The ROI Workforce for Public Health J. Mac McCullough, PhD, MPH - - PowerPoint PPT Presentation

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.

• We don’t really know: how much it costs to administer

vaccine(s), how much we are being reimbursed for each vaccine

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

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
• Revenues
• Average $26.43/patient
• 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

Estimate Sources: National /state data Secondary sources Primary sources

Revenues – Expenses = $3

Questions?

Ongoing Analysis: Dental Sealant Intervention – Return on Investment

• MCDPH conducts dental sealant outreach to hundreds of

schools (2nd & 6th 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

• n investment?

From 10 to 100 per school Screen almost 100% of those who consented About 60% of those screened will require ≥ 1 sealant Can increase by up to 50% Will this remain unchanged? Will this remain unchanged? Intervention: Provide education to students

Initial Findings

• Complex relationship between # served and MCDPH costs:

20 40 60 80 100 120 5 15 25 35 45 55 65 75 85 95

Cost per Child Screened ($) Number of Children Screened

Originally, we thought “the more the better”. But after certain thresholds, a second team or a second visit is needed to screen/ seal all children

Questions?