© 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®
© 2013 Collec,ve Health LLC
Rick Brush | [email protected] | 860.712.2242 collectivehealth.net
• 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
2
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®
© 2013 Collec,ve Health LLC
Rick Brush | [email protected] | 860.712.2242 collectivehealth.net
®
3
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
4
1 2
3
individuals institutions
foundations
employers HC providers
public/private insurers
insurance/ financial actuary
track record of results
ongoing learning � iterative/adaptive � sustainable reinvestment
© 2013 Collec,ve Health LLC
Rick Brush | [email protected] | 860.712.2242 collectivehealth.net
• 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
4
Health Impact Bond® Potential Applications
© 2013 Collec,ve Health LLC
Rick Brush | [email protected] | 860.712.2242 collectivehealth.net
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
5
AIM4Fresno: An Asthma Demonstration Project
© 2013 Collec,ve Health LLC
Rick Brush | [email protected] | 860.712.2242 collectivehealth.net
6
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
© 2013 Collec,ve Health LLC
Rick Brush | [email protected] | 860.712.2242 collectivehealth.net
7
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
++
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%).
© 2013 Collec,ve Health LLC
Rick Brush | [email protected] | 860.712.2242 collectivehealth.net
8
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
4
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
© 2013 Collec,ve Health LLC
Rick Brush | [email protected] | 860.712.2242 collectivehealth.net
9
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
Medical Costs (millions)
Post-intervention
Pre-intervention
Savings
• Payers share validated savings
return on investment
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
®
© 2013 Collec,ve Health LLC
Rick Brush | [email protected] | 860.712.2242 collectivehealth.net
10
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
Medical Costs (millions)
Post-intervention
Pre-intervention
Savings
• Payers share validated savings
return on investment
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
© 2013 Collec,ve Health LLC
Rick Brush | [email protected] | 860.712.2242 collectivehealth.net
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
11
© 2013 Collec,ve Health LLC
Rick Brush | [email protected] | 860.712.2242 collectivehealth.net
12
Rick Brush
[email protected] | 860.712.2242 Web: collectivehealth.net
TwiRer: twitter.com/collectivehlth
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