State Quality Tools: ROI Calculator

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Margie Shofer: Hello. I'm Margie Shofer in the Office of Communications and Knowledge Transfer at the Agency for Healthcare Research and Quality, otherwise known as A-H-R-Q or AHRQ. Thank you for joining us for this Web conference on the Asthma Return-on-Investment or ROI Calculator.

If you have been on past Web conferences for this project, you may notice some differences, as we are using a new Web vendor for the first time. The first difference is that you are not able to download the slides ahead of time, so if you would like to download today's slide presentation, please go to the file share box in the bottom left-hand corner. You will see that there are two sets of slides; one set is PowerPoint slides and the other sets are text alternative slides, and I'm assuming that most of you will want to download the PowerPoint® slides.
Also, when you enter this Web conference you are not muted, so if you haven't already had a chance to do that, please take a moment to mute your lines by pressing "*6" on your phones or by pressing the mute button if your phone has one.

This Web conference is the fourth in a series of events highlighting several AHRQ tools created to help you identify and support ideas for health care quality improvement. We have held Web conferences on HCUP and HCUPnet, MONAHRQ's Preventable Hospitalization Cost and Mapping Tool, and the State Snapshots. If you are interested in learning about these tools but missed the events, the materials will eventually be posted on AHRQ's Web page, and I am pleased to announce that the HCUP Web conference is now on our site, and the address for that Web page for this project will be listed on our final slide.

Today we will be discussing the Asthma ROI Calculator, a tool that can help State officials decide whether it's cost-effective to establish an asthma care management program. The tool is online and evidence based and makes it easier for users to determine the cost savings that likely can be achieved by having an asthma care management program for a specific population, the areas to target so that asthma interventions can achieve cost savings, and the number of years that a program must be in place to have a positive return on investment. Before I go through the agenda for today's event, I just want to remind everyone again to please mute your lines if you haven't already done so by pressing "*6" or the mute button on your phone.

We will begin today's presentations with an overview of the Calculator, discussing the ways to use the Calculator, and examining the literature that supports the tool's findings. We will also touch upon some caveats that stem from the tool and then we'll have a tool developer conduct a step-by-step demonstration of the Calculator. We will take some questions before the live demonstration.

After the demonstration of the tool, we will have another question-and-answer session. Then we will move on to the Web conference's next component, a brief discussion about how Alabama Medicaid's Department has used the tool as a component of their evaluation of a pilot asthma quality improvement program. Finally, we will have a final question-and-answer period.

Today's presentation on the Asthma ROI Calculator will be given by Ginger Carls and Elizabeth Stranges, and Rosanna Coffey will be available to answer questions about the Calculator during the Q&A session. Ginger is an economist at Thomson Reuters and has worked on projects to evaluate the performance of disease management programs and cost burden studies. Elizabeth is an analytic consultant at Thompson Reuters, and among other projects, works on special studies pertaining to the National Healthcare Quality Report and the National Healthcare Disparities Report.

Rosanna Coffey is a senior health services researcher and economist with Thompson Reuters. She's been the architect for the AHRQ State Snapshots, the AHRQ quality improvement guides for diabetes and asthma, and coarchitect of the Asthma ROI Calculator.

The final presentation will be given by Stephanie Lindsay, who is a Medicaid administrator for the Alabama Medicaid Agency. One focus of Stephanie's current responsibilities is assisting with chronic disease data, including cost-effectiveness of interventions and cost burdens on the State.

You may also hear from Mary McIntyre, who is a medical director at the Alabama Medicaid Agency. We would appreciate your active participation in today's events, as the primary purposes are to introduce you to the Asthma ROI Calculator and get your feedback on the tools, explore practical applications for the tool, and learn how you envision using the tool and for what purposes. Related to this last point, we hope that you will tell us about the types of technical assistance that you might need in order to make full or better use of the Asthma ROI Calculator.

I am going to hand this over to Ginger.

Ginger Carls: Thanks, Margie. In this next section, I'm going to give an overview of the Calculator and sort of what is behind it before we get into the demo. But before we get started on that, we'd like to open up for a poll question to see what people are working on, and the question is, and it's a yes or no, you'll see a little box below the slide where you can answer the poll question yes or no. "Are you currently planning a new asthma program or intervention?" We kind of want to get an idea what people are working on, and then during one of the question-and-answer times, during one of the breaks, we will discuss the answers and hopefully get some discussion about what people are working on. If you could take a few minutes to answer that and then I will continue on with the slides.

As people are finishing up answering their poll questions, I'll move on to sort of what is the Asthma ROI Calculator? Why did we develop it? Why we started developing this was for State policymakers. We were working with a group in Michigan who wanted some assistance with figuring out the financial impact of an asthma care program they were considering. So that's sort of where this got started. Like I said, most of the focus is on State policymakers but also health plans could use this Calculator to look at the financial returns from an asthma program.

Why do we need a calculator? First, there are a lot of studies out there on asthma care programs. We included 52 studies in our summary of the literature, and that's a lot of studies for one person or even a team to really get their head around and to think about how that might relate to the program that you're planning. What this Asthma ROI Calculator does is kind of bring all those studies together and try and summarize them in a way that you can make sense of them. You can look at studies with just children or studies with just Medicaid or studies without Medicaid, studies that are just randomized controlled. It gives a way to sort of understand and think about the literature in hopefully a user-friendly way.

The other thing that was missing as we were developing this assistance was that many studies didn't have cost data available, so in the literature they may report that an asthma care program had reduced ER visits by a certain amount. It was hard to figure out what it really meant in terms of costs. There was a need to bring in some cost data from elsewhere to help inform that. Particularly during the demonstration, you will see how that cost data is brought in.

We brought in some data from large medical claims databases to provide some cost data that you can use. Although if you have your own cost information, then that's really even better to use that. You'll see as we go through sort of where you can put in your own information, or if you don't have it, then the calculator has provided some good starting points of what kinds of costs you might expect.

This is how the Calculator works, how the estimates are generated. The real heart of the Calculator is evidence in the literature, which we have combined in a statistical way called a meta-analysis. Then we've combined it with other information on baseline utilization of medical care by people with asthma and their costs of these different pieces of utilization, and you can enter your own population, as I have mentioned, into that.

This next slide, how the Calculator works, is just a simple calculation just to show you sort of really what's behind it. Basically, we start with your input of how many people are in your program and this example is for ER visits and how many ER visits they have per year. In this example, we're looking at 100,000 people, one out of four of the people, .25 ED visits per year.

It is estimated that you typically have 25,000 annual visits to the emergency room, and then you bring in the evidence from this study. In this example, we look at a study that found that they could reduce ER visits by half, by 50 percent, and so that potentially you could save 12,500 visits. Then you just assign a cost for each visit; here it's $300. That's a savings of $3.75 million.

This is just a hypothetical just to show it's a fairly simple calculation. What the Calculator does is put everything all together so that you look at more than just ER visits, as well as inpatient and other aspects all in one place and then also have the literature also sort of in one place to put it all together.

The next slide is how the Calculator works, a return on investment. As Margie said, the name of the Calculator is the "Return-on-Investment Calculator." What return on investment means is you're just comparing the savings from the program with the costs. Here is an example calculation based on the previous example. If you have a program that costs $50 per participant, and here in this example we had 100,000 participants, that's about $5 million in costs. You just divide that by the saving that we found earlier.

In this example, we got an ROI of .75, or 75 cents on the dollar. What that means is that for every dollar invested into the program you get 75 cents back. You don't get your full amount back, so actually for every dollar invested it costs 25 cents. A break-even ROI is $1, where every dollar invested gets a dollar back. This is sort of the main metric that's used in the Calculator to report financial impact, but it also reports the total dollars, so you can look at those as well.

A final definition that we need to make before I move on further is, we have been talking about an asthma care program and developing a tool to help evaluate what the financial impact might be. What are we talking about in terms of an asthma care program? We're really talking about programs that we include in the literature that mostly followed the guidelines of the National Asthma Education and Prevention Program. Primarily these are programs that focus on patient education and also provider interventions.

Patient education might be working with patients to improve their self-management, understanding triggers, how they anticipate problems with their asthma, and how to use their medication. Provider interventions might be looking at working with physicians to help make sure they're prescribing the medications needed, helping them to monitor their patients, and also providing them assistance to educate their patients.

Some of the programs included in the literature focus on all of these aspects with patient education and provider education, and some of the programs included in the literature just really look at certain pieces. You should think about what's in the literature as sort of a combination of what's out there that's sort of patient or provider education related. That's sort of a final definition beyond ROI that I want, before we move on, to talk about.

I mentioned that in the Asthma ROI Calculator, we talked about emergency room visits, but it's also fairly comprehensive in looking at all aspects that might be affected by cost changes, so emergency room, hospital stays, outpatient visits. Sometimes additional quality care can result in more outpatient visits, even though it's fewer emergency room visits. It's the same with medication. Sometimes an asthma care program may result in increased medication use, even though emergency room and hospital stays may decrease. It kind of allows you to have a broader picture.

Another option in the Calculator is you can also look at productivity outputs, such as missed school or missed workdays. It is included optionally if you want to include that aspect of it. Finally, there's the cost of implementing a program.

Ways to use the Calculator. As we talked about, the primary reason we developed the Calculator was to forecast the financial impact of an asthma care program. There are also other uses. You could use the Calculator to assess the impact of key assumptions about the proposed program. For example, the Calculator allows you to look at just children or just adults or just Medicaid or not Medicaid and also look at what work we call "persistent asthma" through the more serious asthma cases versus the ones that maybe have milder asthma. By looking at these different populations, it can help you understand where the greatest potential of a financial savings might be. The goal of your program may not be to achieve financial savings but it may be important to be able to report that.

It can be interesting to look at these different populations and see how results might change if you targeted differently. For example, targeting the very seriously ill population may have the largest savings, but it's a much smaller number of people and may be harder to find them. Those are some factors that you may want to consider as you're working through some different scenarios. Another way to use the Calculator is you can test to see if some of your assumptions are reasonable compared to other evidence.

What the evidence in the Calculator is right now is sort of based on the literature and sort of typically what we find for that kind of population that you selected. You can compare that to other evidence from a pilot study or something like that to see if that pilot study is similar to what you typically found or perhaps low or perhaps high, so kind of giving an idea where things fall. So that's another way to use it.

Another use is in negotiation with vendors. If you are developing an asthma program that will be implemented with a third-party vendor and you're negotiating a price, the Calculator can help you look at sort of a different cost for the program where you see a positive financial impact, and that can be useful in negotiations.

A final use of the Calculator that we found people found useful was as a framework of how to think about how an asthma care program might affect utilization and how that might affect cost in sort of a broader perspective. It could also be useful just sort of in that regard, even if the financial impact case isn't a crucial one to what you're working on, but it can be helpful as sort of a framework and how to think about how your program may affect utilization.

This next slide just gives some examples of how some other teams have worked on the Calculator. As I said, when we were first developing the Calculator, we worked with the Michigan Pediatric Asthma Coalition, and they input some of their own data, I believe, from some counties as one sort of piece of information to help make a funding decision on a county asthma program.

We also met with the New York Department of Health and they were developing a program mostly focused on housing improvements to reduce asthma symptoms. This was a case where they found the sort of framework for the Asthma ROI Calculator, even though maybe the specifics, given that their type of intervention was more on housing, may not have fully applied. I won't say they used the Calculator, per se, in that way, but they found it useful just thinking about the whole framework of how asthma care programs might affect different parts of utilization and productivity.

We also have met with the Massachusetts Asthma Prevention and Control Program who used the Calculator to examine their return on investment for an environmental approach to asthma prevention and control. Finally, you're going to hear from the Alabama Medicaid Agency. Stephanie will be giving us an overview of their experience using the Asthma ROI Calculator. These are some examples of some people that we have talked with who have used it and how they found it helpful.

The next section of slides is to give you some more detail on the sort of evidence that is behind the Calculator. This may be a question that you get sort of right off the bat when you tell someone that you're thinking of using this Asthma ROI Calculator to estimate financial impact. They'll want to know where does their data come from? Is it reliable, and what are the studies behind it?

In this next couple slides, I hope to give you some background on where this evidence comes from. There's a lot more detail in these. There's a final report available that has abstracts of all 52 studies and just gives a lot more detail on how we went about conducting the meta-analysis and the review of the literature, putting it all together. This will just try and give you a high-level overview.

The literature that was included sort of informed all the evidence, so children and adults under 65 in the U.S. As I mentioned, this is self-management of asthma or physician education-type programs, individual interventions that looked at patients for 6 months or more. Then we connected this literature review in 1995 through studies that were published in 2007. Newer studies aren't going to be included in our review meta-analysis, but if you have one, you can use that evidence and just input that in the Calculator if that's one in particular you're interested in. We also just looked at studies that focused on cost and utilization outcomes that were sort of straightforward to turn into dollars. Things like quality of life can be very important, but since they're difficult to turn into dollars, we excluded those.

This next table basically shows the number of studies and the number of patients that inform each of the different outcomes. We looked at emergency department visits, hospitalizations, and all those different outcomes. We also looked at the age group of the patients that were in the study, so if the study was just children, just adults, or both together. Then on the far right is just the total.

The takeaway message from this slide is really that some of the outcomes have more evidence behind them than others. For example, for emergency department visits and hospitalizations and outpatient visits, the studies that inform those results all have over 28,000 patients behind them and over 25 different studies, and emergency department visits had over 40 studies. Some of them were small, but a lot of the evidence from the literature focuses on those things.
Medication costs can be an important piece, and there were 10 studies that basically reported results related to medication costs and that represented about 14,000 patients. There were only three studies that looked at ancillary service costs and these are things like everything that's left over after you're looking at outpatient visits, hospitalizations, ER visits, and medication, and just some lab tests and those kinds of services, and there's only a few studies that looked at that outcome.

Now that I've told you the literature that has gone into forming the evidence, I'll just give a little bit of background on what is a meta-analysis. To boil it down, it's really a physical way to aggregate all the evidence from the studies. I mean the simplest thing that you could do would be to take all the outcomes for ER visits, convert them to the same unit, such as ER visits per patient per year, and then just take the average result. That would be the simplest thing.

What a meta-analysis does is basically uses regression techniques to do that same idea of taking the average over all the studies, but then it allows you to control for a lot of differences between the different studies. The differences that we controlled for were things that were readily reported in all the studies. There might be things that you might be interested in, but if there weren't enough studies that really reported that piece about the study, we couldn't include that.

Things that we could control for were what outcome was used, what age group, if the patients were in Medicaid or SCHIP programs. Also, the studies reported the severity of their asthma, if the patients had persistent asthma or if they included pretty much anyone with asthma regardless of how often they saw the doctor and that idea. We could also control for whether or not the study was randomized or statistically controlled or didn't have a control group. This allowed us to use a lot more information. Generally, the randomized controlled studies are thought of as the gold standard.

The other studies, particularly statistically controlled studies, can be useful because they often have a larger sample size and you may not lose a whole lot of validity when we're using the statistical controls, so they can be pretty valuable to include in there. They're included in this review in meta-analysis, although once you get through the Calculator, you can select to only use the randomized controlled evidence or only the statistically controlled evidence. Actually, the results between the randomized controlled studies and the statistically controlled studies aren't all that different. You have that option of what studies you want to really focus on when you're working with the Calculator.

Finally, we also looked at how long the outcomes were measured, if they were just a year or 2 years long. Then we also controlled for sample size to reflect that studies with larger samples are probably more important than studies with just 20 patients.

This next slide here also has to do with the meta-analysis. It's very similar to the previous table and kind of lists the evidence on each of the different outcomes. I think it's sort of the same takeaway message that there's more evidence for certain outcomes such as ER visits, hospitalizations, and outpatient visits, and less evidence on medication and ancillary service costs.

The main piece of data we just talked about is the literature review and meta-analysis and there's a lot of other data that's included in the Calculator. This is data to help you estimate based on utilization and that also just assigns a cost to a saved ER visit or saved hospital stay. When Elizabeth goes to the demo, I think you'll see a lot more clearly about where all those pieces fit in and where you can either use the Calculator -- the data that's already input into the Calculator -- or you can input your own information. Certainly, you have information on utilization and demographics and costs inside your population where you're going to implement the asthma care program. That's the best information for you to use so that your results are really custom tailored to the population that you're going to do your program with.

The last few slides before I wrap up is just to kind of give some caveats on using the Calculator and then finally just talk about some ideas of how to address some of those. There is limited evidence on program cost, which is the cost to implement the program. If you have a nurse educator, the cost for the nurse's time; you have a bunch of materials that you've distributed and you want to include the cost of those materials. There's a really wide range of costs reported in the study, the seven studies that did actually report those.

The average was $395 per patient, but it went anywhere from $81 to almost $1,000, so it was really quite a large range. Some of this could be because they included not just maybe the cost that had to do with running the program, but also some of the startup costs of developing the program. If you're taking a program from somebody else or using another model, then you might not have all the same startup costs of developing the materials, although you still may have some of those costs. Just keep in mind that there is quite a wide variation in program costs.

As I mentioned, only 10 studies reported the cost of asthma medications. In general, studies that didn't use a control group reported larger increases in medication costs associated with doing an asthma care program. Studies that were controlled and sort of were the best gold standard would tend to find a smaller impact of the program on medication costs.
Also, based on each different population, medication costs can vary greatly. If you're looking at patients with persistent asthma who have more frequent asthma attacks, they're likely to be using a lot more medications, taking long-term controllers, and perhaps costing more than patients who have asthma attacks less frequently and so maybe aren't taking a daily medication. Those are some things to keep in mind.

There were other sorts of caveats. The literature does continue to grow, so the literature review included in the meta-analysis is only through April 2007, but you can monitor results since then and input results from those other studies. The baseline data is from 2005, but you can use your own data to populate the Calculator to change that. We encourage people to do that actually, because I think if you're looking at a specific program and a specific population, those are going to be the best estimates with your own data. The baseline data is really a place to get started.

Then another caveat is that our estimate predates the current year. I believe all the dollars are in 2007 dollars, so you can use simple inflation estimates to describe in the appendix of the report to inflate and solve that problem or, again, just putting your own data in there to get around some of these things.

So now we're into the Q&A section, and I'll throw it over to Margie.

Margie Shofer: Thanks. As we mentioned earlier, there are two ways you can ask questions of our presenters. You can submit a question at any time by typing your inquiry into the Q&A box, or you can ask a live question by unmuting your line. You can unmute your line by pressing "*6." We'd really love to hear your voice, so please consider asking your question verbally.

Before we get to the questions, I just want to remind folks that if you want to download the slides, you can find them in the file share pod. There are actually four documents there. Two of them are PowerPoint slides and one of them is the Asthma ROI Calculator presentation that Ginger just gave. Then the other one is a presentation that Stephanie will be giving in a bit, and then there are two what we call "text alternative slides." Those are slides we provide for people with visual disabilities. Please feel free to click on those and download them.

I do have a question. If we want to produce some ROI estimates for a hypothetical asthma care quality improvement program in our State, do you recommend generating baseline data specific to our State, and what recommendations do you have for doing this?

Ginger Carls: That's a great question. Certainly you can get started with the data that's already input because this is sort of adjusted for the different States; however, if you have your own data, that's going to be even better, so certainly you'd want to do that. There's a variety of different things you want to think about. You want to make sure that you're estimating each piece. You want to look at utilization and cost and asthma prevalence, and make sure you are looking at that for the same population. For example, we use medical claims data to inform everything. If you're going to end up using that, then you'd want to make sure the denominator population for utilization rates and costs are all the same for each of the different pieces. So, medical claims data is a good source of information.

Margie Shofer: Thanks. I just want to remind folks, if you do have a question, there's no operator, so you can just feel free to pipe right in. Ginger, I'm wondering, this might be a good time to share the results from the poll.

Ginger Carls: Yeah. We had about a third, 33 percent of people who were planning a new asthma program or intervention. I don't know if any of those people would like to share sort of what they're thinking they would like to get out of this Web conference. Also, what they're looking for help on or learning information on or what they're working on, I guess, if anyone wants to comment on that.

Margie Shofer: Any of you six who said you have an asthma care program going on, if you want to come on, and we can chat about your program, that would be great. We're all ears. Okay, we don't have any takers at the moment, so I'm thinking it might be time to go into the live demo. After seeing the live demo, people might have some additional questions. I'm going to turn this over to Elizabeth.

Elizabeth Stranges: Thanks very much, Margie. As Margie and Ginger mentioned, today I'm going to show you how to use the Calculator to determine the return on investment of your asthma care quality improvement program or perhaps hypothetical program if you're considering it. I'm bringing up the Web page right now. I'm going to be explaining the basic features of the Calculator and how it synthesizes the data from the meta-analysis that Ginger was just explaining with the default data that's in the Calculator or with data that you have input. It synthesizes these things to produce an ROI estimate based on your specifications for a quality improvement program.

Before I begin I want to mention that at the bottom of your screen you will see there are a few buttons. There's a full screen button, and at the very end, if you go to the right of that, there is a scroll button. If you click on that, it will enlarge what you see if you'd like to do that to zoom in a little bit to see what's on my screen.

What you see here is the Calculator home page, and we've got a brief written overview up there. I want to draw your attention to the orange bar on the left-hand side of the screen. This is a step-by-step guide, which will be on the screen as you navigate through all the components in the Calculator. Section One provides some brief information on getting started if you were to click on that. Section Five offers more detailed resources through links to a User's Guide and to a Technical Guide. Sections Two, Three, and Four deal with the operations of the Calculator. This is what we'll be walking through today.

The first step to determining your program's ROI is to define for the Calculator the key features of your quality improvement program. We're going to begin by clicking right here under number two on required information. The required information page asks you for a few things and asks you to define who is going to be eligible for the asthma program, whom you want to target. It asks you what type of studies you'd like to use to estimate the impact of the asthma program, and it asks you what costs and savings you would like to include in the results.

We'll begin up here at the top. Today we're going to go through a hypothetical program dealing with Medicaid-covered individuals, and we're going to choose Virginia as our State for today. You will see a number of dropdown menus as indicated by these little arrows, and you will also see a number of terms that are underlined, and these are links. If you click on the link, it will take you to the area in User's Guide that provides more detail on that particular item.

As Ginger mentioned, you can choose to look at a program for just children or just adults, and today we're going to do the combination of the two. Then we also have a choice of asthma severity levels, and we'll begin by looking at all asthma. These are patients who have a claim in which asthma is listed as a primary or a secondary diagnosis.

As Ginger mentioned, randomized controlled studies are gold standards, so we're going to select those to use to estimate the impact of the asthma program today. We're going to go with the defaults we have here, and the type of costs we'll be looking at are the costs associated with asthma treatment. We could also look at the costs associated with any kind of treatment. The cost perspective we're going to be looking at today is that of the program, in this case, Medicaid, so the cost of Medicaid, and then any cost that the patient bears, so any copays in this case.

Down here under types of savings, we're going to leave selected both of these options. The first one tells the Calculator that when we see the results, we want to see what the health care savings are, and we want to see those included. We also want to see the productivity gains included. Once we have made all of our selections on this page, we'll click submit and proceed to the population page.

Here on the population page, if you look at that orange bar on the left-hand side, you'll see we've moved down into Section Three of the Calculator. For the next couple of items, we're going to be reviewing and editing the program features, and we will have the opportunity to edit some of the data. Here, the calculator has provided us with information on the Medicaid population in the State of Virginia. We have information on how that population breaks down in terms of age, gender, and race. All these data come from the Centers for Medicare & Medicaid Services. If we had selected a different type of insurance, such as private insurance, we would be pulling data from other data sources. We're not making any changes to this right now, so we're just going to click "Submit" and proceed to participants page.

On the participants page, what the Calculator does is it takes that population data that we just looked at for Virginia's Medicaid population and it applies some prevalence rates to that data to come up with the number of asthma patients who would be eligible for a quality improvement program. We had defined on our first screen, the required information screen, the people that we're interested in looking at are all asthma patients, those with severe as well as those with milder cases of asthma. The number of asthma patients eligible for our program based on that definition is over 55,000 in the State of Virginia.

The prevalence rates that the Calculator is applying to population data come from the MarketScan Medicaid claims database. If we were looking at private insurance, we would be drawing from the MarketScan commercial claims database. For Medicaid, we have information and we have these rates by age, gender, and race. For the privately insured population, we just have them by age and gender.

The Calculator knows that not all the eligible patients in a State or in a particular segment of the population are going to participate, so it allows you to input what you expect the participation rate to be. The default is set at 25 percent, as you can see here, and based on that default rate, we expect to have about 14,000 patients participating in our program. Again, we're not going to change any of this right now. If we had specific data to input about the size of the population that we're targeting and we wanted to cut right to this screen and begin here, we could do that. We'll click "Submit" and proceed to baseline page.

On this page, we see the asthma-related health care utilization rates and costs, which Ginger was referring to. The rates you see here are for the population which we have defined, so that's for all asthma patients, and we've already defined Medicaid and for both children and adults. These rates are not State specific. Again, if you have data for your State you can use, you can input them here. Anywhere in our Calculator where you see these black outline cells, you can simply click and highlight and change the data.

Again, today we're going to leave in the default data, but when Stephanie from the Alabama Medicaid Department picks up her part of the presentation and explains what they did, this is where they were able to come in and change the data. We're going to click "Submit" and proceed to the program impact page.

On this page, you see the results of the meta-analysis. You see how an asthma care quality improvement program will potentially affect the costs and utilization rates that we saw on the previous page. Here, under health care measures, you see program impact on emergency department visits, an 11 percent decrease. These estimates are based on what we entered on that required information page. They're based on the study type we selected, which was randomized controlled studies. If we had selected something else, we'd see different data right now. These are also specific to the asthma severity level we selected, so these are the impact estimates for the all asthma severity level.

While we're looking at this, I want to note that as we're walking through these different steps, if you scroll down on the screen, underneath that first navigation bar I showed you on the left-hand side there's a box titled "Assumption," and this box tracks what we have input so far. If you're running this a couple times and you lose track, you can just refer to this box and say, "Oh, that's right, we're looking at Medicaid in Virginia for adults and children." That's just a nice reference.

If you've done a pilot program and you have this data for your program, this is where you'd enter it. I don't have any data that I'm going to be entering here right now, so I'm going to click "Submit" and proceed to program cost page.

This is the last step in Section Three. We're confirming information on the program that we're setting up. Again, right now this is populated with default data, so I'll just run through what our default data is here. This is where you would come in and change things to make them specific to your program if you've got a program in mind or one that you've already run. If you're using this to kind of test out some concepts, you might want to start off with just leaving things as they are.

Here, the Calculator asks you how long the program will operate, how many years until the program achieves full impact. We've put in that our program will operate for 5 years, and it will be 2 years until it achieves full impact. The annual program cost per participant is set at $421, and the discount rate for the ROI calculation is set at 3 percent. We'll confirm this and hit "Submit" and proceed to the results page. You can see in the left-hand navigation bar that we have moved down to the section for reviewing results.

The results page allows you to review the results in one of two ways. You can see this box in the middle of the screen asks you, Do you want to look at the average per participant or do you want to look at the total for all participants? We're going to leave it as it is right now and just look at the averages per participant.

You can see here we've got kind of four sections of data to look at. We've got information about health care, information about productivity, information about program costs, and then information about the overall impact. For our hypothetical program for Medicaid-covered individuals in Virginia with mild to severe asthma, we are estimating a savings per participant of about $60. We can see that most of the savings would come in as money saved on hospital stays, and that money saved on hospital stays is balanced out by money spent on asthma medication.

Down here, again, we can see what the cost of the program is. We can see that there are productivity gains, that there are fewer lost days of work for adults and fewer missed days of school for children. We can see that for the overall impact of the program, our return on investment is $1.02. For every $1 we invest, we're saving two cents.

One of the nice features of the Calculator is that you can save all this information, including the information that you input, into an Excel® file. That's what I'm going to do right now. I'm going to click on "Save this scenario to an Excel® file." Up at the top, you'll get a little red note that tells you that that's been successful.

I'm going to briefly walk through a second scenario so that you can see how you can use this "Save to an Excel® file" feature and to also illustrate the concept that Ginger was talking about of how targeting patients with more severe asthma produces a greater ROI. To do this, I'll go back to the required information page. I'm going to leave everything on this page the same, except where it says asthma severity I'm going to select persistent asthma with an acute visit. Then I'm going to select "Submit" and proceed to population page. Again, I'm going to submit and proceed through all these pages because the only thing I want to change is that asthma severity level.

I do want to point out when we get to this next page, the baseline page, because we're looking at those asthma patients with an acute visit, you can see this reflected in the baseline data. Here we have annual emergency department visits per patient is 1.22, and in the last page it was much less than one. I also want to remind you that this is where you would enter your own baseline data if you have it. We'll click "Submit" and proceed to program impact page and we'll proceed again.

Again, here, these data are different because we've selected a different severity level. We'll leave all of our program specifications the same and we'll proceed to the result page, and here we have a new set of results. The program cost is the same because we did not change that. You can see the health care savings per participant is much greater than last time. Last time it was $60. This time we're closer to $3,000. You can see that the return on investment down here under the overall impact of the program this time is $2.36. For every dollar you invest, you're yielding $2.36.

Again, I am going to click "Save this scenario to an Excel® file." Then if I click "Download saved scenarios," it will open up an Excel® file for me, which contains both scenarios that I walked through just now. I actually did this earlier, and what I did was on the first half, it provides you with a list of all of the things that you input, so you can keep it as a record. Then the second tab provides you with the results in terms of the savings, the gains, and the overall effect of the program.

I brought the results from scenario one and scenario two together onto a summary tab. If you are using the Calculator to test out some different concepts, this feature allows you to kind of create the workbook and then easily compare and contrast some of the different things that you're looking at. In this case, we already saw that our health care savings are greatly increased when we focus on those patients who have persistent asthma with an acute visit, and our ROI is much greater.

At this point, I'm going to return to the slides, and I'm just going to summarize the items we just went through. Basically, when you're dealing with a Calculator, you've got to fill in your current information in Section Two of the Calculator. That's going to tell the Calculator what type of population you're dealing with and what type of studies you want to use in the calculation, and that's very helpful as you're considering how to go about creating a program or considering a program.

With that, I think we're going to wrap up the demonstration, and I'm going to turn it back over to Margie for more questions and answers.

Proceed to Next Section