Asthma Impact Model for Fresno (AIM4Fresno) Building the ... · PDF...

© 2013 Collec,ve Health LLC

Rick Brush | [email protected] | 860.712.2242 collectivehealth.net

Asthma Impact Model for Fresno (AIM4Fresno)

Building the Foundation for Health Impact Investing

Community Action to Fight Asthma � 2013 Annual Meeting May 15, 2013

identify1 invest2

improve3return4

HealthImpact

BondSM®



•  Developed by Collective Health in 2011 with support from

The California Endowment and UC Berkeley

•  First-ever HIB to launch in Fresno – focus on asthma •  Pursuing asthma bonds in additional markets and expansion to

other diseases

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Health Impact Bond®

Raise capital to address the underlying social and environmental causes of disease, in exchange for a share of future health care cost savings (shared savings model)

identify1 invest2

improve3return4

HealthImpact

BondSM®



®

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What intervention and service

providers are evidence-based?

Can the savings be validated, shared and reinvested?

Where are the hot spots – and who is paying?

What is the investment and

risk/return?

Health Impact Bond®

How It Works

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individuals institutions

foundations

employers HC providers

public/private insurers

insurance/ financial actuary

track record of results

ongoing learning � iterative/adaptive � sustainable reinvestment



•  Asthma and COPD

•  Diabetes prevention

•  Mental illness (especially with comorbidity), addiction/recovery

•  Superutilization/ED/readmission reduction

•  Onsite/location-based clinics and telehealth

•  At-risk prenatal/maternal

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Health Impact Bond® Potential Applications



Philanthropy as a Bridge to Health Impact Investing

•  Build the business case for health-focused impact investment –  Advance health policy: Better health outcomes at lower costs

•  Minimize risk while creating a pathway to scale

–  Capture the “right” data for impact investment strategies •  Investors: Optimize risk allocation by quantifying risk/return with medical claims •  Payers of Outcomes: Mapping allocation of risk among various health care payers

(public and private)

–  Prepare service providers for outcomes-based financing •  Identify key operational drivers for successful outcomes achievement •  Standardize operations to prepare for scale-up

–  Build government support early •  Navigate legislative and budgetary process •  Eliminate potential perverse incentives •  Design for sustainability

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AIM4Fresno: An Asthma Demonstration Project



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Asthma in Fresno: A Crisis for Children and Community

20.2% children 5-17 diagnosed with asthma*

Every day, 20 go to the ER and 3 hospitalized for asthma

$34.8M per year for asthma-related ER and hospitalizations

* significantly higher for some race/ethnicity and socioeconomic groups



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Asthma: A Business Case for Prevention

Asthma Control: Home-Based Multi-Trigger, Multicomponent Environmental Interventions

Home-based multi-trigger, multicomponent interventions with an environmental focus for persons with asthma aim to reduce exposure to multiple indoor asthma triggers (allergens and irritants). Theseinterventions involve home visits by trained personnel to conduct two or more activities. The programs in this review conducted environmental activities that included:

Assessment of the home environmentChanging the indoor home environment to reduce exposure to asthma triggersEducation about the home environment

Most programs also included one or more of the following additional non- environmental activities

Training and education to improve asthma self-managementGeneral asthma educationSocial services and supportCoordinated care for the asthma client

Summary of Task Force Recommendations & Findings

The Community Preventive Services Task Force (/about/task-force-members.html) recommends (/about/methods.html#categories) the use of home-based multi-trigger, multicomponent interventions with anenvironmental focus for children and adolescents with asthma based on evidence of effectiveness in improving overall quality of life and productivity, specifically:

Improving asthma symptomsReducing the number of school days missed due to asthma

The Task Force (/about/task-force-members.html) finds insufficient evidence (../about/methods.html#categories) to determine the effectiveness of home-based multi-trigger, multicomponent interventions with anenvironmental focus for adults with asthma based on the small number of studies identified and the mixed results across the outcomes of interest.

Task Force Finding & Rationale Statement for review of interventions for children and adolescents (rrchildren.html)

Task Force Finding & Rationale Statement for review of interventions for adults (rradults.html)

Economic Review

The Task Force finds that home-based multi-trigger, multicomponent interventions with a combination of minor or moderate environmental remediation with an educational component (rrchildren.html#range)provide good value for the money invested based on:

Improvement in symptom free daysSavings from averted costs of asthma care and improvement in productivity

Results from the Systematic Reviews

Twenty-three studies qualified for the effectiveness review.

Children and Adolescents:

Asthma symptom days: median decrease of 21 days per year (6 studies)School days missed: median decrease of 12 days per year (5 studies)Acute healthcare visits: combined median decrease of 0.57 visits per year (10 studies)

Hospitalizations: median decrease of 0.4 hospitalizations per yearEmergency department visits: median decrease of 0.2 visits per yearUnscheduled office visits: median decrease of 0.5 visits per year

Pulmonary function: overall, no significant improvement (7 studies)

Adults:

Three intervention studies reported one or more outcome measurements in adults. Although two studies observed improvements in quality of life or symptom scores, the results for health care utilization, andproductivity outcomes showed borderline or no improvement. No studies in adults reported any physiologic outcomes.

Applicability

The reviewed multi-trigger multicomponent intervention studies were conducted:

Mostly in the homes of US urban minority childrenBy a wide range of organizations including:

State and local health departmentsHealth care systemsCommunity organizations

By a wide range of trained personnel including:

Community health workers (most common)NursesRespiratory therapists

Asthma Control: Home-‐Based Mul,-‐Trigger, Mul,component Environmental Interven,ons Economic Review Cost-‐benefit studies show return of $5.3 to $14.0 for each $1 invested.

www.thecommunityguide.org/asthma/mul,component.html

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PediatricsPediatricspediatrics.aappublications.org

Published online Published online February 20, 2012February 20, 2012Pediatrics Vol. 129 No. 3 March 1, 2012 March 1, 2012 pp. 465 pp. 465 -472 -472 (doi: 10.1542/peds.2010-3472)

Article

Community Asthma Initiative: Evaluationof a Quality Improvement Program forComprehensive Asthma Care

Elizabeth R. WoodsElizabeth R. Woods, MD, MD, MPH, MPHa, , Urmi BhaumikUrmi Bhaumik, MBBS, MBBS, MS, MS, DSc, DScb,,Susan J. SommerSusan J. Sommer, MSN, MSN, RNC, RNC, AE-C, AE-Ca, , Sonja I. ZinielSonja I. Ziniel, PhD, PhDc,,Alaina J. KesslerAlaina J. Kessler, BS, BSa, , Elaine ChanElaine Chan, BA, BAa, , Ronald B. WilkinsonRonald B. Wilkinson, MA, MA,,MSMSd, , Maria N. SesmaMaria N. Sesma, BS, BSe, , Amy B. BurackAmy B. Burack, RN, RN, MA, MA, AE-C, AE-Cb,,

Elizabeth M. KlementsElizabeth M. Klements, MS, MS, PNP-BC, PNP-BC, AE-C, AE-Cf, , Lisa M. QueeninLisa M. Queenin, BA, BAb,,g,,

Deborah U. DickersonDeborah U. Dickerson, BA, BAb, and , and Shari NethersoleShari Nethersole, MD, MDb,,h

Author Affiliations

ABSTRACT

OBJECTIVES:OBJECTIVES: The objective of this study was to assess the cost-effectivenessof a quality improvement (QI) program in reducing asthma emergencydepartment (ED) visits, hospitalizations, limitation of physical activity, patientmissed school, and parent missed work.

METHODS:METHODS: Urban, low-income patients with asthma from 4 zip codes wereidentified through logs of ED visits or hospitalizations, and offered enhancedcare including nurse case management and home visits. QI evaluation focusedon parent-completed interviews at enrollment, and at 6- and 12-monthcontacts. Hospital administrative data were used to assess ED visits andhospitalizations at enrollment, and 1 and 2 years after enrollment. Hospitalcosts of the program were compared with the hospital costs of a neighboringcommunity with similar demographics.

RESULTS:RESULTS: The program provided services to 283 children. Participants were55.1% male; 39.6% African American, 52.3% Latino; 72.7% had Medicaid; 70.8%had a household income <$25!000. Twelve-month data show a significantdecrease in any ("1) asthma ED visits (68.0%) and hospitalizations (84.8%),and any days of limitation of physical activity (42.6%), patient missed school(41.0%), and parent missed work (49.7%) (all P < .0001). Patients with greatestfunctional impairment from ED visits, limitation of activity, and missed schoolwere more likely to have any nurse home visit and greater number of homevisits. There was a significant reduction in hospital costs compared with thecomparison community (P < .0001), and a return on investment of 1.46.

CONCLUSIONS:CONCLUSIONS: The program showed improved health outcomes and cost-effectiveness and generated information to guide advocacy efforts to financecomprehensive asthma care.

KEY WORDSKEY WORDSasthma cost analysis community health worker

emergency department visits health disparities health outcomeshospitalizations nurse case management pediatrics

return on investment

Abbreviations:

AAP —Asthma Action Plan

CAI —Community Asthma Initiative

CHW —Community Health Worker

hRp://pediatrics.aappublica,ons.org/content/129/3/465.abstract

Twelve-‐month data show a significant decrease in any (≥1) asthma ED visits (68%) and hospitalizaFons (84.8%).



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AIM4Fresno Project Components

Medi-Cal plans

Self-insured employers

Target Population & Savings Analysis

1 Funding & Investment

Phase 1: 200 individuals

Phase II: 3,500 individuals foundations

institutions individuals

2

Intervention Design & Implementation 3 Savings Methodology & Validation

Validation: third-party actuary

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Actuarial-‐based savings methodology using insurance claims data: •  Randomized control study •  Baseline/lookback period •  Trend analysis post-intervention

Health Impact Bond® advisory group

$0$4.0$8.0$12.0$16.0

2012 2013 2014 2015 2016

Medical Costs (millions)

Post-intervention

Pre-intervention

Savings

à Lower ED (30%) & hospital (50%)

à Save $7,773 per person per year



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AIM4Fresno: Potential Scale Up Projections – 1,100 children

$8.5M savings opportunity

•  Bond investors provide upfront capital • Agreed interest rate and

payback period

•  Evidence-based intervention by qualified service providers

$3M upfront investment

Home-based multi-trigger,

multi-component asthma

intervention

$3M principal + interest repaid to bond investors

Intermediary/infrastructure costs

Most of savings is retained/re-invested by financial stakeholders (plus ongoing savings after first year)

$0$4.0$8.0$12.0$16.0

2012 2013 2014 2015 2016


Post-intervention

Pre-intervention

Savings

•  Payers share validated savings


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identify opportunity 1 invest in prevention 2

improve outcomes 3

• Reduce ED visits (30%) and hospital stays (50%) §  Medi-‐Cal health plans §  Self-‐funded employers

®



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AIM4Fresno: Potential Scale Up Projections – 1,100 children

$8.5M savings opportunity

•  Bond investors provide upfront capital • Agreed interest rate and

payback period

•  Evidence-based intervention by qualified service providers

$3M upfront investment

Home-based multi-trigger,

multi-component asthma

intervention

$3M principal + interest repaid to bond investors

Intermediary/infrastructure costs

Most of savings is retained/re-invested by financial stakeholders (plus ongoing savings after first year)

$0$4.0$8.0$12.0$16.0

2012 2013 2014 2015 2016


Post-intervention

Pre-intervention

Savings

•  Payers share validated savings


4

identify opportunity 1 invest in prevention 2

improve outcomes 3

• Reduce ED visits (30%) and hospital stays (50%) §  Medi-‐Cal health plans §  Self-‐funded employers

AssumpFons

Unit Costs ED visit Hospital Child $1,375 $16,181 Adult $1,375 $23,074 All $1,375 $19,078

Avg # of Units 1.50 0.75 Pre-‐IntervenFon

ReducFon 30% 50% Due to IntervenFon

Per Person Per Year

Emergency and Hospital Costs Pre-‐interven,on: Post-‐interven,on: Savings: Program Investment and Infrastructure Net Savings Net ROI

$16,371 $8,598 $7,773

$2,728

$5,045 1.8



Impact Investing to Scale ��Beyond the Demonstration Project

•  Validate existing evidence-base with rigorous evaluation design –  Coupling asthma education with home remediation significantly reduces

asthma-related health care expenditures –  Asthma-related cost savings are greater than the intervention cost

•  Confirm risk/return proposition will attract impact investors (philanthropy to commercial investors) –  Variance analysis indicates consistent outcomes achievement –  Articulate operational risk and mitigating strategies through active

performance management

•  Identify payer(s) of outcomes (e.g., state, county, or managed care organization) for scale-up phase –  Articulate value proposition: health care savings and social value (e.g., reduce

school absences and increase worker productivity) –  Develop roadmap to transition from demonstration to scale-up

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Rick Brush

[email protected] | 860.712.2242 Web: collectivehealth.net

TwiRer: twitter.com/collectivehlth

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