State Quality Tools: ROI Calculator (continued)

Margie Shofer: Thanks, Elizabeth. As Elizabeth just said, we're entering our second Q&A session, and as you know by now, you can submit a written question by typing your inquiry into the Q&A box, or if you'd like to ask a verbal question, please unmute your line by either pressing "*6" or hitting the mute button or the unmute button, I guess, on your phone.

Khosrow Heidari: Hi, this is Khosrow with the South Carolina Department of Health and Environmental Control. South Carolina doesn't have an asthma program in the public health setting; however, we are thinking about establishing something. I'm not exactly sure in what shape it will be, but I was wondering if other States have used an ROI like this to establish something in their State. It doesn't matter what, but just an example that we can learn from.

Rosanna Coffey: This is Rosanna Coffey. We are going to hear from Alabama next about what they have done with the Asthma ROI Calculator. I suspect your question has to do with setting up an asthma prevention and control program. Am I right, that you do not have one of those with the CDC?

Khosrow Heidari: Correct. Well I'm interested in all aspects of it. I think we need to start somewhere, and using examples that others have used and gone forward would be helpful to us.

Rosanna Coffey: Yes. The CDC program provides a lot of information. I'm not an expert on how they help you get started but I know that they will give you some advice. The other thing that is available from AHRQ is an Asthma Quality Improvement Guide. That's available on the AHRQ Web site, and I'm sure we can send you a link to that. What that does is take you through the process of trying to improve asthma in your State. It talks about the quality improvement cycle. It provides sort of a business case on why you would want to improve asthma care.

I think Elizabeth and Ginger showed you that the literature suggests that you'll get a return if you do it in a smart way. That asthma guide also has in it some information on how you need to collect data so that you can tell whether or not you've made an improvement. What other States have done is part of that. There's a chapter in there that might help to answer your question about what other States have done. Then the guide ends with a set of action steps of what you can do.

Of course, then the improvement cycle, if you are trying to pull together a local coalition because certainly a national health policymaker and even a State-level policymaker can't make improvement on their own. Improvement happens at the point of care, between the physician, the health care provider, and the patient. A big important step is to pull together a coalition of thought leaders, champions for asthma care in your State. They could be physicians; they could be program folks, or it could be your Medicaid director. It could be lots of different people. You may have a lot of people around the table, and this guide sort of helps you go through that.
Even before you get to developing a quality improvement program, I think you will want to check in with the CDC program and what they have and how they collect data and help you understand your prevalence and so on and so forth. Does that help?

Khosrow Heidari: Yes, absolutely. In fact, while you were talking, I went online to your Web pages, and I saw that Asthma Quality Improvement Handbook.

Rosanna Coffey: Okay. Great.

Khosrow Heidari: I appreciate your instruction. Thank you.

Rosanna Coffey: I don't know, Margie, if you want to talk about any of the other things that are going on at AHRQ in terms of technical assistance.

Margie Shofer: Oh, you mean through this program?

Rosanna Coffey: Yes.

Margie Shofer: Certainly, we are available to help you use any of the tools we've shared as part of this project. Obviously, the Asthma ROI Calculator is one of them. If anyone does go and download the tool Rosanna just talked about, which is the Asthma Quality Improvement Guide, and you have questions as you go through that, feel free to contact us, and our contact information will be on the last slide, and we can provide assistance with that too.
I don't know if any other State folks who are on the call who have an asthma care program in place, if you wanted to share a little bit about sort of how you got started for the gentleman from South Carolina. Don't be shy.

Mary McIntyre: This is Dr. McIntyre from Alabama Medicaid. Stephanie is going to go into it a little bit of it in her presentation, but there's a lot of information out on our Web site. We actually got started as part of our transformation grant. We pulled together a clinical workgroup that basically is your team that consisted of a lot of people from what you would consider to be more of a local coalition. It was made of people from across the State in different areas: physicians; pharmacists; nurses; people that were with the health department; others like Blue Cross/Blue Shield; AQAF, which is our QIO; and a lot of other entities that were involved in it that were just interested in trying to work on it.

We actually did put together a program that you'll learn a little bit more about during Stephanie's presentation. She'll give just some idea about the Q4U, which is a component, but if he's interested in more information, we'll be really happy to share the info on the Q4U component of our care management program.

Margie Shofer: Thank you, Dr. McIntyre.

Rosanna Coffey: Could I add one more thing, Margie?

Margie Shofer: Sure.

Rosanna Coffey: He said he went out on the Web site and he found the handbook. I just wanted to note there is a handbook, as well as a guidebook, and the guidebook is where all of the details are about what I just talked about. The handbook is to help you gather your own data to make your own business case for a program.

Margie Shofer: Thanks, Rosanna. I think this might be a good time to move to Stephanie's presentation. Stephanie, I'm going to hand this over to you.

Stephanie Lindsay: Thank you. I'm Stephanie Lindsay with the Alabama Medicaid Agency's Statistical Support Unit. Today, I'm going to discuss Alabama Medicaid's experience with the AHRQ Asthma Return-on-Investment Calculator. The first thing I'm going to do is give you an overview of our State's TFQ program. TFQ stands for Together for Quality. Specifically, I'm going to go over the Q4U component of our TFQ program.

The TFQ grant requirements have been simplified to these three goals that we use in presentations and in any publication. All of this is being done using our PCCM program, patient first, as the foundation, which allows us to target the providers for participation and provides us with leverage to enter into contracts for purposes of this pilot. The Together for Quality initiative is composed of three actual component parts: TFQ, QX, and QTool.

The Asthma Return-on-Investment Calculator is being used to determine the return on investment only for the asthma component of Q4U. Here you have the definitions of each of those components. The chronic care management component, known as Q4U, consisted of care management services provided to persons identified by the Medicaid agency for enrollment in care coordination programs based on meeting the technical specification developed with the assistance of the TFQ clinical workgroups. This pilot ended March 31, 2010, with an external evaluation currently in process.

On this slide we have a map of Alabama with the counties highlighted that were in our pilot program. The pilot was designated with care management only in 2 counties, clinical support was in 3 counties, and both clinical support and care management were in the remaining 6 counties, so only 11 counties were included in our data.

Several factors limited the number of individuals to be targeted for enrollment in care management. Some of those factors identified were the number of care management staff, refusal of providers to participate, and patient or caregiver refusal to participate, and inability to locate recipients. An estimated 1,200 Q4U participants were determined based on the aforementioned factors. The estimated enrollment was met with an actual enrollment of 1,296. Of these, 795 were enrolled for at least 6 months, which was the minimum enrollment timeframe. That was our goal decided upon prior to implementation.

Alabama Medicaid wanted to have the ability to input our TFQ information into the AHRQ Return-on-Investment Calculator. We weren't able to do so initially because TFQ data did not appear to include all of the variables that the ROI tool used. Alabama was instructed by AHRQ and Thomson Reuters that we would be able to use the population data for the pilot counties in order to see the ROI for this subset of the Alabama population.

Alabama had several discussions with AHRQ and Thomson Reuters in order to determine what information should be used to capture the variables, such as asthma-related ancillary costs, outpatient visits, and prescription utilization. This information was input on the baseline page of the ROI tool, which we just saw. AHRQ and Thomson Reuters were available for all questions and concerns that Alabama Medicaid had. Numerous calls and E-mails were placed in order to answer our questions.

This slide gives you a general idea of the timeframe that was involved. We got started back in January of 2008, and as I said earlier, our pilot just ended. We have started doing the full participation numbers, and in July of 2010 we began calculating the return on investment. For the rest of 2009, we requested assistance interpreting our results. The pilot program ended on March 31, and we included a 3-month tail period to allow for submission of the majority of claims for the dates of service in question. In July we started calculating our actual claims data.

On this slide we have some TFQ highlights. We had 213,000 Medicaid eligibles in the pilot counties; 21,000 of those eligibles were asthma recipients, and 1,296 were recipients who actually participated in the TFQ care coordination. The TFQ program saw a decrease in the number of recipients with ER and hospital visits and a decrease in ancillary charges. We also noticed an increase in the number of recipients on asthma medication.

On this slide we just have our total health care saving, our productivity gains, our total cost, and our return on investment. Alabama Medicaid's return on investment was 4 percent. For every dollar that we spent on the program, we saved 4 cents. The fact that we achieved a positive ROI was hopeful but not expected due to our short timeframe for the pilot. Our pilot was only active for 2 years.

This slide gives you the contact information for Dr. McIntyre and myself. As she said earlier, please feel free to contact us with any questions that you may have regarding our presentation. That is the end of my presentation. Thank you for allowing me the opportunity to speak regarding Alabama's experience with the Asthma ROI Calculator. I'll send it back to Margie for discussion.

Margie Shofer: Thank you, Stephanie. We've entered the final opportunity for you all to ask questions of our presenters, and as you know really well by now, you have two options. You can type your inquiry into the Q&A box, or you can ask a live question by unmuting your line. Stephanie, how difficult was it for you to use the Asthma ROI Calculator?

Stephanie Lindsay: Once we determined the procedure codes, the NDC codes, and the costs for each of the variables that we were to enter on the baseline page of the Calculator, the process actually to enter in the data was not difficult at all. We were very fortunate to have AHRQ and Thomson Reuters available whenever we had any questions, so I would say that it was not difficult at all.

Margie Shofer: What have you done with the results that you got from the Calculator?

Mary McIntyre: Hi. This is Dr. McIntyre. I'll go ahead and answer that. We just received the initial results on this. Basically, what we've done is reached a break-even point with it, just saving a little money because of how high our costs were. What we've done right now with it is we made the commissioner aware and several key members of the Medicaid staff. We also provided our director of our Transformation Initiatives Division, who actually headed up the Together for Quality pilot program, with plans to actually provide the information to our external evaluator. As part of the process that we have to do, we have to complete a full evaluation for the Together for Quality program.

We've looked at the results and the potential as to how we can increase our return on investment. For every dollar spent, we actually got a return of $1.04, or 4 percent return on investment, which is a break-even in 2 years and is something we didn't expect. What we actually have done is determined how we can reduce our costs. What we looked specifically at is the population to target, doing a better job with that and actually making a change in the way we do the referrals so that we have a lower number or percentage that the care coordinators would actually have to contact in order to meet the enrollment target.

A lot of these people they were unable to find. If we had actually done the initial connection with the physician's office, we have identified that we would have reduced that. If we can go in and reduce those care management costs, we believe we can reduce it by 30 to 40 percent just by changing the number of visits that are defined and what a care management visit is, those types of things. By doing that, if we can reduce the care management costs by 30 to 40 percent, then we can increase that return on investment so we could actually, for every dollar spent, get a return on investment of $1.30. Instead of 4 percent return on investment, we could get a 30 percent return on investment. We've learned quite a lot from being able to use the Return-on-Investment Calculator.

Margie Shofer: That's great. That sounds very ambitious, Mary.

Mary McIntyre: I know.

Rosanna Coffey: This is Rosanna. That's great. This is the first time I'm hearing about these results, so it's really exciting. I have a question for you, and I'm trying to understand how much of what you put in the Calculator was based on your own baseline and your own impact for the clients that were in your program. So you did include your own baseline costs and utilization, and then you did include your own impact numbers?

Mary McIntyre: Yes, we did. Stephanie can probably give you the full thing on that. We actually went in and identified that number, how it calculates a percentage of what you're expected to achieve. I think the Calculator had that at 6 percent. We actually had initially looked at trying to enroll at least 5 percent, but we reached almost 6 percent. When we made the calculations, we made sure it actually fit what we ended up with as far as enrollment actually in that. We included the number of people in our counties that were eligible and also identified as having asthma. Based on what we actually obtained as far as results from our logic that we used for the TFQ program.

Rosanna Coffey: Okay. That's very interesting, because what you've done is, if I understand you correctly, is you've overridden what the literature says the impact would be with your own impact. So the percentage of hospitalizations that declined, the percentage of ED visits that fell are your estimates, correct?

Mary McIntyre: Stephanie can answer that. My understanding from the information, though, is yes. Stephanie?

Stephanie Lindsay: Yes, that is correct.

Rosanna Coffey: That's really great because I was thinking that you were using your baseline and then you were still depending on what the literature was telling you. But you're actually using the tool as a little quick evaluator. I heard you say that you have to do a full-scale evaluation. This gave you a really fast look at what you were seeing from your data, and that's a great tool for helping you decide, do I need to make any changes, do we need to target this more carefully?

Did you target just on the severely ill asthma patients, or were you able to do anything around severity?

Mary McIntyre: One of our lessons learned from this Calculator is that if we had really focused on that ER inpatient hospital group that we would have had a bigger return on investment. That's part of what I was talking about, about better targeting the population. We actually did what was for us kind of like a surrogate for that, and we used what we called "missed opportunities," and we started trying to identify people with what we called "five missed opportunities for initial enrollment."

The reality is we ended up going all the way down our little logic tree that we had developed, where we ended up with some folks that did not have all of those missed opportunities. Within our logic, basically, we looked at people that were not using their medications appropriately, those that didn't have controllers, emergency room visits, and hospital visits. Then the thing that we included that we probably shouldn't have was that influenza. Absence of having a flu shot was one of our missed opportunities. That's one of our lessons learned, that we know we can get a bigger bang for our buck with less effort with having to have fewer visits than we actually had in our protocols because we went through the trouble to even identify the specific timeframes that care coordinators had to make the contact. There were risk assessment tools required, face-to-face visits within the home, and then a return visit to the home.

This was pretty labor intensive, which really made our costs high on the care management side. We have identified, based on using this Calculator and with the external evaluator that's at the University of Alabama in Birmingham, the information they pulled as part of that. We probably could have gotten similar results by actually targeting a smaller population, even though you're talking about harder to find. If we make that initial stage the provider instead of us trying to get the care coordinators to find these people, we think we can focus on the smaller group and still get that bigger return. That's our lesson learned from this.

We're actually looking at how do we roll this in? We're going to start doing some stuff with working with what we call care network, similar to North Carolina. What we hope to do as part of that local coalition piece with those networks is work with them in defining specifically what those quality improvement initiatives need to be.

Margie Shofer: Great.

Rosanna Coffey: I was going to say I do have a followup discussion on this, but I don't want to take all the time.

Margie Shofer: Let's pause for a second. Does anyone else have a question for the Alabama folks or Ginger, Elizabeth, or Rosanna? Hearing none at the moment, Rosanna, why don't you proceed?

Rosanna Coffey: Ginger, I want to come back to you with the Alabama experience. The fact that they have entered their own impact estimates in their own baseline and so on makes me think that what they're looking at in this return is an uncontrolled kind of analysis, which would be more positive than what you would get if you did a statistically controlled one. Am I thinking correctly?

Stephanie Lindsay: Rosanna, I'm sorry, I think that we've led you to believe something that's not true.

Rosanna Coffey: Okay.

Stephanie Lindsay: On the program impact page of the Asthma ROI Calculator, we did not change those health care measures and productivity measures. What we changed were the population numbers.

On the participants, the number of eligibles for the program, that information came from the pilot counties. Then the percentage of eligibles who would participate, I think when we put in the number of patients eligible for the program, the percentage of eligibles who would participate was like 5 percent. We actually had about 6 percent participate, so we changed that in order to get the expected patients who would participate to about 1,300 or 1,296.

Rosanna Coffey: Okay.

Stephanie Lindsay: Sorry about that.

Rosanna Coffey: No problem. This is part of what you learn as you look at things and try to understand. Let me correct for the audience what I had said. In fact, what Alabama has done is take their own enrollment figures and the number of people that participated and they have put that up against the literature, basically, because they have kept the impact estimates from the literature. It's suggesting that they are probably covering their costs as Dr. McIntyre said, and that's really good because a lot of the scenarios that we went through showed that you could not cover your costs with some of these programs. I think it's helped them get a handle on their costs and know that they need to be careful about the costs of the program to get a return.

In fact, you will be doing a full-scale evaluation where you're looking at your own costs. You've got a control group, we hope, that you'll be looking at, because when you have a bunch of people that go to the hospital in a year or go to the emergency room in a year, you expect next year those people, even if you did nothing, wouldn't be as likely to come back to the hospital. Some of them will, but on average, you'll have a decrease in that. There's a technical term for it that's called "regression to the mean," and that's why people want to see randomized controlled studies or statistically controlled studies.

I think you used the Calculator in the way that we originally intended it to be used. I thought you were stepping one ahead of us, but that's fine the way you used it. It'll be exciting to see what your actual evaluation results come out to be compared to what the literature tells you, which is what the Calculator says. That's it, Margie. I won't say anymore.

Margie Shofer: Before I wrap up, does anyone else have any questions? I thought I heard perhaps someone unmuting their phone. Is that someone who wants to ask a question? Okay. I'm going to think it's someone who was muting their phone.

I want to thank you all for your participation in today's Web conference, and we hope this discussion was helpful for you. I do want to give one last reminder that if you want to download the slides, you can find them in the "File share" box. You will see two Word documents and two PowerPoints, one of which is the overview of the Asthma ROI Calculator, and the other one is the slides. Please feel free to download those now.

If you have any questions about follow-on technical assistance opportunities, please do not hesitate to submit them to the quality tools E-mail address shown on the slide. If you have any questions or comments about this tool, please send an E-mail to the same address. As you can see, we have also provided a link to the Asthma ROI Calculator and to AHRQ's Web site where the archive of the HCUP Web conference is housed. As I said, the other Web conferences we held as part of the series will be housed there as well.

Before we end this Web conference, you will see a final set of polling questions that we will use to evaluate this event, so we would appreciate your taking the time to answer these questions. It helps us for future planning.

Thanks again for joining us, and this concludes the Web conference, and we look forward to hearing from you.