before the 3 rd trimester and had at least 3 visits) to a matched sample of mothers Non-MIHP moms had 2.9 excess preterm per 100 births AVERAGE COST SAVINGS: $71,733.52 per 100 infants

14. Michigan Net Savings to Medicaid: Preterm birth costs in the control group (222*$24,612.94 = 5,464,072.68) minus program costs ($4,225,503) = $1,238,569

15. Kansas Intervention: Cerebral Palsy Research Foundation (CPRF) outreach seating clinics vs. Wichita clinic for Title V Children with Special Health Care Needs (CSHCN) program

16. Kansas Intervention: Cerebral Palsy Research Foundation (CPRF) outreach seating clinics vs. Wichita clinic for Title V CSHCN program Outreach Clinics 100% of families satisfied or very satisfied with services received 100% of families reported their child’s needs were met 50% of families reported they incurred travel expenses to attend an outreach clinic Wichita Clinic (fixed location) 73% of families very satisfied, 20% satisfied and 7% somewhat satisfied 100% of families who attended the Wichita clinic incurred travel expenses 48% Attended both fixed location PLUS one or more outreach clinic 52% All needs were able to be met in the outreach clinic Average One-way Travel Distance  45 miles to attend outreach clinic  205 miles to attend Wichita

17. Kansas 94% of families must travel to Wichita if no outreach clinic were available Average hours of work missed by parents 16 hours to attend Wichita Clinic 9 hours for outreach clinic visits Average hours of school missed by students 7 hours to attend Wichita Clinic 4 hours to attend an outreach clinic Cost benefit to the CSHCN program = $951 per outreach clinic Cost savings to families attending an outreach clinic vs. the Wichita clinic = $230 in direct cost plus 8 hours work and 3 school hours Indirect cost of lost earnings of approximately $130 per trip to Wichita relative to an outreach visit

18. Kansas

19. Challenges Making time to practice a new skill Turnover of health department staff Availability of cost data and comparison groups

20. Round 2 ALC ROI Projects Preventive dental services for children aged 0-20 FL Early identification through newborn screening for genetic disorders GA MA Project LAUNCH MA Breastfeeding / Baby Friendly MS Triple P (Positive Parenting Program) for families with children aged 0 to 16 NC

21. Thank you! AMCHP Economic Analysis Resources: http://www.amchp.org/programsandtopics/data- assessment/Pages/Return-on-Investment.aspx Staff Contact: Krista Granger, MPH Program Manager, Data & Assessment (202) 266-3057; kgranger@amchp.orgkgranger@amchp.org