The “ROI” Workforce for Public Health J. Mac McCullough, PhD, MPH Assistant Professor School for the Science of Health Care Delivery Arizona State University
The LHD Health Economist Workforce • The position “Health Economist” is quite rare for local health departments • More state health departments have this capacity • Full-time, internal positions: currently found in large jurisdictions • Los Angeles County (pop. 9,285,379) • Maricopa County (pop. 3,880,244)
Adding Health Economics Capacity • For full-time, internal staff: • Motivating a HE position • Creating a HE position within the department • Getting a HE position approved by administration • Recruiting for a HE position • Other arrangements are possible: Identify and leverage capacity where it exists • External Consultant • Part-time • Project by project • Collaboration with local university • Faculty/Staff • Understand academic tracks (tenure vs. non) & incentives (% effort, publications) • Students • Program requirement vs. Research opportunity
Working with a Health Economist • Prioritizing projects • Who decides how to allocate the scarce resource (HE labor)? • County leadership, Health Department Director, HE Supervisor, HE him/herself • When is a HE brought in on a project? • At project conception, during data collection, during analysis • Who supervises?
Working with a Health Economist • Project requirements • Are the data already available? • Can they be compiled from secondary sources? • Will we have to conduct primary data collection? • Are data from elsewhere sufficient? • Can we use estimates from elsewhere in the state? From New York? From Canada? • Study timelines • “We need this by Friday” “If all goes well, I can get it to you by the end of the month”
My Experiences • Just because there isn’t a “$” doesn’t mean I can’t help • E.g., one recent project involved gathering Census data to estimate the number of uninsured in the county • Just because there is a “$” doesn’t mean I can • Meet-n-greets & site visits are critical • Warm intros and shared understanding of project(s) • I’m not a consultant here to outsource or eliminate your job! • Position funding matters • County funding Broad range of work within or beyond the dept • Grant funding Deep involvement in defined range of projects
Current Work
Ongoing Analysis: Cost of Immunizations to a LHD • MCDPH provides childhood vaccines at 3 clinics • We bill Medicaid and recently began billing private insurance providers • We know: total amount budgeted for the 3 clinics, total amount of revenue received from our billing partner. Clinic A Clinic B Clinic C Total Revenues $100,000 $220,000 $60,000 Total Expenditures $97,000 $190,000 $75,000 # Clients 20,000 35,000 5,000 • We don’t really know: how much it costs to administer vaccine(s), how much we are being reimbursed for each vaccine
Purpose of Study • We anticipate looming changes in patients served under the ACA. • Likely shifts in insurance plans & uninsurance • Comparison of last year’s costs vs. last year’s revenues does not facilitate future projections • For each client, do the costs of providing immunizations exceed, meet, or fall short of the revenues eventually realized through insurance billing? • Does this vary by insurance type? • Does this vary by immunization type?
Determining Costs • Two types of costs: • Fixed • Rent, utilities • Office supplies (refrigerator, computers) • Administration (program manager) • Variable • Vaccine cost (for non-VFC) • Vaccine supplies (needle, bandaids) • Nurse Labor? • Labor can be tricky: • Fixed in the short-term, variable in the long-term • How to allocate down time?
Determining Costs • To determine total cost: perform microcosting analysis • Observe workflow at each clinic • Luckily, they all generally use the same processes • Major events: • Client arrives and completes paper form • Intake clerk verifies data and checks against insurance databases • Client moves to next window/station • Intake nurse determines necessary shots by consulting online portal or patient-provided information • Client moves to next window/station • Immunization nurse draws up and administers vaccine(s) • Client departs • Time each step of the process and record other relevant details
Matching Costs & Revenues • Match time data to administrative wage data • Intake clerk time: 3 mins @ $12.00/hour $0.60/patient • Intake nurse time: 5 mins @ $29.16/hour $2.43/patient • Immunization nurse time: 5 mins @ $34.78/hour $2.90/patient • Other variable costs: $7.50/patient • Fixed costs: $10.00/patient • Total: $23.43/patient Estimate Sources: Revenues – Expenses = $3 • Revenues National /state data Secondary sources • Average $26.43/patient Primary sources • A lot of work to arrive at $3! • Payoff will be the following: • Average for Medicaid patients is $X • Average for private insurance is $Y • Average for Clinic A if total patient volume drops 25% is $x • Average for Clinic B without Medicaid patients is $y
Questions?
Ongoing Analysis: Dental Sealant Intervention – Return on Investment • MCDPH conducts dental sealant outreach to hundreds of schools (2 nd & 6 th grade) • Reimbursed on a per-child basis through contract with state • Purpose of study: • What is the minimum number of students needed for MCDPH to schedule a visit with positive cash flow? • A new intervention may help increase the number of students seen per school. What is the minimum boost needed for a positive return on investment?
Intervention: Provide education to students From 10 to 100 per school Can increase by up to 50% Screen almost 100% of Will this remain unchanged? those who consented Will this remain unchanged? About 60% of those screened will require ≥ 1 sealant
Initial Findings • Complex relationship between # served and MCDPH costs: 120 Cost per Child Screened ($) Originally, we thought “the 100 more the better”. 80 60 But after certain thresholds, 40 a second team or a second 20 visit is needed to screen/ 0 seal all children 5 15 25 35 45 55 65 75 85 95 Number of Children Screened
Questions?
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