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Asthma Return on Investment (ROI) Calculator

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Web Conference Presentation


On September 9, 2009, Rosanna Coffey, Ginger Carls, and Elizabeth Stranges presented a Web conference on the Asthma Return-on-Investment (ROI) Calculator. This is the text version of the event's slide presentation. Please select the following link to access the slides: (PowerPoint® File, 2.6 MB). Free PowerPoint® Viewer.

Slides: 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 | 18 | 19 | 20 | 21 | 22 | 23 | 24 | 25 | 26 | 27 | 28 | 29 | 30 | 31 | 32 | 33 | 34 | 35 | 36 | 37 | 38 | 39 | 40 | 41 | 42 | 43


Slide 1: The Asthma Care Return-on-Investment Calculator: Overview and Demonstration

Rosanna Coffey, Ph.D.*
Ginger Carls, M.S.* Elizabeth Stranges, M.S.*

September 9, 2009

* Thomson Reuters (formerly Thomson Medstat)

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Slide 2: Outline

  • Overview of calculator
  • Ways to use the calculator
  • Information behind the calculator
  • Caveats
  • Question and answer
  • Demonstration
    • Calculator steps with default data sources
    • Results with default data
  • Insights from Alabama Medicaid
  • Question and answer

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Slide 3: Poll Question

Have you ever used or reviewed the Asthma ROI Calculator?

  • A short poll will appear on your screen. Please take a few seconds to answer the poll and provide valuable feedback!

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Slide 4: Why an Asthma ROI Calculator?

  • Purpose
    • Help State policymakers and health plans estimate potential financial returns from asthma quality improvement programs
  • Why developed?
    • Most studies don't address financial impact - only clinical and use impacts
    • Clinical or use impacts must be converted to costs or savings
  • How are estimates generated?
    • Evidence from the literature (meta-analysis) combined with baseline utilization and costs
    • Enter your population and other optional estimates into calculator at AHRQ Web site

The bottom of the slide contains a graphic of books (evidence) leading to money (savings)

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Slide 5: How the Calculator Works

This slide contains graphics indicating the following:

  • Baseline utilization: 100,000 participants who average 0.25 ED visits per year lead to 25,000 annual visits to ED
  • Evidence: Asthma program (could use pilot) with a reduction of 50 percent leads to 12,500 visits to ED saved per year
  • Assign costs to utilization changes: At $300 per ED visit leads to $3,750,000 saved

The bottom of the slide contains a box with the following text:

  • Repeat for each service and productivity component
  • Compare change in medical care expenditures with program cost

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Slide 6: How the Calculator Works (cont'd)

Return on Investment (ROI): A program that costs $50 per participant leads to an ROI* equal to $3,750,000 saved divided by $5,000,000 cost ($50 cost per participant multiplied by 100,000 participants), which is equal to $0.75. This result means that every $1 invested returns only 75 cents, or costs 25 cents.

A breakeven ROI is equal to $1.00.

*Formula involves discount rate. See Calculator Appendix, "How the Model Works."

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Slide 7: Cost Components Included

  • Asthma-related medical care
    • Emergency room visits
    • Hospital stays
    • Outpatient visits
    • Medications
    • Ancillary testing
  • Productivity (optional)
    • Missed school or work days (not caregiver time)
  • Costs of implementing a program

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Slide 8: Ways To Use the Calculator

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Slide 9: Applications: Ways To Use Calculator

  • Forecast financial impact
  • Assess impact of key assumptions about proposed program
    • Examine alternative target populations to assess tradeoffs
    • Are assumptions "reasonable" compared to other evidence?
  • Estimate "cost hurdle" needed to break even
    • Negotiate with vendors
  • Observe components of calculator in planning an evaluation of an asthma care program

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Slide 10: Applications: How It Helps With Policy

  • Michigan Pediatric Asthma Coalition: Used to make a funding decision for a county asthma program
  • New York Department of Health: Used to consider evaluation components for a housing improvement project aimed to reduce asthma symptoms
  • Massachusetts Asthma Prevention and Control Program: Used to consider ROI for environmental approaches to asthma prevention and control
  • Alabama Medicaid Agency: Using to plan and justify a pilot asthma care improvement program for Medicaid recipients

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Slide 11: Information Behind Calculator

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Slide 12: Methods: Literature Review Inclusion Criteria

Population

  • Includes: Children, adults under 65
  • Excludes: Adults 65 and over

Setting

  • Includes: United States
  • Excludes: Non-U.S. settings

Intervention

  • Includes: Self-management of asthma or physician education
  • Excludes: Clinical trials comparing medications, summer camp

Type of study

  • Includes: Individual interventions
  • Excludes: Meta-analysis, editorials

Timeframe of outcomes

  • Includes: Studies of long-term effects of intervention (≥ 6 months)
  • Excludes: Studies of short-term effects of intervention (< 6 months)

Year published

  • Includes: 1995-2007 (March)
  • Excludes: Before 1995; after March 2007

Outcomes

  • Includes: Hospitalization, outpatient visit, ED visit, total costs, cost of medications, cost of ancillary services, or productivity losses (missed work or school days)
  • Excludes: Studies with no utilization outcomes (e.g., only changes in quality of life, knowledge of asthma)

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Slide 13: Methods: Evidence Built Into Calculator (52 Unique Studies)

ED visits

  • Children only
    • Number of patients: 13,213
    • Number of studies: 21
  • Adults only
    • Number of patients: 714
    • Number of studies: 11
  • Both children and adults
    • Number of patients: 8,812
    • Number of studies: 9
  • Total
    • Number of patients: 22,739
    • Number of studies: 40

Hospitalizations

  • Children only
    • Number of patients: 17,575
    • Number of studies: 19
  • Adults only
    • Number of patients: 7,161
    • Number of studies: 9
  • Both children and adults
    • Number of patients: 2,526
    • Number of studies: 7
  • Total
    • Number of patients: 27,262
    • Number of studies: 33

Outpatient visits

  • Children only
    • Number of patients: 20,229
    • Number of studies: 18
  • Adults only
    • Number of patients: 6,986
    • Number of studies: 4
  • Both children and adults
    • Number of patients: 1,888
    • Number of studies: 5
  • Total
    • Number of patients: 29,103
    • Number of studies: 25

Missed work/school days

  • Children only
    • Number of patients: 4,172
    • Number of studies: 11
  • Adults only
    • Number of patients: 521
    • Number of studies: 5
  • Both children and adults
    • Number of patients: 443
    • Number of studies: 3
  • Total
    • Number of patients: 5,136
    • Number of studies: 17

Medication cost

  • Children only
    • Number of patients: 486
    • Number of studies: 2
  • Adults only
    • Number of patients: 301
    • Number of studies: 3
  • Both children and adults
    • Number of patients: 13,580
    • Number of studies: 5
  • Total
    • Number of patients: 14,367
    • Number of studies: 10

Ancillary service cost

  • Children only
    • Number of patients: 61
    • Number of studies: 1
  • Adults only
    • Number of patients: 148
    • Number of studies: 2
  • Both children and adults
    • Number of patients: 0
    • Number of studies: 0
  • Total
    • Number of patients: 209
    • Number of studies: 3

Notes: Total studies can be less than the sum for the category (e.g., ED visits) because some studies reported results for both adults and children. Patients include both treatment and control groups.

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Slide 14: Methods: Meta-Analysis

  • Observations: Each study outcome (child/adult, hospital/etc.) = 1
  • Dependent variable: Percent change in measure
  • Explanatory variables/indicators:
    • Type of measure (e.g., hospital, ED, productivity)
    • Age group (children, adults, both)
    • Whether most patients in the study were Medicaid/SCHIP
    • Study patients' asthma severity (persistent, intermittent, or all)
    • Study design used (randomized, all controlled, uncontrolled)
    • If intervention primarily focused on physicians (not patients)
    • Whether outcome measured after 2 years
    • Sample size and sample size squared
  • Regressions: Weighted linear, clustered SE
  • Impact: Percent change predicted from coefficients

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Slide 15: Methods: Meta-Analysis Observations

  • Number of studies
    • 76 studies met inclusion criteria
    • 52 of them had usable findings
  • Number of findings
    • 93 findings for emergency department visits
    • 78 findings for hospitalizations
    • 57 findings for outpatient visits
    • 24 findings for productivity
    • 17 findings for medication costs
    • 2 findings for cost of ancillary services
    • 22 findings for total medical cost
    • 2 findings for total indirect costs

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Slide 16: Methods: Baseline Costs and Utilization

  • Calculator includes baseline estimates for costs and utilization specific to the population selected (national or State):
    • Medicaid
    • Employer-sponsored health insurance (privately insured)
    • State government employees and dependents
  • Demonstration lists these and other sources used in calculator

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Slide 17: Caveats

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Slide 18: Caveats

  • Limited evidence for some components:
    • Few studies (7) reported program cost - wide range:
      • Average = $395 dollars per patient per year
      • Minimum = $81 automated general educational mailing
      • Maximum = $989 program for highest cost patients
    • Few studies (10) reported asthma medication costs:
      • Studies without a control group reported larger increases in medication costs
      • Baseline asthma medication costs varied
  • AHRQ does not plan updates at this time

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Slide 19: Caveats and Solutions

Problems:

  • Literature continues to grow
  • Baseline data becomes obsolete
  • Estimate predates current year

Solutions for users:

  • Monitor literature post April 2007 and input results
  • Use your own data to populate the calculator
  • Inflate estimates using inflation factors described in appendices

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Slide 20: Questions?

  • To ask verbal questions: Please press *1 on your phone to be placed in the queue for questions

    OR

  • To ask electronic questions: Type your question into the Q and A box on the right-hand side of your screen

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Slide 21: Demonstration

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Slide 22: Demonstration Outline

  • Calculator steps with default data sources
  • Results with default data

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Slide 23: Overview of Calculator Steps

This slide contains an image of the navigation bar of the Asthma ROI Calculator Web page. From top to bottom, the bar contains the following options:

Asthma Calculator Home

  1. Introduction
        Getting Started
  2. Define Key Program Features
        Required Information
  3. Review/Edit Program Features and Data (Optional)
        Population
        Participants
        Baseline
        Program Impact
        Program Cost
  4. Review Results
        Results
  5. Resources
        User's Guide
        Technical Guide
              How the Model Works
              Default Values

In section 3, Review/Edit Program Features and Data, the user can use default or user data in all five subcategories. Meta-analysis of the literature occurs in Program Impact and Program Cost.

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Slide 24: Define Key Program Features: Required Information

This slide contains an image of the navigation bar and a screen shot of the Required Information page under section 2, Define Key Program Features. The following text is circled on the screen shot:

  • Who will be eligible for the asthma program?
  • What types of studies should be used to estimate the impact of the asthma program?
  • What costs/savings should be included?

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Slide 25: Review/Edit Program Features/Data: Population

This slide contains an image of the navigation bar and a screen shot of the Population page under section 3, Review/Edit Program Features and Data. This page includes information such as population size and race.

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Slide 26: Review/Edit Program Features/Data: Population

This slide contains an image of the navigation bar and a screen shot of the Population page under section 3, Review/Edit Program Features and Data.

Superimposed on the screen shot is a text box containing the following:
Default data sources:

  • Center for Medicare and Medicaid Services
  • Current Population Survey, Annual Social and Economic Supplement
  • Bureau of Labor Statistics Quarterly Census of Employment and Wages

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Slide 27: Review/Edit Program Features/Data: Participants

This slide contains an image of the navigation bar and a screen shot of the Participants page under section 3, Review/Edit Program Features and Data. This page includes information such as participants' age and gender.

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Slide 28: Review/Edit Program Features/Data: Participants

This slide contains an image of the navigation bar and a screen shot of the Participants page under section 3, Review/Edit Program Features and Data.

Superimposed on the screen shot is a text box containing the following:
Default data sources:

  • MarketScan™ Medicaid or Commercial Claims databases
Calculator operation:
  • Applies default prevalence and participation rates to population data

    OR

  • Allows user to enter the number of eligible participants and participation rate

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Slide 29: Review/Edit Program Features/Data: Baseline Data

This slide contains an image of the navigation bar and a screen shot of the Baseline Data page under section 3, Review/Edit Program Features and Data. This page includes information such as annual emergency department visits per patient, hospital stays per patient, cost of an emergency department visit, and cost of a hospital stay.

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Slide 30: Review/Edit Program Features/Data: Baseline Data

This slide contains an image of the navigation bar and a screen shot of the Baseline Data page under section 3, Review/Edit Program Features and Data.

Superimposed on the screen shot is a text box containing the following:
Default data sources:
MarketScan Claims Database (2005)

  • Medicaid (8 geographically dispersed States)
  • Employer-sponsored health insurance (over 100 large self-insured employers, 15 million lives, geographically balanced)

National Health Interview Survey (2003)

  • Number of missed work or school days due to asthma

Bureau of Labor Statistics (2006)

  • Average wage rate
  • Federal poverty line (for value of missed work day for Medicaid recipients)

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Slide 31: Review/Edit Program Features/Data: Baseline Data

Other potential data sources:

  • State, local, or plan-level claims data
  • Special surveys of number of missed school/work days due to asthma

Advice for calculating data fields:

  • Decide what use and cost components to include
  • It's okay to combine use and cost from different sources
    • Just make sure measures are calculated the same way for the same population

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Slide 32: Review/Edit Program Features/Data: Program Impact

This slide contains an image of the navigation bar and a screen shot of the Program Impact page under section 3, Review/Edit Program Features and Data. This page includes health care measures, such as program impact on hospital stays, and productivity measures, such as program impact on missed workdays.

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Slide 33: Review/Edit Program Features/Data: Program Impact

This slide contains an image of the navigation bar and a screen shot of the Program Impact page under section 3, Review/Edit Program Features and Data.

Superimposed on the screen shot is a text box containing the following:
Data source:

  • Meta-analysis of literature

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Slide 34: Review/Edit Program Features/Data: Program Cost

This slide contains an image of the navigation bar and a screen shot of the Program Cost page under section 3, Review/Edit Program Features and Data. This page includes information such as length of program operations and annual cost per participant.

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Slide 35: Review/Edit Program Features/Data: Program Cost

This slide contains an image of the navigation bar and a screen shot of the Program Cost page under section 3. Review/Edit Program Features and Data.

Superimposed on the screen shot is a text box containing the following:
See User's Guide for:

  • What to include in your estimates of annual cost per participant
  • How to choose a discount rate

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Slide 36: Demonstration Results

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Slide 37: Results

This slide contains an image of the navigation bar and a screen shot of the Results page under section 4, Review Results. This page includes information such as health care savings per participant and return on investment. The scenario showing program results can be saved to an Excel file.

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Slide 38: Results

This slide contains a table of the results page from the Asthma ROI Calculator, which contains the following:

Input Values for Scenario 1
This page displays the inputs used to return the results for Scenario 1.

Input

  • Study design: Randomized controlled studies
  • Asthma Only or All Costs: Asthma-Related Medical Costs
  • Cost Perspective: Program/plan and patient

Population Age/Gender (in percent)

  • Male 1-4: 6.20
  • Male 5-17: 15.00
  • Male 18-34: 9.20
  • Male 35-44: 4.60
  • Male 45-54: 3.70
  • Male 55-64: 1.80
  • Female 1-4: 9.10
  • Female 5-17: 21.90
  • Female 18-34: 13.70
  • Female 35-44: 6.70
  • Female 45-54: 5.60
  • Female 55-64: 2.50

Population Race (in percent)

  • White: 43.80
  • Black 23.10
  • Hispanic: 22.10
  • Asian/Pacific Islander: 3.50
  • American Indian/Alaska Native: 1.50
  • Other: 6.00

Baseline Data

  • Annual emergency department visits per patient: 0.12
  • Cost of an emergency department visit: $91.00
  • Annual hospital stays per patient: 0.03
  • Cost of a hospital stay: $6,683.00
  • Annual outpatient visits per patient: 1.06
  • Cost of an outpatient visit: $41.00
  • Annual cost of asthma medications per patient: $439.00
  • Annual cost of asthma-related ancillary services per patient: $28.00
  • Annual missed workdays per adult from asthma: 5.53
  • Cost of a missed workday: $68.73
  • Annual missed schooldays per child from asthma: 5
  • Cost of a missed schoolday: $37.38

Program Impact (in percent)

  • Program impact on emergency department visits? -14.00%
  • Program impact on hospital stays? -48.00%
  • Program impact on outpatient visits? -9.00%
  • Program impact on the cost of ancillary services? -66.00%
  • Program impact on the cost of asthma medications? 25.00%
  • Program impact on missed workdays per adult? -88.00%
  • Program impact on missed schooldays per child? -58.00%

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Slide 39: Results

This slide contains a table called "Results of the AHRQ Asthma Return on Investment Calculator for Care Management," which contains the following text:

This page summarizes the assumptions you made in the calculator and shows the impact of the asthma program. Results for other choices you may have made in this session and exported to Excel are on other tabs of this spreadsheet.

Choices Made

  • Population type: Medicaid
  • Geographic location: Nation
  • Asthma definition: All asthma
  • Adults and/or children: Adults and Children
  • Estimated persons with asthma: 3,816,893
  • Percent who will participate: 25.00
  • Estimated program participants: 954,223
  • Annual program cost per participant: $421.86
  • Years the program operations: 5
  • Program phase-in period (years): 2
  • Discount rate for NPV and ROI: 3.00%
  • Display totals or per participant: Show averages per participant
  • Include productivity gains: Savings and Productivity

Results:
Health Care Savings: $42.60

  • Emergency depart visits: 14.69%
  • Hospital confinements: 924.86%
  • Outpatient visits: 37.59%
  • Asthma-specific ancillary services: 177.60%
  • Asthma medications: -1054.74%

Productivity gains: $1,813.23

  • Productivity for adults: 75.52%
  • Productivity for children: 24.48%

Program Cost over Years Program Operates: $1,932.00
Overall Impact of Program

  • Net Present Value (NPV): -$76.16
  • Return on Investment (ROI): $0.96
  • Break-Even Program Impact: -13.00%
  • Break-Even Program Cost: $405.23

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Slide 40: Summary of Steps in the Asthma ROI Calculator

Determine target population and studies to use in calculation (Required Info)
     Target most expensive patients!
     Use controlled study results to achieve most realistic results!

  1. Estimate population
  2. Estimate number of participants
  3. Estimate baseline costs and utilization
  4. Estimate impact of asthma program
  5. Estimate program cost

Tips on using your own data:

  • Ideally, find data from a single source
  • If not feasible, be sure that the underlying populations that generated the data are similar
    • Use claims data to obtain number of eligible asthma patients and their baseline utilization and costs
    • Find evidence from studies of a similar population

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Slide 41: Comments from

Stephanie Lindsay, Medicaid Administrator, Alabama Medicaid Agency

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Slide 42: Questions?

  • To ask verbal questions: Please press *1 on your phone to be placed in the queue for questions

    OR

  • To ask electronic questions: Type your question into the Q and A box on the right-hand side of your screen

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Slide 43: Additional Assistance

Technical Assistance:

Copy of calculator:

Questions about the tool:

For more information about AHRQ Quality Tools:

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The information on this page is archived and provided for reference purposes only.

 

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