Community Health Workers Make Cents: A return on investment analysis MHP SALUD WORKS TO UNDERSTAND THE FINANCIAL IMPACT OF COMMUNITY HEALTH WORKERS

Community Health Workers Make Cents: A return on investment analysis MHP SALUD WORKS TO UNDERSTAND THE FINANCIAL IMPACT OF COMMUNITY HEALTH WORKERS

Overview Background Literature Methods Results Conclusion Group Activity

Background

What is return on investment and why should I care?

Common Expen$ive Chronic Conditions Diabetes Costs of diagnosed diabetes increased to $245 billion in 2012 ($174 billion in 2007) Hypertension Direct medical spending to treat hypertension totaled $42.9 billion in 2010 Obesity Medical costs of obesity total $147 billion in U.S. in 2008

Where does the money go? Direct Medical Costs In-patient Out-patient Laboratory and testing Prescription treatment Increased risk for related conditions Indirect Societal Costs Value of lost work Absenteeism Presenteeism Life expentency Higher insurance premiums for individuals and employers Higher wages

Cost of avoidable hospitalizations Avoidable Hospitalizations among the general public cost an average of $10,358 per person, and $10,715 among Medicare/Medicaid enrollees. Value of annual healthinsurance benefits Based on national estimates, Medicare paid out about $11,751 per consumer, while private insurance paid out about $1,327.

What is return on investment? Total Value of Benefits ROI = Program Costs ROI > $1 ROI = $1 ROI < $1

What is return on investment? Give me Examples Your industry Your Life Your Work Often this information is not available or is not published on existing CHW programs.

Various types of return for CHWs COMMUNITY LEVEL INSTITUTIONAL LEVEL INDIVIDUAL LEVEL

Why Return on Investment (ROI)? Estimates direct financial impact Versatility and simplicity Rudimentary gauge of an investment s profitability Understandable

Why

MHP Salud 32 years of service Offices in Michigan, Texas, Florida, Ohio, Washington Technical Assistance on the CHW Model Nationwide Direct Service to Latino populations using the CHW Model in Texas, Florida, Michigan, Ohio

Our Mission MHP Salud implements Community Health Worker programs to empower underserved Latino communities and promotes the CHW model nationally as a culturally appropriate strategy to improve health.

Direct Services In 2014 Assisted over 6,500 individuals 90% Female 98% Hispanic Median Age = 39 years 70% Uninsured 25% Agriculture Work

Indirect Services In 2014 95 organizations received training and technical assistance 27 trainings on the CHW model 362 total hours

Existing Literature

What exists on ROI?

Denver/Molina Study Measuring Return on Investment of Outreach by Community Health Workers (M2006) Tracked spending on primary and specialty care, urgent care, inpatient and outpatient behavioral health care. ROI estimate of $2.28 saved per dollar spent. Costs included in the investment were limited to direct personnel costs. Not included were program development, management, or evaluation. Used in state of Massachusetts to lobby for CHW certification and inclusion in Medicaid-reimbursable activities Whitley EM, Everhart RM, and Wright RA. Measuring Return on Investment by Community Health Workers. Journal of Healthcare for the Poor and Underserved, 17 (2006):6-15.

Visual Representation Pre Intervention Intervention Post Intervention Utilization and Cost of Health Care Services Utilization and Cost of Health Care Services $1000 $500 $500 Average Savings

Community Health Access Program (CHAP) in Ohio Great example of a specific targeted outcome providing hard evidence of financial return. Not designed for ROI, but used a comparison group to demonstrate a significant reduction in the number of low-weight births. 64% reduction in low birth weight risk based on pre-existing risk factors in matched control group. Cost savings in first year of life of $3.36 for every $1 spent (community level) Long term cost savings of $5.59. Redding S, Conrey E, Porter K, Paulson J, Hughes K, Redding M. Pathways Community Care Coordination in Low Birth Weight Prevention. Maternal and Child Health Journal. 2015;19(3):643-650. doi:10.1007/s10995-014-1554-4.

Methods

CHWs Make Cents A HRSA-Funded Project Received funding to use 3 existing CHW programs to conduct retrospective ROI analysis. Will present 3 case studies, and 1 attempted Application process beginning in December 2014. Targeted FQHCs with 330g funding. Selected 3 to begin analysis by March 2015. One additional FQHC was selected in June.

A Note on Program Costs Whittier Personnel and benefits costs represented the vast majority of costs Illinois Ampla All programs included here relied fully on paid CHWs and managers, rather than mixed volunteer models. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Personnel Supplies Space Communication Travel Training Promotions Contracted Services

CASE 1: Ampla Health Patient-Centered Medical Home based in Yuba City, CA Use 14 CHWs to help with ACA enrollment over the past 2 years California uses the Covered California State Marketplace, which did expand Medicaid Over 40,000 contacts resulting in applications to cover over 11,000 individuals by 2015

Ampla Health Methods Summary Define and aggregate program outcomes of interest What and how to include Match with existing research on economic impact Community Level Impact Based on research on the link between insurance status and avoidable hospitalizations Estimated changes in healthcare utilization based on health-insurance status Individual level Impact Calculated value estimates for each enrollment outcome

Ampla Health Methods Summary Adjusted for inflation Programmatic costs were adjusted using standard inflation Medical cost inflation was adjusted for using the Medical Expenditure Panel Survey, which included medical spending information at a national level. Compared return outcomes with calculated program cost

Ampla Health Methods Summary 3500 3000 2500 2000 1500 1000 500 0 Ampla Health Enrollments by Year 2013 2014 Med-Cal Covered CA Medicare Private

Avoidable Hospitalizations Values Year 2013 2014 TOTAL Privately Insured Enrolled 598 1,225 1,823 90% Adj. 538 1,103 1,641 Expected AH Risk 18.5 18.5 18.5 30% Change 14.2 14.2 14.2 50% Change 12.3 12.3 12.3 MME** Enrolled 1,793 512 2,305 90% Adj. 1,614 461 2,075 Expected AH 59 59 59 30% Change 45.4 45.4 45.4 50% Change 39.3 39.3 39.3 Uninsured individuals have a 30-50% increased risk of avoidable hospitalizations. The change in Avoidable Hospitalization Risk was calculated separately for the general population and for Medicare/Medicaid eligible individuals (higher baseline risk)

COMMUNITY LEVEL ROI Year 2013 2014 TOTAL Privately Insured 598 1225 1823 Savings (30%) $23,801 $48,756 $72,557 Savings (50%) $34,379 $70,424 $104,803 MME* 1793 512 2305 Savings (30%) $235,427 $67,227 $302,654 Savings (50%) $340,061 $97,106 $437,167 Total Savings (30%) $259,227 $115,983 $375,210 Savings (50%) $374,440 $167,531 $541,970 Program Cost $137,043 $85,954 $222,997 ROI (30%) $1.89 $1.35 $1.68 Final ROI Ranged from 1.35 to 2.73 depending on year and 30% or 50% difference in Avoidable Hospitalization Risk ROI greater than 1.00 for all calculations ROI (50%) $2.73 $1.95 $2.43

Individual ROI Enrollment Program Medi-Cal 2013 2014 Overall Enrollments 1,736 309 2,045 Total Benefits $2,702,999 $481,121 $3,184,120 Received Medicare Enrollments 57 203 260 Total Benefits Received $602,803 $2,146,825 $2,749,629 Private Insurance Enrollments 598 1,225 1,823 Total Benefits Received $714,434 $1,463,514 $2,177,947 Overall Benefits Received Overall Program Cost $4,020,236 $4,091,460 $8,111,696 $137,043 $85,954 $222,997 Individual ROI $29.34 $47.60 $36.38 Individual benefits received ranged from $29.34 to $47.60 per dollar invested Benefits received per individual patient were higher for state and federally funded program enrollments. This is expected, as these programs generally offer assistance to at-risk populations

Ampla Health Results Overall reductions in healthcare spending: $1.68-2.43 Benefits received by target population: $36.36 (avg)

Case 2: Community Health Partnership of Illinois (CHP) CHP uses Promotoras de Salud to reach out to Hispanic migrant farmworkers near Chicago, IL. CHW-patient interactions are recorded in Electronic Medical Records (EMR) using ICD-9 codes. While many education based interactions are reported, we used blood glucose (diabetes) and blood pressure (hypertension) screenings to track patients with these outcomes Collected number of referrals for each from 2013-2014, then tracked patient outcomes.

A1C levels and blood pressure readings Several research models were used to evaluate the impact of reduced A1C percentages over a 3 years period as initial healthcare costs are often higher during the intervention, but drop steeply over a longer time period. For consistency, the impacts of blood pressure were also estimated over a 3 year period CHP Methods Outcome Count P-Value Total Patients 165 Full A1C Data 57 Initial A1C > 7.0% 21 Final A1C > 7.0 % 11 0.037 Mean A1C Change -0.53 0.048 Full BP Data 121 Initial Elevated BP (<140/90) 82 Final Elevated BP (<140/90) 15 <0.001 Mean Systolic Change -21.95 <0.001 Mean Diastolic Change -11.61 <0.001

A1C Cost Results Method 1: Tier-Cost Reduction Model Change Count Savings Error Sum Sum Error Two separate methods were used to evaluate the impact of A1C 10.0-9.0 2 1374 599 2748 1198 10.0-8.0 3 2677 1138 8031 3414 10.0-7.0 4 3050 1626 12200 6504 9.0-8.0 1 1303 539 1303 539 8.0-7.0 1 373 448 373 448 Overall $24,655 $12,103 Method 2: Overall Reduction Model Decrease Count Savings Sum 1.50 9 5700 51300 1.25 2 4600 9200 1.00 0 3600 0 Total 11 $60,500 Method one used the relative change in healthcare spending based on steps or tiers. Method 2 was based on a study which evaluated overall changes in spending for any patient with unregulated A1C. Method one showed a lower overall impact.

Hypertension Hypertension cost estimates were based on national averages among U.S. Adults. U.S. adult Hispanics averaged $981 per person treated for hypertension. Medication costs were 47.6% of this. Average annual cost saved per case resulted in about $514 per individual. Only cases with elevated Blood Pressure were included,

Method Method 1 Estimate Low Estimate High Estimate Method 2 Target Diabetic Patients 57 21 Improved Patients 32 10 3-Year Cost Savings Estimate $34,788 $17,711 $51,866 $65,643 Total Hypertension Patients 128 128 Elevated BP at Start 82 82 Elevated BP at final visit 15 15 3-Year Cost Savings Estimate $121,411 $121,411 Annual Program Cost $111,088 $111,088 3 Year ROI Estimate $1.41 $1.25 $1.56 $1.68

Community Health Partners of Illinois Results Both estimates had ROI calculations above 1.00, with the first method ranging between $1.25-1.56 and the second method estimating $1.68. These are viewed as a 3-year ROI, meaning the full impact will not be realized until this point. While only Diabetic and Hypertension related diagnoses were considered, it is likely that many other associated risk factors (i.e. weight, cholesterol, cardiovascular disease, etc.) were also positively affected.

Case 3: Whittier Street The Challenges of Weight Loss Whittier Street s program used CHWs in public housing projects to target high risk individuals for hypertension and obesity Clear target outcomes and a high-risk population were factors when selecting this program The Depression-Anxiety-Stress Survey was also a component of this program, but was not used as a part of this analysis

Whittier Street Methods Summary Outcome Time Count % Missing Mean SD Before 363 40.98% 187.99 53.25 Weight After 241 60.81% 191.32 52.85 BMI Systolic Blood Pressure Diastolic Blood Pressure Change 230 62.60% -1.47 4.53 Before 300 51.22% 32.39 9.04 After 287 53.33% 19.94 17.44 Change 170 72.36% -0.20 0.80 Before 338 45.04% 128.02 18.29 After 235 61.79% 130.70 17.81 Change 219 64.39% 0.28 17.46 Before 321 47.80% 78.88 10.96 After 218 64.55% 80.47 11.56 Change 202 67.15% 1.21 11.20 Missing Data Understanding the why of evaluation and data collection Anecdotal verses data points Open/rolling participant enrollment

Review of Outcome Measures BMI Distribution Classification BMI Range US Prevalece Group (Pre) Group (Post) % n % n % Net Change Underweight < 18.5 1.7 1 0.6 1 0.6 0 Normal 18.5-24.9 29.5 28 16.5 27 15.9-1 Overweight 25-29.9 35.7 33 19.4 35 20.6 +2 Obese 30-39.9 33.1 73 42.9 72 42.4-1 Morbidly Obese > 40 6.3 35 20.6 35 20.6 0 Little overall change in distributions of weight class

Review of Outcome Measures Biometric Outcomes from Whittier St Measure Number Pre SD Post SD Change P-value* BMI 170 33.37 8.00 33.17 7.86-0.20 0.82 Weight 230 191.51 52.32 190.04 51.53-1.47 0.78 Systolic BP 219 130.33 17.54 130.61 17.50 0.28 0.97 Diastolic BP 202 79.07 10.87 80.29 11.62 1.22 0.35 No significant changes in BMI, Blood Pressure

Whittier Street Results Weight and Blood Pressure were not sufficient to evaluate this program High number of missing values severely limited analysis Holistic focus of the classes, which also included mental health and access to health foods, made it more difficult than anticipated to hone in on quantifiable outcomes in retrospective analysis

Whittier Street Results Alternative Methods Use a control group from within the housing project to account for the extremely high-risk study population Conduct a more formal study to evaluate healthcare spending over time after participating in this program based on medical and billing records Most Importantly Involve CHWs Understand why data is important and why it helps

The Case that Wasn t: Franklin Primary Healthcare Franklin Primary Health Center is a Federally-Qualified Health Center located in Gilbertown, LA. CHWs were responsible for making and following up on patient referrals, reminding patients about upcoming appointments, and performing outreach activities related to various preventative screening services. This small program had only 2 CHWs The CHWs worked with almost all new patients, rather than a targeted subgroup Interactions were not linked to any medical records or clinical data.

Franklin Primary Healthcare Data Collection Challenges Interactions with patients were recorded anonymously, which didn t allow for follow up of patients who had seen CHWs or allow for monitoring to see which patient groups were being targeted. Several concurrent administrative changes had occurred during the previous year, making it difficult to compare aggregate outcomes among patients.

Results Evidence exists to suggest that CHW programs have a positive financial impact on the individuals and communities they serve Not all CHW programs collect sufficient evidence to estimate this impact Calculations on the programs included in this study can be replicated to allow for comparison between programs

Conclusion

Conclusions Evidence that CHW programs have a positive financial impact on the individuals and communities they serve Ampla Health: Overall reductions in healthcare spending: $1.68-2.43 Benefits received by target population: $36.36 Community Health Partners of Illinois first method ranging between 1.25-1.56 second method estimating 1.68 Conservative estimates that correlate with existing studies

Conclusions/Caveats Not all CHW programs collect sufficient evidence to estimate this impact Calculations on the programs included in this study can be replicated to allow for comparison between programs Resulting comparison shouldn t be viewed as direct evaluation of program effectiveness, but rather as one tool for comparing between program sizes, types, and environments.

MHP Salud is currently working to develop an ROI Toolkit which can be used to help CHW programs evaluate their own financial impact

Questions?

Group Activity

Your turn! SAMPLE CASE STUDIES

Table Case Studies 1. Read case study description. Identify what would be necessary to conduct an ROI analysis of your sample program. 2. Program outcomes and related cost estimates can be found on the back page of your case study. Use these numbers to calculate the ROI. 3. Discuss what this number might mean, and any limitations which should be considered when sharing this result.

Doulas for High-Risk Mothers CASE 1

Case 1 Discussion Findings 1 year ROI: (6 x $30,000)/$100,000= $1.80 1 year ROI: Potential Limitations No control group, so must be careful about expected outcome Key differences between ROI definitions Clearly defined cutoff point, as opposed to a spectrum of costs (6 x $50,000)/$100,000= $3.00

High-Spending Medicaid Users CASE 2

Case 2 Discussion Findings Overall ROI= 500 patients x $2,000 reduction per patient $250,000 program cost $4.00 Potential Limitations No control group? Medical inflation may be a factor Based on one year medical spending before and after enrollment Defined target population may impact replication of results

Irwin Mendoza, MPH Research, Evaluation, and Technology Analyst imendoza@mhpsalud.org (800) 461-8394 ext. 1038 Brad Klos, MPH Lead on ROI Research, Evaluation, and Technology Analyst bklos@mhpsalud.org (800) 461-8394 ext. 1029