**MEASURING**

**THE RETURN ON A COMMUNITY'S INVESTMENT (ROCI)**

**RESULTING FROM**

**PROVIDING ACCESS TO AFFORDABLE HEALTH COVERAGE**

**David P. Rogoff**

**July 2003**

**[TABLE OF CONTENTS]{.underline}**

**[Page]{.underline}**

ABSTRACT

REPORT:

I.  INTRODUCTION 1

II. GUIDING PRINCIPLES 5

III. THE PHASES OF MEASUREMENTS 12

IV. SPECIFIC MEASUREMENTS 18

V.  PRESENTING THE FINDINGS 44

APPENDICES:

A.  EXAMPLE OF A GROUP PROCESS TO APPLY

> THE RETURN ON COMMUNITY INVESTMENT (ROCI) CONCEPT

B.  PRESENTATION GRAPHICS EXAMPLES:

> ROCI FOR COUNTY PROGRAM EMPHASIZING INFLUX OF STATE FUNDS

C.  TALKING POINTS FORMAT---

"COUNTY HEALTHCARE PROGRAM\"

***[ABSTRACT:]{.underline}***

**[PURPOSE OF THIS DOCUMENT:]{.underline}**

This document addresses how a community can measure the ROCI from
addressing health care access for the underinsured, as well as how the
findings can be most profitably presented to key stakeholder groups.

**[ACCESS TO AFFORDABLE HEALTH CARE IS NOT ONLY SOCIALLY THE RIGHT THING
TO DO BUT ALSO MAKES GOOD FINANCIAL SENSE:]{.underline}**

In order to sustain funding for programs that increase access to
affordable health coverage, it is necessary to show that this access is
not just socially the right thing to do but also that it makes good
financial sense. The resolution of the issue of the vast numbers of
people who do not have access to affordable health coverage has been
deterred by too much emphasis on the value-laden question whether health
care is a right or a privilege rather than looking at the aggregate
financial impact on the community of people not being insured (the
"uninsured") or not having adequate insurance (the "underinsured").
Another deterrent to the resolution of the issue of affordable health
coverage has been the focus on who should pay for the resolution of the
problem, before there is actual agreement that it is a community
problem.

**[THE BUSINESS CASE STRESSES RETURN ON COMMUNITY INVESTMENT (ROCI) THEN
SHOWS RETURNS TO INDIVIDUAL STAKEHOLDERS:]{.underline}**

The business case for meeting the needs of the underinsured must
emphasize that there is an aggregate return on the community's
investment (ROCI). Unless all stakeholders believe that what is good for
the community on the whole is good for the individual stakeholders, the
business case must also show that the desired distribution of expenses
between key stakeholders is accomplished and that individual
stakeholders receive a return on their investment as well. It is
relatively easy to demonstrate benefits to the broader community when
stakeholders agree that it is in everyone's best interest to make the
investment. However, the typical situation is that the individual
stakeholders, particularly those funding the effort, must first be shown
that there is a return on their investment and that their expectations
are met.

**[FINANCIAL IMPACT INCLUDES MORE THAN JUST DIRECT COST
SAVINGS:]{.underline}**

In the past, organizations measuring their return have focused only on
the direct cost savings. To address the complete picture, the indirect
cost savings, the ability to bring funds into the community, and changes
in the quality of life must also be measured.

**[GUIDING PRINCIPLES IN MEASURING ROCI:]{.underline}**

The guiding principles for the measurement of the return on community
investment (ROCI) for access to affordable health coverage are:

-   Address the benefits to the community and the return to individual
    stakeholders' investments.

-   View ROCI as part of the business case.

-   Attempt to quantify the financial impacts of as many factors as
    possible.

-   Be conservative.

-   Set up ongoing measurements of ROCI.

-   Measurement of the financial benefits of a program should be
    compared to how the community would be without the program.

-   The measurement of the ROCI includes more than just the direct
    health care cost savings. It includes indirect cost savings, the
    value of money brought into the community, and the value of improved
    quality of life such as improved morbidity, mortality, and
    productivity.

The document provides additional explanations of the above principles
and specific guidance, including examples, on how to actually measure
the ROCI.

***[I. INTRODUCTION:]{.underline}***

Have you ever stated or heard someone else state that investment in
access to affordable health care for the low-income population is not
only socially the right thing to do but that it makes good business
sense? Then, were you asked to prove it? Could you do so? In order to
obtain initial funding for programs, and to it, it is critical that you
can prove that there is a return on the community's investment.

It is true that obtaining affordable health care coverage has become a
serious problem for many Americans, resulting in vast numbers of people
who do not have insurance (the "uninsured") or have inadequate insurance
(the "underinsured"). Many communities across the country are debating
why this problem has developed, how it can be rectified, and who should
pay for its resolution.

Historically, we have created a problem for sustaining funding by
focusing just on the social issues, asking only the fundamental question
whether health care is a right or a privilege. Assessing the importance
of access to health care by starting with the value-laden question has
been a deterrent to resolving the issue. When there is agreement that
access to health care makes financial sense, however, cooperation toward
finding solutions develops regardless if it is determined to be a right,
a privilege, or something else entirely.

Another deterrent to the resolution of the issue of affordable health
coverage has been the focus on who should pay for the resolution of the
problem, before there is actual agreement that it is a community
problem. Therefore, this document will address how a community can
measure the return on its investment in addressing health care access
for the underinsured as well as how the findings can be most profitably
presented to key stakeholder groups.

The federal Health Resource Services Administration (HRSA) has supplied
seed money to communities in the form of grants such as the Healthier
Communities Access Program (HCAP), formerly known as the Community
Access Program (CAP). While the CAP recipients have successfully
implemented programs, they too are now faced with the challenge of
obtaining sustaining funding when their HCAP or CAP grant period is
over.

When this ROCI model was first developed several years ago, in the
"pre-9/11" days, it was presented in the context that although the
economy was good, there were many who were uninsured. The economy was
sound enough to address the issue. Then, we cited that 1 out of 6
Americans were uninsured, totaling over 40 million people. We now hear
the argument that the economy has softened and that society does not
have the money to address affordable health coverage. However, society
must still address affordable health coverage in order to rebuild the
economy and it must be through partnerships. To compound the challenge,
the weak economy and rapidly increasing health coverage costs have
increased the number of uninsured and underinsured people.

In order to obtain sustaining funding, the business case for investing
in affordable health care for the low-income population must be shown.
It is relatively easy to demonstrate benefits to the broader community
when stakeholders agree that it is in everyone's best interest to make
the investment. However, the typical situation is that the individual
stakeholders, particularly those funding the effort, must first be shown
that there is a return on their investment and that their expectations
are met. In the past, organizations measuring their return have focused
only on the direct cost savings. To address the complete picture, the
indirect cost savings, the ability to bring funds into the community,
and changes in the quality of life must also be measured.

Therefore, the first financial goal of meeting the needs of the
underinsured is that there will be aggregate return on the community's
investment (ROCI), while the second financial goal is that a desired
distribution of expenses between key stakeholders is accomplished and
that individual stakeholders receive a return on their investment.

This document will describe a framework for measuring the return on a
community's investment in addressing health care access as well as
identifying stakeholders, their expectations, and their concerns that
they receive a return on their investment. This framework will also
assist in the documentation of the case for the community and
stakeholders' investment.

This ROCI framework was developed over a three-year period and applied
to over thirty communities and counties. With each two project or
application, the approach was further refined. This document provides
insight resulting from these applications.

While the main body of this document does not detail the actual group
process for doing the ROCI measurement, Attachment A provides an example
of a process that could be used.

***[II. GUIDING PRINCIPLES]{.underline}***

Before we start looking at the specifics of measuring the return on
community investment (ROCI) for health care access for the underinsured,
it is useful to understand key guiding principles.

-   **[Address the benefits to the community and the return to
    individual stakeholders' investments.]{.underline}**

    -   The most convincing argument is made when there is concurrence
        amongst key stakeholders that money spent on improving access to
        health care is an investment in the community.

    -   With the increasing use of public-private partnerships to
        address care for the underinsured, it makes sense to first look
        at an aggregate ROCI as a means of building these partnerships
        but then to customize the ROCI to the expectations of individual
        stakeholders.

-   **[View ROCI as part of the business case.]{.underline}**

    -   Identify the targets for the business case -- As summarized
        below and further described in Exhibit 1, the four general
        target groups for the business case are:

        -   Current funders who want accountability for their
            investment.

**Exhibit 1.**

**STAKEHOLDER GROUPS AND THEIR EXPECTATIONS**

+-----------+--------------+--------------------+---------------------+
| **C       | **EXAMPLES** | **EXPECTATIONS**   | **MEASUREMENTS**    |
| ATEGORY** |              |                    |                     |
+-----------+--------------+--------------------+---------------------+
| ***( A    | 1)  Private  | -   Benefits       | 1)  Return on       |
| )***      |     and      |     exceed risks   |     Community       |
|           |     public   |     and costs.     |     Investment:     |
| ***C      |     grantors |                    |                     |
| URRENT*** |     /        | -   Return on      | -   Direct and      |
|           |              |     investment.    |     indirect cost   |
| ***       | reimbursers. |                    |     impact.         |
| DIRECT*** |              | -   Prudent and    |                     |
|           | 2)           |     legal use of   | -   Quality of life |
| ***F      |   Taxpayers. |     funds.         |     impact.         |
| UNDERS*** |              |                    |                     |
|           | 3)           | -   Process        | -   Ability to draw |
|           | Subsidizers. |     matches        |     down funding.   |
|           |              |     expectations.  |                     |
|           | 4            |                    | 2)  Agreed upon     |
|           | )  Insurers. | -   Better off     |     financial       |
|           |              |     with program   |     performance.    |
|           |              |     than without.  |                     |
|           |              |                    | 3\) Influx of funds |
|           |              |                    | from other sources. |
+-----------+--------------+--------------------+---------------------+
| ***( B    | 1)  Clients. | -   Ease of access | Quality, access,    |
| )***      |              |     (financial,    | and service have    |
|           | 2)           |     convenience).  | financial impact    |
| ***CUS    |   Providers: |                    | that will be        |
| TOMERS*** |              | -   Satisfaction   | reflected in ROCI   |
|           | -            |     \-- \"They     | measurement.        |
|           |   Hospitals. |     seek you       |                     |
|           |              |     out.\", they   |                     |
|           | -            |     receive what   |                     |
|           |    Community |     expected.      |                     |
|           |     Health   |                    |                     |
|           |     Centers  | -   Better off     |                     |
|           |     / Other  |     with program   |                     |
|           |     Primary  |     than without.  |                     |
|           |     Care     |                    |                     |
|           |              |                    |                     |
|           |   Providers. |                    |                     |
|           |              |                    |                     |
|           | -            |                    |                     |
|           |  Physicians. |                    |                     |
+-----------+--------------+--------------------+---------------------+
| ***( C    | 1)           | -   Can access     | Measurements are    |
| )***      |   Community: |     services.      | the same as for ( A |
|           |              |                    | ) Direct Funders    |
| ***NON-   | -            | -   Ability to     | and an overall      |
| INVESTING |    Business. |     understand     | funding strategy is |
| BENEFIC   |              |     their          | to show that the    |
| IARIES*** | -   All      |     benefits.      | benefits are so     |
|           |     people.  |                    | great that specific |
|           |              | -   Better off     | indirect            |
|           | 2)  Teaching |     with program   | beneficiaries       |
|           |     i        |     than without.  | should support the  |
|           | nstitutions. |                    | program and even    |
|           |              |                    | become direct       |
|           |              |                    | funders.            |
+-----------+--------------+--------------------+---------------------+
| ***( D    | 1\) More     | > Same as ( A ).   |                     |
| )***      | funding from |                    |                     |
|           | Group A.     |                    |                     |
| ***       |              |                    |                     |
| POTENTIAL | 2\) New      |                    |                     |
| F         | funders.     |                    |                     |
| UNDERS*** |              |                    |                     |
+-----------+--------------+--------------------+---------------------+

NOTE: This framework was initially put together in a work session with
the Arkansas River Valley Rural Health Network and has had subsequent
refinement.

-   Clients who, although they do not make a significant dollar
    investment in the program directly, the quality, service, and cost
    performance of the services they receive are evaluated by those who
    do invest on their behalf.

-   Other beneficiaries who do not currently invest in the program but
    might do so if shown the benefit they could receive.

-   Potential funders who could be convinced to invest in the program.

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-   Program objectives should emphasize quantifiable financial results.

As illustrated in Exhibit 2, the ongoing funding for care for the
underinsured typically comes from one of four sources:

-   Government subsidy to providers -- Could be a combination of local,
    state and federal subsidy.

-   Out of pocket payment from recipients of care.

-   The value of the care that providers give for which they are
    uncompensated -- If the provider intentionally directs care to lower
    cost settings, the uncompensated care is called "voluntary". By
    comparison, uncompensated care in less desirable settings is called
    "involuntary". For example, providing pro bono primary care for
    people who would otherwise use emergency rooms for their primary
    care is an example of reducing total uncompensated care by providing
    voluntary uncompensated care as a replacement for involuntary
    uncompensated care.

**Exhibit 2.**

![](media/image1.wmf){width="6.375in" height="4.773611111111111in"}

-   Subsidy from other users of services -- This is what is popularly
    called cost shifting. Unless there are specific programs in place to
    surcharge insurance premiums or specific patient bills to support
    the underinsured, it is becoming more difficult for providers to
    cost shift.

With some exceptions, while private sector philanthropy or government
grants can be used to start up programs for improving health care
access, these outside funds cannot be relied upon for ongoing funding.
Examples of exceptions are when a private source endows the fund to pay
for services for the underinsured.

-   **[Attempt to quantify the financial impacts of as many factors as
    possible.]{.underline}**

    -   Financial quantification is the most objective and least
        value-laden measure. Individuals may differ in their perceptions
        of the social importance of health care for the underinsured and
        its qualitative link to the community, but should agree with the
        quantification of financial impact if it is supportable by data.

    -   If impacts cannot be financially measured directly, measure a
        proxy for the financial outcome or quantify non-financial
        returns to the community. This is particularly true when it is
        too early to measure financial outcome but a process and
        structure has been put in place that would indicate that the
        outcome will be achieved. For example, access to health care
        alone is not a financial measure; the measure of the value of
        the access is a proxy for financial outcome.

-   **[Be conservative.]{.underline}**

    -   Use the highest, most accurate, and broadly accepted values.
        Often times the goal of measurement is to find a financial
        benefit with which the targets for the business case will agree.

    -   If this conservative number is adequate to make the case,
        additional time and effort that will result in showing
        additional financial benefit may not be needed.

-   **[Set up ongoing measurements of ROCI.]{.underline}**

    -   The measurement of ROCI should not be viewed as a one time
        study. You will continually be challenged to prove a return on
        the investment in care for the underinsured. Setting up an
        ongoing measurement of ROCI will allow you to prove the ROCI
        whenever you are challenged.

    -   Over time, expect improved accuracy.

        -   Initially, components of the ROCI will be projected using
            the results of national studies and experience at similar
            programs. Then the ROCI component should be measured to
            confirm or adjust the projection.

        -   If the measurement is conservative from the beginning there
            should be the ability to show increased ROCI with more
            accuracy. It is important that you are sure the financial
            impact is "at least the amount measured even if it means
            sacrificing some of the ROCI.

-   **[Measurement of the financial benefits of a program should be
    compared to how the community would be without the
    program.]{.underline}**

    -   This is a more meaningful measurement than a comparison to how
        society was before the program was implemented.

    -   It can be difficult and time-consuming to reconstruct the way it
        was before the program and may not contribute any useful
        information.

-   **[The measurement of the ROCI includes more than just the direct
    health care cost savings. It includes indirect cost savings, the
    value of money brought into the community, and the value of improved
    quality of life such as improved morbidity, mortality, and
    productivity.]{.underline}**

Guided by these principles, we can now look at the specifics of a
measurement of the return on a community's investment in addressing
health care access.

***[III. THE PHASES OF MEASUREMENTS:]{.underline}***

Ultimately, the principal financial measure of the effectiveness of a
program to improve access to health care is improved quality of life
accompanied by reduced direct cost of health care. It is initially
difficult to measure these outcomes in the early life of a program, and
if a program has been in existence for a period of time, it is difficult
to assess outcomes if the measurement tools are not in place.

As illustrated in Exhibit 3, it is recommended that the ROCI measurement
be developed in three phases.

-   Phase 1: Identification and measurement of actual and projected
    financial benefits to date and development of measurement for more
    refined measurements.

-   Phase 2: Completion of activities started in Phase 1 and
    commencement of outcome measurements.

-   Phase 3: Ongoing calculation of the ROCI.

**Exhibit 3.**

![](media/image2.wmf){width="6.750694444444444in" height="5.05625in"}

The three phases of measuring the ROCI are further described below.

-   **[Phase 1: Identification and measurement of actual and projected
    financial benefits to date.]{.underline}**

> A mistake that is often made when it is decided to measure ROCI is to
> wait until the perfect measurements are done to release findings. It
> should be remembered that if the objective is to prove that there is a
> positive ROCI, the most important consideration is whether there is
> agreement that the ROCI is what is indicated. Therefore, it is
> recommended that an initial ROCI be determined as rapidly as possible
> using conservative assumptions that are agreed upon. It should be
> presented as "at least" and that as the process continues a more
> refined ROCI can be measured.
>
> Unless there has already been progress toward the measurement of
> specific outcomes, the first phase will focus on the measurement of
> the impact of process measures such as the value of additional funds
> brought into the community and indirect and administrative savings due
> to improved coordination. The initial ROCI may also include a
> projection of the financial impact of direct cost savings and quality
> of life.
>
> In many cases, data on ROCI has already begun to be collected. In
> these situations, Phase 1 can be abbreviated.
>
> Phase 1 also sets the stage for future ROCI measurements by including
> the identification of ongoing measurement activities that need to be
> put in place as well as the identification of the audiences for the
> ROCI analysis and customization of the ROCI presentation to meet
> target audiences\' expectations
>
> Often times, a program has been set up with initial grant funding or
> investment by providers, government, etc. Therefore, the target
> audience for Phase 1 is often current investors and potential
> investors.
>
> Phase 1 should be completed quickly, often within two to three months.
> The process data to be collected in usually available or conservative
> projections can be made. The results of Phase 1 are clearly labeled as
> conservative, with the emphasis made that over time the results will
> be expanded and fine-tuned.

-   **[Phase 2: Completion of activities started in Phase 1 and
    commencement of outcome measurements.]{.underline}**

> Phase 2 includes finishing initial measurements started but not
> completed at Phase 1 deadline as well as commencing more detailed
> measurement of outcome measurements (direct costs and quality of life)
> including applying the more rigorous measurements that were designed
> in Phase 1. Phase 2 will also include updating the measurements
> conducted in Phase 1.
>
> The amount of time for Phase 2 will typically be longer than Phase 1.
> At the beginning of Phase 2, the expected completion date should be
> identified. As noted earlier, in many cases, data on ROCI has already
> begun to be collected. In these situations, Phase 1 could be
> abbreviated and work started on Phase 2.

-   **[Phase 3 -- Ongoing calculation of the ROCI.]{.underline}**

> After Phase 2, the mechanism for the ongoing measurement of the ROCI
> should be put in place. Frequency of the measurement will be
> determined as well as ongoing refinement of methodologies.
>
> In addition, the ROCI will begin to be used as a performance tool. For
> example, if initially project outcome is not achieved, the reasons
> would be identified and adjustments made.

Examples of the use of project phasing will be illustrated in later
sections of this document.

***[IV. SPECIFIC MEASUREMENTS:]{.underline}***

Exhibit 4 illustrates the factors to be considered under each of the
four categories of financial benefits:

-   Decreased direct health care costs.

-   Decreased indirect costs.

-   Improved influx of funds into the community.

-   Improved quality of life.

The rest of this section will describe how these factors could be
measured and how the measurement may differ during the three phases of
work.

ROCI could be measured for a program, a series of activities, or a
specific activity, therefore, the generic term, *intervention*, will be
used in this section to represent any of the above targets of
measurement.

**Exhibit 4.**

![](media/image3.wmf){width="6.625694444444444in"
height="4.957638888888889in"}

-   **[Direct Cost Measurements:]{.underline}**

The direct health cost savings due to new programs and interventions to
improved access is typically not experienced until 2 to 3 years after
implementation. Methodologies should be developed to identify a per
person projection of the direct cost savings as well as quality of life
measurements. The actual results will then be used to project savings
when enrollment numbers increase.

**[Projections \-- Phase 1.]{.underline}**

If there is not available data to measure the actual direct health care
savings resulting from the INTERVENTION, in Phase 1, a projection can be
made to identify potential savings.

-   In most situations, the reduction of direct health care costs for
    the low-income population is the result providing coordinated health
    care at the least expensive, timely location such as primary care.
    The primary care is the focal point for coordination of referral
    health care and inpatient care when needed, as well as prevention,
    early detection and management of health problems. For the
    low-income population, links to social services are critical.
    Outreach is also important to make the low-income population aware
    of the availability of services and how to access them. The
    provision of health care in coordinated health care settings, as in
    this model, rather than ad-hoc use of expensive health care in
    costly settings is the most significant way to reduce direct health
    care costs. Exhibit 5 illustrates a primary care driven model, based
    upon the model that the Bureau of Primary Health Care promotes.

-   Methodologies should be developed to identify a per person
    projection of the direct cost savings as well as quality of life
    measurements. The actual results from a sample of current
    participants could be used to project savings when enrollment
    numbers increase or results from other locations could be used.

-   When the uninsured had access to managed care rather than ad hoc
    services, mostly through unscheduled care, participants tend to
    enroll when they have an illness or medical condition. Therefore, it
    is not unusual to see average \$1,000 to \$2,000 cost savings per
    person per year for programs that obtain access to comprehensive
    care.

    -   Therefore, as an initial projection, if detailed data is not
        available, use the \$1,000 to \$2, 000 per person range. The
        lower end of the range is the most conservative; while if your
        program is targeted at chronic diseases that have high resource
        use, the mid-range could be used.

    -   It is important to set up the measurement of actual financial
        impact as part of Phase 2 to confirm the estimate. This is
        discussed below.

> **EXHIBIT 5**

![](media/image4.wmf){width="6.752083333333333in"
height="5.047916666666667in"}

-   Working with hospitals to identify the number of ER patients who
    were linked to primary care providers for ongoing care, that is, the
    number who was given "primary care homes."

    -   For the hospitals whose ER\'s are at capacity, the methodology
        should include the opportunity for additional revenues resulting
        from seeing individuals who left (reduction of the \"elopement
        rate.\") These are typically paying patients, representing lost
        revenue.

    -   For the other ERs that are not at capacity, a methodology should
        be developed to measure the cost savings and revenue enhancement
        of patients being seen in primary care homes rather than the ER.

    -   Consideration should be given to applying an ER use methodology
        (such as the one developed at NYU) to assess the opportunity for
        shifting ER patients to primary care homes, thereby adding the
        value of reducing the use of ERs. This measurement would be
        applied in Phase 2 or even Phase 3. The CAP office has been
        negotiating with the NYU group to provide assistance to CAP
        recipients. Therefore, the CAP representative may be able to
        assist in technical advisor support for this study.

    -   These calculations will have increased importance when the ROCI
        is applied to provider expectations as part of Phase 2.

    -   As new programs are implemented, mechanisms for measuring their
        direct cost impact will be put in place. Whether these
        activities are part of Phase 1, or later, will depend upon when
        they are implemented.

**[Measurements -- Phases 2 and 3.]{.underline}**

Processes will be put in place to measure whether these projections were
achieved. This measurement will occur in Phase 2.

-   The methodology chosen will include sampling and records-review and
    could be a comparison to a control group based upon the Agency for
    Healthcare Research and Quality's Medical Expenditures Panel
    (AHRQ-MEPS).

    -   Dr. William Custer from Georgia State University has developed
        this type of approach and gave a CAP TA call on this topic.
        Contact data and his presentation are available through CAP. See
        my note on page 18

    -   More information about AHRQ-MEPS is available on the website:
        <http://www.ahrq.gov/data/mepsix.htm>[.]{.underline} This site
        includes the states in which AHRQ-MEPS has been implemented and
        the contact in these states.

-   In Phase 2 and 3, continue with measurements from Phase 1.

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-   In all phases, the increased expense to operate direct care programs
    must be determined, as the ROCI equals incremental costs minus
    incremental benefits.

-   There are local programs that exist for the principal reason to
    enroll individuals in government subsidized health coverage. In
    these types of programs, direct cost is not a significant part of
    the return on the community investment.

-   The actual measure of the incremental direct health care reduction
    may be controversial. When looked at from a community perspective,
    the positive impact of the program is the reduction of
    [total]{.underline} health care costs. This is usually the result of
    getting the individual coordinated health care rather than episodic
    care often at a level of service that is higher and more expensive
    than necessary and lacks prevention and ongoing management. This
    increment is more clearly understood as the community impact when
    the payers for the service are the same before and after the program
    is implemented. For example, provider partnerships can coordinate
    services as a means of reducing their expenses.

However, when the funder of health care changes but the actual cost of
the service does not change, it may be harder for stakeholders to view
that there has been change in the cost to the community. To illustrate
this point, consider a government-subsidized program to provide
coordinated care for individuals who previously did not have access to
care. To agree that true community impact is just the direct cost
reduction, the providers' uncompensated care should be viewed as a
community expense. Therefore, when the government pays for the care, the
objective is to develop coordinated care to reduce the community's
direct health care costs. Under this scenario, the expense to achieve
this cost reduction is the administrative cost of the new program and
the benefit is the direct cost reduction.

The concept that reduction of the number of uninsured individuals has a
community impact is the main theme of a recent report from the Institute
of Medicine of the National Academies: [A Shared Destiny, Community
Effects of Uninsurance]{.underline} (Committee on the Consequences of
Uninsurance, 2003). This report summarizes its findings by saying: "The
costs of care for uninsured Americans are passed down to taxpayers and
consumers of health care in the forms of higher taxes and higher prices
for services and insurance (p. 11)". The report uses the term,
*uninsurance*, to define not having health care coverage and cites the
following economic impacts of uninsurance:

-   Threats to the survival of individual providers and hospitals.

-   Health care providers and particular hospitals are a form of
    economic development and bring and maintain jobs in the community.

-   Negative impacts on the public health of the community.

Therefore, although it is difficult to measure the exact impact of
uninsurance on a community, it is reasonable to view public subsidy to
create access as at least an offset of uncompensated care. The following
example, which uses real numbers, illustrates this point.

There is a large county run health care program with a tax supported
annual budget of approximately \$83M. Of this budget, \$70.5M is paid
out for services per year, e.g. the annual administrative and overhead
costs of the program are approximately \$12.5M. It has been calculated
that the program's existence reduces direct costs by approximately
\$44M. For this program:

-   From a community perspective, \$12.5M is the incremental expense
    that resulted in a \$44M direct cost benefit. From this view, the
    direct cost savings alone justifies the expense and yields a 3.5 to
    1 annual return.

-   However, if uncompensated community health care is not viewed as a
    community expense, and it is perceived that the return must be
    measured on the full government expense, then the direct cost
    expense is \$83M and the direct cost benefit is \$44M. From this
    perspective, an additional \$39M in financial benefits from indirect
    cost reductions, influx of funds, and quality of life improvement
    would need to be identified in order to claim a positive return on
    the \$83M investment.

**[Indirect Cost Measurements:]{.underline}**

There are several factors to measuring indirect costs, such as the
savings of centralizing functions, the impact of centralized negotiation
of benefits and expenses, and the cost benefits to related functions
(e.g. the improvement in physical health reduces the costs to the mental
health and judicial systems, sayings in non-health care needs of the
individuals.), among others.

-   The decrease in the cost of operations is calculated under indirect
    costs while improved outcome, increased leverage of funds, and
    decreased direct costs are evaluated in other sections.

-   Indirect costs of operations include the following activities:

    -   Qualifying people for government subsidized programs.

    -   Training and development.

    -   Education and marketing to make consumers aware of the programs
        and services available to them

-   In order to identify the financial benefits of centralization,
    compare the cost of each provider to provide the function with the
    cost resulting from centralizing the function. If a particular
    service is offered centrally, the provider may either reduce total
    personnel hours, or re-allocate his personnel to other activities.

-   If an individual provider indicates that it would not have provided
    the service on its own, the ROCI for that service must be justified
    by categories other than indirect costs.

-   In addition, there may be a rationale for including the indirect
    cost savings due to the reduction of malpractice costs.

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-   In Phase 3, continue activities started in Phase 1 and 2.

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-   In all phases, incremental expenses to operate the indirect care
    programs must be calculated.

**[Examples of Specific Application of Decrease in Indirect
Costs:]{.underline}**

There are several states such as Wisconsin, Minnesota, and Pennsylvania
that have Medicaid waiver programs to cover the underinsured, for
example, expansions of State Children's Insurance Program (S-CHIP) to
cover the families of the child. Other states such as Colorado have
state programs for health care for indigent populations that exceed the
typical Medicaid coverage. For these states, the local challenge is to
maximize their residents' enrollment in this program. By creating a
central program to assist in the cost of enrollment of residents in
these subsidized programs, the aggregate costs for enrollment, if
handled at individual sites, is decreased. This is the result of
improved processes and efficiencies. This was encountered for numerous
ROCI projects in these states.

In several of these programs, the centralizing of the enrollment process
facilitated the availability of individuals culturally sensitive to
underserved ethnic groups. In one a Midwest-urban area, specific workers
are available for Latino, Southeast Asian, Central American, and Eastern
European populations. This is clearly a cost that could not have been
borne by each participant.

There are several sites that are developing methodologies to measure
specific types of indirect savings. For example, it is often
hypothesized that there is a link between access to physical health care
and mental health and a link to the cost of the judicial system. Several
locations are trying to measure the financial impact of these links.
Completion of these studies may demonstrate that improved access to
physical health services leads to the community benefit of reduced
mental health and judicial systems costs.

**[Improving Inflow of Funds and Leveraging Funds:]{.underline}**

Improved inflow of funds is a measurement of dollars brought into or
retained in the community as the result of the *intervention*. As
relevant to an individual *intervention*, this measurement could include
the value of:

-   Services brought into the community.

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-   Pharmaceuticals acquired on behalf of participants in programs for
    low-income people.

-   Grants acquired.

-   Increased reimbursement.

-   In-kind contributions and volunteers.

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-   Health care services retained in the community.

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-   An important financial impact of services brought into the community
    is the value of the health care for residents that enroll in state
    and federal government subsidized health care coverage as the result
    of the existence of the program. This government subsidized funding
    includes:

    -   Medicaid.

    -   State Children's Health Insurance Program (S-CHIP).

    -   Expansions of Medicaid and S-CHIP such as coverage of families.

    -   Social Security.

    -   Other state and federally subsidized care.

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    -   A methodology that can be used is:

        -   Identify the number of people that had increased access to
            subsidized programs due to the existence of the
            intervention.

        -   Determine the volume that would have not obtained access at
            all. For these people, multiply the total annual value of
            the \"premium\" times the number of people. \"Premium\" is
            defined as the average cost to insure the person.

        -   Determine the volume of patients who access care earlier due
            to *intervention*. For these people, identify the number of
            months earlier that they obtained access. Convert to
            fraction of a year and multiply times the annual time value
            of money used by the County. Then multiple the resultant
            number times the annual value of premiums times the number
            of people.

        -   The above calculations are repeated for each subsidized
            program.

    -   Also in Phase I include the value to partners of enhanced
        reimbursements. This will Include benefits that accrue to
        individual partners such as any advantages of using
        *intervention* programs as conduits for cash flow that results
        in draw down or the ability to put *intervention* enrollees into
        individual partner\'s reimbursement stream (such as additional
        reimbursement to disproportionate share providers.) There will
        be a need to talk with individual partners to identify
        applicable examples and measurements.

    -   In addition, if applicable, reimbursable Medicaid administrative
        costs or other state incentives to appropriate placement should
        be added.

    -   As part of Phase 1, identify how to measure the draw down of
        other State, Federal, and private funds. In Phase 1, if the CAP
        grant is being used to fund the budget, there is an equal cost
        and benefit of draw down of the CAP federal funds.

    -   Partners can assist in the projection of their reduced
        uncompensated care as the result of *intervention* activities.
        Be careful not to double count by including the value of reduced
        uncompensated care and the payments of subsidized programs.

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-   In Phases 2 and 3, continue with measurements from Phase 1.

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-   In all phases, incremental expense to achieve the leverage of funds
    should be calculated.

    -   The time period of these expenses must match the time period of
        the financial benefits. For example, if benefits are being
        measured since the start of *intervention* then the expenses for
        the same time period should be measured.

    -   If outside grants are being used to support staff and
        operations, the expenses to run these programs offset part of
        the benefits of dollars brought into the community. It is easier
        to understand the final presentation if both entries are made.

**[Examples of Specific Application of Influx of Funds
Measurements:]{.underline}**

For states that have programs that expand State Children's Insurance
Program (S-CHIP) to cover the families of the child or, in general, have
state programs to subsidize health care for the low-income population,
the local challenge is to maximize their residents' enrollment in these
programs. These programs have significant, positive local financial
impact that results from bringing state and federal funds into the
community.

For each of these programs, the cost per month coverage for the State
program was obtained. In some situations, the State knew the actual per
enrollee per month cost. In other situations, per enrollee per month
coverage was calculated using annual costs and average per month
enrollee statistics. The calculation of the number of additional months
of coverage for enrollees was determined through analysis in each case.
It required making assumptions that resulted from data collection and
interviews of personnel.

For many other ROCI projects, while there was less potential for
additional state and federal Medicaid dollars, there was still the value
of S-CHIP enrollment or enrollment in the Medically Needy Medicaid
program such as in Florida. The benefits of enrollment efforts were
calculated in a similar manner as described above.

In some situations, such as in the Florida Medically Needy program, if a
share of cost is met then eligible individual can receive extended
Medicaid benefits. If the local program pays the share of cost, the ROCI
calculation should include the value of the extended Medicaid benefits
while the expense to receive this benefit is the share of cost.

A comprehensive program also brought dollars into the community as the
result of assisting its enrollees who are legitimately disabled to
become eligible for federal Social Security Disability Income (SSDI). In
the case of one large coverage program, evaluation of cases indicated
that, on the average, individuals were becoming SSDI eligible 6 months
earlier as the result of the program. The financial impact was two-fold.
First, there is the actual value of 6 additional months of SSI payments.
Second, after two years on SSDI, most of these individuals became
eligible for Medicare. Therefore, there was a future benefit of the
value of 6 additional months of Medicare coverage brought into the
community. The Medicare cost per month per disabled enrollee was then
used to calculate the value brought into the community. The impact of
earlier Medicare coverage had a particularly important on the program
because until these individuals became eligible for Medicare, the
program paid for their health care. For this program, the combined
impact of additional SSDI payments and earlier Medicare was over \$3M
per year.

For programs that provide access to pharmaceuticals or other medical
goods, the benefits are easy to identify. The net benefit is the value
of the acquired goods less the incremental cost of the program to obtain
the goods. In some cases, the ROCI calculation applied the conservative
approach of applying the value of the good if acquired from an easy to
join buyer plan while others used the actual market values.

**[Value of Quality of Life Improvement:]{.underline}**

-   Quality of life measurements will include, as appropriate, improved
    morbidity and mortality. There will be an attempt to add financial
    quantification by identifying lost time and applying the value of
    the time.

    -   Initially, this may mean applying productivity improvement to
        the working segment of the target population unless there are
        agreed upon measurements of the value of time of people who are
        not working.

    -   Since this will require further evaluation, Phase 1 will include
        the identification of general quality of life measures of
        existing *intervention* enrollees and Phase 2 will include
        projections of impact under higher enrollment, as well as
        methods to be implemented over time to quantify financial
        impact.

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    -   Methodologies should be developed to identify a per person
        projection of the direct cost savings as well as quality of life
        measurements. The actual results of current *intervention*
        participants will be used to project savings when enrollment
        numbers increase. Methodologies will include sampling and
        records-review, comparison to a control group base upon the
        Agency for Healthcare Research and Quality's Medical Expenditure
        Panel Survey (AHRQ-MEPS), and projecting expected savings based
        upon experience at other locations. Processes will then need to
        be put in place to measure whether these projections were
        achieved.

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    ```
    -   During Phase 1, determine the gross measurement for productivity
        improvement due to having access to care. While the literature
        (such as the May 2002 report, [Sicker and Poorer: The
        Consequences of Being Uninsured]{.underline} by the Kaiser
        Family Foundation, available at:
        [http://www.kff.org](http://www.kff.org/)) indicates that an
        individual who presents with a disease but does not have health
        care access could lose 15% to 30% earning power, initially it is
        more conservative to use 5% or 10%. This is then applied against
        an annual value of workers such as an average income of clients.
        This can be an actual measurement or an estimate based upon a
        percent of the federal poverty number.

> Another study, [Care Without Coverage: Too Little, Too
> Late]{.underline}, from the Institutes of Medicine, May 2002
> (available at:
> http://[www.iom.edu/uninsured](http://www.iom.edu/uninsured))
> indicated that the access to health care has a short term impact on
> daily living and in the longer term (over 5 to 17 years), these
> individuals have a 25% death rate.

-   Over time, there should be a validation of productivity improvement
    by sampling or some other measurement. It is recommended that there
    be measurement of the client's perceptions of the impact of the
    program on their health. One measurement could be client's estimate
    on lost time due to illness. Over the longer term (Phase 3), there
    may be opportunities to do employer surveys.

-   In economic development models, it is assumed that for every dollar
    of wages brought into a community, there is a multiplier due to the
    activity that the dollar generates. The multiplier for a specific
    community can be obtained from the local or regional economic
    development council or the Chamber of Commerce. The multiplier will
    typically be between 1.5 and 3.0. This can then be used to estimate
    the value of lost income to the community. Also, confirm if the
    economic development council assumes the same multiplier for
    retained wages in the community as for new jobs.

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-   Ongoing outcome measurement.

    -   With providers, identify activities that will maximize cost
        impact and quality of life improvements (such as identified in
        May 2002 reports, [Care without Coverage, Too Little Too
        Late]{.underline} by the Institute of Medicine and [Sicker and
        Poorer: The Consequences of Being Uninsured]{.underline} by the
        Kaiser Family Foundation.) *intervention* has already begun many
        of these activities and could project potential savings
        utilizing data from these reports. These activities include:

        -   Increased primary screening and prevention.

        -   Improved access to cancer care and improved outcomes.

        -   Improved access to chronic disease care and outcomes.
            (Diabetes, cardiovascular including hypertension, renal,
            HIV, and mental illness were cited).

        -   Trauma and decision to admit.

        -   Overall negative impact:

    -   Continue to identify processes to measure quality of life
        impact. For example, measure years of lost life or lost
        productivity. The annual value of life is a controversial
        measurement but it could then be used to determine dollar value
        of quality of life. For *i*nterventions that utilize disease
        management with calculated estimates of years productivity lost
        there are now attempts to use this measurement. Diabetes and
        hypertension are two disease entities that are now beginning to
        yield measurable results.

**[Examples of Specific Application of Quality of Life
Measurements:]{.underline}**

The actual examples below illustrate two communities for which a 15% was
used for the productivity factor adjusted by the economic development
factor, although the reasons for using 15% differed.

In the first example, the economic development factor used by the
county's economic development council and the Chamber of Commerce was
almost 3X. In that case, applying the economic development factor to a
very conservative 5% productivity improvement yields a 15% return.
Therefore, to be ultra-conservative, this was the number used.

In the second example, the program had been in place for almost ten
years. Because there had been time to measure actual positive results
and a higher return had been substantiated. It had been calculated that
70% of its enrollees of the program were the working poor and that the
average income of the families served was 80% of federal poverty level
and the average family size in the program was approximately 3 people.
In this case, the economic development council had a conservative 1.5
factor -- one of the lowest encountered in ROCI work. The productivity
factor was calculated by multiplying the 10% productivity improvement
factor time 1.5 resulting in an overall 15%.

***[V. PRESENTING THE FINDINGS:]{.underline}***

There are a variety of ways to present the ROCI data. In all of them,
the data should be presented in a concise manner that presents the case
clearly. The extent of backup data included may range from a lengthy
detailed study to a presentation with tables and explanations of
methodologies to one with no written backup at all. Clearly, the
audience will be the main determinant of the format of the presentation.

In most situations, a concise power point presentation with backup
tables and methodologies was adequate. This section will concentrate on
a presentation in this format. Even when the data is used as part of
another presentation, it is good to have backup to illustrate how the
ROCI was calculated.

The overall ROCI should be presented from a community perspective. It
could then be adapted to individual target groups or sub-populations.

-   **[General Application:]{.underline}**

To assist in the preparation of the final presentation, data should be
compiled in a summary Excel spread sheet and illustrated graphically,
consistent with the format in Attachment B. This allows ready creation
of the graphic presentation of the ROCI.

The summary spread sheet is tied to more detailed spread sheets and
should be broken down by individual service areas and providers as well
as by specific measurements (as described above.) This allows the
flexibility to later cluster data in multiple ways and to repeat the
measurement periodically in a consistent format.

For the power point presentation, graphics can include:

-   [Summary of Components]{.underline} \-- A summary of the impacts by
    each of the four categories of components of the ROCI. A list of
    specific measurements of each component can be listed under the oval
    for the components. Exhibit 6 is an example.

-   [ROCI Measurement Graphic]{.underline} -- The three-bar chart in
    Exhibit 7 uses the same ROCI data as Exhibit 6. Exhibit 7
    illustrates that the ROCI is the result of measuring benefits of the
    program and subtracting incremental costs. From left to right the
    stacked bars are the benefits from each of the ROCI components, the
    expenses necessary to achieve the benefits, and the resulting ROCI.
    If the stacked expense bar is the same height as the benefits bar
    the white space at the top is the difference the benefits and the
    expenses and equals the ROCI which then equals the third bar. If
    expenses are greater than benefits then the ROCI is negative and
    would be the space at the top of the benefits bar. An example of a
    negative ROCI is illustrated in Exhibit 8.

-   [Summary of ROCI Measurement Chart]{.underline} \-- It is useful to
    include a table that summarizes the ROCI calculation. Exhibit 9 is
    an example that uses the same data as Exhibits 6 and 7.

More detailed spreadsheets can be used as background for these graphics
and could be set up to actually drive the creation of the graphics.

The above sets of graphics could be repeated by scenario or by
individual stakeholder. These scenarios are further discussed below.
Specific applications are described for:

-   Aggregate vs. specific impact measurement of ROCI.

-   Measurement of ROCI by individual stakeholders or partners.

-   Measurement of ROCI by specific program.

-   Detailed vs. summary presentation of findings.

-   Presentation of ROCI by Phases and Scenarios.

**Exhibit 6.**

![](media/image5.wmf){width="6.490277777777778in"
height="4.852777777777778in"}

**Exhibit 7.**

![](media/image6.wmf){width="6.75625in" height="4.641666666666667in"}

**Exhibit 8.**

![](media/image7.wmf){width="6.291666666666667in"
height="4.316666666666666in"}

**Exhibit 9.**

![](media/image8.wmf){width="6.125694444444444in"
height="6.530555555555556in"}

-   **[Aggregate vs. Specific Impact Measurements:]{.underline}**

In general, when looking at how specifically to measure programs, it
should be remembered that one always add up the specific impact
measurements to equal the aggregate. However, if the specific
measurement is not initially collected, it is difficult to later go back
and do the detailed collection.

-   **[Measurement of ROCI by Individual Stakeholders or
    Partners:]{.underline}**

> Often times it is important to measure the ROCI for individual
> stakeholders. This is particularly true if a major objective of
> measuring the ROCI is to sustain or further develop funding. From a
> financial standpoint, stakeholders include:

-   Current direct funders of the program,

-   Customer,

-   Non-investing beneficiaries

-   Future funders.

> In order to sustain funding, the objective is to show current
> investors that there was a ROCI and that it will continue with further
> investment. It is also useful to show that there would be an increased
> ROCI to the investor with increased investment. There is an objective
> to show non-investing beneficiaries why they should invest, maximize
> the future funders list, and, when appropriate, show customers why
> they should share the costs. As detailed earlier in Exhibit 1,
> specific stakeholder groups have specific expectations and therefore,
> certain components of ROCI measurement have more meaning to them than
> others.
>
> Therefore, when addressing a specific stakeholder group, it is
> important to take the overall community ROCI and focus on the
> measurement that best relates to the expectations of the specific
> stakeholder group. For example, if the target group is local,
> maximizing the influx of state funds is important. However, if the
> target is state government, increasing their funding is viewed as a
> negative while influx of federal funds is more important.

-   **[Separating ROCI for Individual Programs:]{.underline}**

> The ROCI approach can be used for a comprehensive program and / or
> individual interventions. Similar to setting up the ROCI measurement
> separately for individual partners, it is also useful to set up the
> ROCI for specific interventions and totaling. This approach was used
> for several specific programs. In some cases, certain interventions
> were further advanced than were others. The ROCI for these
> interventions are based upon actual measurements. For less advanced
> interventions the potential ROCI can be projected and then actual
> measurements put in place. Measuring intervention separately allows
> the impacts to be totaled while not doing separate measurements
> precludes the ability to later break out the comparisons.
>
> Exhibit 10 is an example format that was used for a rural,
> multi-county target area with multiple hospital partners and multiple
> programs. These hospitals were investors in a network that emphasized
> getting individuals enrolled in state funded disease management
> programs. Oftentimes it is important to measure the ROCI for
> individual partners. A key objective of the partnership was to
> identify low-income people who would be enrolled in state-funded
> disease management programs. The first two diagnoses targeted by the
> partnership were diabetes and hypertension. Data on individual
> enrollees and the ROCI needed to be collected by counties. The
> hospital partners had service areas that included multiple counties. A
> Community Access Program grant was used for initial startup funding
> but ongoing funding will come from the four hospitals in the 10-county
> rural area covered.
>
> In this case while the overall ROCI is important, it needs to be
> measured for each individual partner as well. This data helps show the
> administration and boards of each hospital that there is a return on
> their investment.

<table>
<colgroup>
<col style="width: 13%" />
<col style="width: 14%" />
<col style="width: 10%" />
<col style="width: 10%" />
<col style="width: 8%" />
<col style="width: 8%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 2%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="18"><blockquote>
<p><strong>Exhibit 10.</strong></p>
</blockquote>
<p><strong>EXAMPLE: MEASURING DISTRIBUTION OF</strong></p>
<p><strong>THE LEVERAGE OF FUNDS IMPACT BY PARTNER HOSPITAL AND
COUNTY</strong></p></td>
</tr>
<tr class="even">
<td rowspan="2"><strong>PARTNER HOSPITAL</strong></td>
<td rowspan="2"><p><strong>SERVICE</strong></p>
<p><strong>AREA BY COUNTY</strong></p></td>
<td colspan="4"><strong>DIABETES</strong></td>
<td colspan="4"><p><strong>HYPER-</strong></p>
<p><strong>TENSION</strong></p></td>
<td colspan="4"><strong>OTHER</strong></td>
<td colspan="4"><strong>TOTAL</strong></td>
</tr>
<tr class="odd">
<td><strong># of Enrollees</strong></td>
<td><p><strong>Value</strong></p>
<p><strong>of Coverage</strong></p></td>
<td><p><strong>Pharm.</strong></p>
<p><strong>Value</strong></p></td>
<td><strong>SUB-TOTAL</strong></td>
<td colspan="4"><p><strong>(Same</strong></p>
<p><strong>columns</strong></p>
<p><strong>as</strong></p>
<p><strong>Diabetes)</strong></p></td>
<td colspan="4"><p><strong>(Same</strong></p>
<p><strong>columns</strong></p>
<p><strong>as</strong></p>
<p><strong>Diabetes)</strong></p></td>
<td colspan="4"><p><strong>(Same</strong></p>
<p><strong>columns</strong></p>
<p><strong>as</strong></p>
<p><strong>Diabetes)</strong></p></td>
</tr>
<tr class="even">
<td rowspan="3"><em><strong>Hospital A</strong></em></td>
<td><em><strong>County 1</strong></em></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><em><strong>County 2, etc.</strong></em></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><em><strong>SUBTOTAL – Hospital A</strong></em></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td rowspan="3"><em><strong>Hospital B</strong></em></td>
<td><em><strong>County 1</strong></em></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><em><strong>County 2, etc.</strong></em></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><em><strong>SUBTOTAL – Hospital B</strong></em></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td rowspan="3"><em><strong>Hospital C</strong></em></td>
<td><em><strong>County 1</strong></em></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><em><strong>County 2, etc.</strong></em></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><em><strong>SUBTOTAL – Hospital C</strong></em></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td rowspan="3"><em><strong>Hospital D</strong></em></td>
<td><em><strong>County 1</strong></em></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td><em><strong>County 2, etc.</strong></em></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td><em><strong>SUBTOTAL – Hospital D</strong></em></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"><em><strong>TOTAL HEALTH PARTNERSHIP</strong></em></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

> While this example emphasizes the measurement of the influx of outside
> funds, this format could be used for presenting other specific
> components or combinations of components of the ROCI.
>
> As a caution, it is important that these data not be used in a manner
> that violates anti-trust concerns. Since the individuals impacted are
> underserved, by definition there is probably more leeway. Do not,
> however, use the data in any way that suggests "carving up territory"
> or excluding other providers. An opinion from your legal counsel is
> advised.

-   **[Detailed vs. Summary Reporting:]{.underline}**

As noted earlier, in some situations, a report must be quite detailed
while in other situations, the report can be a summary with background
support available if necessary.

This section includes two actual applications for government funded
programs that needed to show the return on the taxpayers' investment. In
the first example, a detailed presentation of findings was required
while in the second example, the financial impact was part of a single
page fact sheet, and therefore needed to be brief.

In the first example, there was a large county program in an urban area
with a State Children's Health Insurance Program expansion. The initial
indicators of the success of the program are to maximize the enrollment
of individuals in the state program and to minimize the costs of getting
people enrolled in it, particularly comparing the advantages of
centralizing the program versus each hospital's doing its own
enrollment. The county commissioners wanted a detailed study. Therefore,
there was a long detailed report with a power point presentation summary
with a subsequent printing of the report for distribution in the
community. This level of detail in the study is atypical. However, the
level of detail in the power point presentation is typical. The
presentation included slides with general background about the program,
the methodology used, and the results. Attachment B contains examples of
key presentation slides showing study results.

In the second example, a program to support the needs of low-income
populations needed state government reauthorization. While this program
is paid for with local taxes, the laws of its state require that the
state approve all local taxes. The desired report was a one-page bullet
point presentation of the program and its impact. This one page summary
would allow consistent information for individuals visiting legislators
with a concise summary of the program. The full ROCI was important as
backup if asked about the source of the impact measurement. The program
had been in existence for over 10 years, therefore reduction of direct
health care costs is relevant. Appendix C is the bullet point handout.

When the ROCI is part of an overall business case there may also be a
lower level of detail.

-   **[Presentation of ROCI by Phases and Scenarios:]{.underline}**

When there is a difference in the ROCI during phases, the finding should
be presented for each phase and then summarized over time.

This is an important presentation when the ROCI is used to measure the
financial impact of changes being considered as part of a business plan.

In several examples, an Excel spread sheet was developed that had links
to summary tables, charts, and graphics. This allowed the ability to
make changes in assumptions and generate the tables, charts, and
graphics for reports. It also allowed the planning group to make changes
in assumptions -- the simulation of "what if" scenarios.

-   **[Incremental Changes]{.underline}**

Setting up a measurement of the ROCI of the core program allows the
opportunity to measure the impact of incremental programs. The initial
ROCI creates the baseline and an additional program can be measured
individually or their ROCI can be measured by subtracting the ROCI
without the new program from the ROCI with the new program.

For example, in the second government funded program described above and
in Appendix C, the key determinants of eligibility are income level and
access to other health care coverage. It is the "payer of last resort".
Exhibit 11 illustrates the current health care program eligibility.

As illustrated in Exhibit 12, strategies have been identified to expand
the program, principally through partnerships. It is possible to project
the ROCI of potential programs to evaluate options.

**Exhibit 11.**

![](media/image9.wmf){width="6.626388888888889in"
height="4.954166666666667in"}

**Exhibit 12.**

![](media/image2.wmf)

**[EXAMPLE OF A GROUP PROCESS]{.underline}**

**[TO APPLY THE RETURN ON COMMUNITY INVESTMENT (ROCI)
CONCEPT]{.underline}**

While an individual could do the ROCI concept, there is merit to a group
discussion of the concept and determination of how the concept can be
applied to the specific program

Below is an example of one process that could be used. This process has
a facilitator leading a series of meetings to understand the concepts
and develop the specific measurements. The facilitator and staff can
then implement the measurements identified. This was the process used
for numerous locations.

**[OVERALL OBJECTIVE:]{.underline}**

The facilitator assists a local program in structuring how it can create
a business case for its efforts in improving health care access for the
underinsured and reducing health care disparities. This business case
will be structured to address the community on the whole and how it
would be applied to show individual stakeholders that their expectations
have been met. The concept of measuring the return on the community's
investment will be used.

**[SPECIFIC ACTIVITIES:]{.underline}**

-   Put together a work plan to measure the return on community
    investment and how it can be applied to present a business plan for
    improving health care access for the underinsured and reducing
    health care disparities. This includes:

    -   The measurement of the current ROCI.

    -   A mechanism to repeat the ROCI measurement in the future.

    -   Identification of the current and future uses of the ROCI
        measurement including how it can be applied to present a
        business plan for its efforts in improving health care access
        for the underinsured and reducing health care disparities.

-   Identify how staff can complete the data collection or the types of
    additional technical assistance needed.

The next page presents a general description of the work sessions. The
description of the work sessions could be amended as applicable.

**[DESCRIPTION OF PROJECT MEETINGS]{.underline}**

+--------+---+--------------------------+---+--------------+-----------------+
| **     | * |                          | * |              | *               |
| TIME** | * |                          | * |              | *PARTICIPANTS** |
|        | A |                          | A |              |                 |
|        | C |                          | C |              |                 |
|        | T |                          | T |              |                 |
|        | I |                          | I |              |                 |
|        | V |                          | O |              |                 |
|        | I |                          | N |              |                 |
|        | T |                          | * |              |                 |
|        | I |                          | * |              |                 |
|        | E |                          |   |              |                 |
|        | S |                          |   |              |                 |
|        | * |                          |   |              |                 |
|        | * |                          |   |              |                 |
+--------+---+--------------------------+---+--------------+-----------------+
| ***P   |   |                          |   |              |                 |
| ROJECT |   |                          |   |              |                 |
| MANA   |   |                          |   |              |                 |
| GEMENT |   |                          |   |              |                 |
| PR     |   |                          |   |              |                 |
| E-MEET |   |                          |   |              |                 |
| ING*** |   |                          |   |              |                 |
+--------+---+--------------------------+---+--------------+-----------------+
| 30     |   | > Clarification of       | - |              | -   Project     |
| M      |   | > Process and "Last      |   |              |     management  |
| inutes |   | > Minute Questions."     |   |              |                 |
|        |   |                          |   |              | ```{=html}      |
|        |   |                          | R |              | <!-- -->        |
|        |   |                          | e |              | ```             |
|        |   |                          | v |              | -   Facilitator |
|        |   |                          | i |              |                 |
|        |   |                          | e |              |                 |
|        |   |                          | w |              |                 |
|        |   |                          |   |              |                 |
|        |   |                          |   |              |                 |
|        |   |                          |   |              |                 |
|        |   |                          |   |              |                 |
|        |   |                          | s |              |                 |
|        |   |                          | c |              |                 |
|        |   |                          | h |              |                 |
|        |   |                          | e |              |                 |
|        |   |                          | d |              |                 |
|        |   |                          | u |              |                 |
|        |   |                          | l |              |                 |
|        |   |                          | e |              |                 |
|        |   |                          | . |              |                 |
|        |   |                          |   |              |                 |
|        |   |                          | - |              |                 |
|        |   |                          |   |              |                 |
|        |   |                          |   |              |                 |
|        |   |                          |   |              |                 |
|        |   |                          | O |              |                 |
|        |   |                          | t |              |                 |
|        |   |                          | h |              |                 |
|        |   |                          | e |              |                 |
|        |   |                          | r |              |                 |
|        |   |                          |   |              |                 |
|        |   |                          |   |              |                 |
|        |   |                          |   |              |                 |
|        |   |                          |   |              |                 |
|        |   |                          | q |              |                 |
|        |   |                          | u |              |                 |
|        |   |                          | e |              |                 |
|        |   |                          | s |              |                 |
|        |   |                          | t |              |                 |
|        |   |                          | i |              |                 |
|        |   |                          | o |              |                 |
|        |   |                          | n |              |                 |
|        |   |                          | s |              |                 |
|        |   |                          | . |              |                 |
+--------+---+--------------------------+---+--------------+-----------------+
| **     |   |                          |   |              |                 |
| *TOTAL |   |                          |   |              |                 |
| = 1/2  |   |                          |   |              |                 |
| H      |   |                          |   |              |                 |
| rs.*** |   |                          |   |              |                 |
+--------+---+--------------------------+---+--------------+-----------------+
| ***P   |   |                          |   |              |                 |
| ROJECT |   |                          |   |              |                 |
| OV     |   |                          |   |              |                 |
| ERVIEW |   |                          |   |              |                 |
| SESS   |   |                          |   |              |                 |
| ION*** |   |                          |   |              |                 |
+--------+---+--------------------------+---+--------------+-----------------+
| 5      | M |                          | - |              | -               |
| M      | e |                          |   |              |    Stakeholders |
| inutes | e |                          |   |              |     needed for  |
|        | t |                          |   |              |     buy-in.     |
|        | i |                          | I |              |                 |
|        | n |                          | n |              | ```{=html}      |
|        | g |                          | f |              | <!-- -->        |
|        | O |                          | o |              | ```             |
|        | v |                          | r |              | -   Key         |
|        | e |                          | m |              |     decision    |
|        | r |                          | a |              |     makers.     |
|        | v |                          | t |              |                 |
|        | i |                          | i |              | -   Project     |
|        | e |                          | o |              |     management. |
|        | w |                          | n |              |                 |
|        | / |                          | . |              | -   Individuals |
|        | I |                          |   |              |     with        |
|        | n |                          |   |              |     knowledge   |
|        | t |                          |   |              |     of local    |
|        | r |                          |   |              |     data        |
|        | o |                          |   |              |     sources     |
|        | d |                          |   |              |     (Data       |
|        | u |                          |   |              |     Commandos). |
|        | c |                          |   |              |                 |
|        | t |                          |   |              | -               |
|        | i |                          |   |              |    Facilitator. |
|        | o |                          |   |              |                 |
|        | n |                          |   |              |                 |
|        | s |                          |   |              |                 |
+--------+---+--------------------------+---+--------------+-----------------+
| 55 --  | R |                          | - |              |                 |
| 75     | O |                          |   |              |                 |
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+--------+---+--------------------------+---+--------------+-----------------+
| 45 -   | > |                          | - |              | -   Board       |
| 60     |   |                          |   |              |     Members     |
| M      | A |                          |   |              |                 |
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| ***WO  |   |                          |   |              |                 |
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| ION*** |   |                          |   |              |                 |
+--------+---+--------------------------+---+--------------+-----------------+
| 5      |   | Meeting Overview /       |   | -            | -   Project     |
| M      |   | Introductions:           |   | Information. |     management. |
| inutes |   |                          |   |              |                 |
|        |   | -   Agenda overview.     |   |              | -   Board       |
|        |   |                          |   |              |     Members     |
|        |   | -   Introductions        |   |              |     (can leave  |
|        |   |                          |   |              |     after       |
|        |   |                          |   |              |     objectives  |
|        |   |                          |   |              |     session).   |
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|        |   |                          |   |              |     knowledge   |
|        |   |                          |   |              |     of local    |
|        |   |                          |   |              |     data        |
|        |   |                          |   |              |     sources     |
|        |   |                          |   |              |     (Data       |
|        |   |                          |   |              |                 |
|        |   |                          |   |              | Commandos).     |
|        |   |                          |   |              |                 |
|        |   |                          |   |              | -               |
|        |   |                          |   |              |    Facilitator. |
+--------+---+--------------------------+---+--------------+-----------------+
| 110    |   | Description of work      |   | -            |                 |
| M      |   | plan:                    |   |  Discussion. |                 |
| inutes |   |                          |   |              |                 |
|        |   | -   Identification of    |   | -            |                 |
|        |   |     specific data        |   |    Agreement |                 |
|        |   |     measurements and     |   |     on:      |                 |
|        |   |     sources.             |   |              |                 |
|        |   |                          |   | > \--Time    |                 |
|        |   | -   Discuss individual   |   | > schedule.  |                 |
|        |   |     responsibilities and |   | >            |                 |
|        |   |     resource to complete |   | > \--Respo   |                 |
|        |   |     project.             |   | nsibilities. |                 |
|        |   |                          |   | >            |                 |
|        |   |                          |   | > \--Other   |                 |
|        |   |                          |   | > logistics. |                 |
+--------+---+--------------------------+---+--------------+-----------------+
| 5      |   | > Wrap-Up                |   | -            |                 |
| M      |   |                          |   | Information. |                 |
| inutes |   |                          |   |              |                 |
+--------+---+--------------------------+---+--------------+-----------------+
| **     |   |                          |   |              |                 |
| *TOTAL |   |                          |   |              |                 |
| = 2    |   |                          |   |              |                 |
| 1/2    |   |                          |   |              |                 |
| H      |   |                          |   |              |                 |
| rs.*** |   |                          |   |              |                 |
+--------+---+--------------------------+---+--------------+-----------------+
| ***P   |   |                          |   |              |                 |
| ROJECT |   |                          |   |              |                 |
| MANA   |   |                          |   |              |                 |
| GEMENT |   |                          |   |              |                 |
| FOL    |   |                          |   |              |                 |
| LOW-UP |   |                          |   |              |                 |
| MEET   |   |                          |   |              |                 |
| ING*** |   |                          |   |              |                 |
+--------+---+--------------------------+---+--------------+-----------------+
| 30     |   | > Project Management     |   | -   Wrap-up  | -   Project     |
| M      |   |                          |   |              |     management  |
| inutes |   |                          |   |   questions. |                 |
|        |   |                          |   |              | ```{=html}      |
|        |   |                          |   |              | <!-- -->        |
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+--------+---+--------------------------+---+--------------+-----------------+
| **     |   |                          |   |              |                 |
| *TOTAL |   |                          |   |              |                 |
| = 1/2  |   |                          |   |              |                 |
| H      |   |                          |   |              |                 |
| rs.*** |   |                          |   |              |                 |
+--------+---+--------------------------+---+--------------+-----------------+

**[PRESENTATION GRAPHICS EXAMPLES:]{.underline}**

**[ROCI FOR COUNTY PROGRAM EMPHASIZING]{.underline}**

**[INFLUX OF STATE FUNDS]{.underline}**

![](media/image3.wmf){width="6.750694444444444in"
height="5.0472222222222225in"}

![](media/image4.wmf){width="7.126388888888889in"
height="5.3277777777777775in"}

![](media/image5.wmf){width="7.126388888888889in"
height="5.399305555555555in"}

**[TALKING POINTS FORMAT\--]{.underline}**

**["COUNTY HEALTHCAR E PROGRAM\"]{.underline}**

-   THE COUNTY HealthCare Program provides access to health care for
    low-income residents of THE COUNTY [who do not have private
    insurance, Medicaid or Medicare.]{.underline} THE COUNTY PROGRAM
    emphasizes:

    -   Primary and preventive care rather than costly emergency room
        services.

    -   Integration of health care, social services and workforce
        programs.

    -   Partnerships with local hospitals and physicians to provide
        services.

    -   Community oversight by the Health Care Advisory Board.

    -   Stewardship by working with stakeholders and partnering with
        providers to contain costs, avoid duplication, and leverage
        other available sources of funds to address the needs of program
        participants.

    -   Flexibility and responsiveness to changes in health care
        delivery.

-   THE COUNTY HEALTHCARE PROGRAM funds the State required local match
    for Medicaid payments and the special payment to Tampa General
    Hospital.

-   THE COUNTY HEALTHCARE PROGRAM has the support of the X, Y, AND Z
    HOSPITALS, A AND B COMMUNITY HEALTH CLINICS, as well as the COUNTY
    Medical Association.

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-   COUNTY residents eligible for THE COUNTY HEALTHCARE PROGRAM are:

    -   At or below 100% of federal poverty level, i.e., \$8,860 single
        person or \$15,020 family of three.

    -   For some diseases, people between 100% and 150% of federal
        poverty guideline whose expenses for medical services cause them
        to have net income below 100% of poverty.

    -   Senior citizens receiving Medicare but needing assistance for
        prescription drugs, dental, and vision services.

-   In 2002, THE COUNTY HEALTHCARE PROGRAM served over 31,000 residents
    by funding 105,123 outpatient visits and 15,268 inpatient hospital
    days and filled 519,035 prescriptions.

-   THE COUNTY HEALTHCARE PROGRAM is important to local small
    businesses. Approximately 70% of those served by the THE COUNTY
    HEALTHCARE PROGRAM are either employed or seeking work. The rest are
    disabled or on a fixed income.

**[IMPACT:]{.underline}**

The investment in THE COUNTY HEALTHCARE PROGRAM exceeds expectations.

-   Decreased direct health care costs (Over \$44M per year.)

-   Strengthened hospitals and physicians by reducing unpaid bills.

-   Maximized health care dollars for COUNTY residents by:

    -   Increased enrollment and quicker payment from other insurers and
        Medicaid (\$3M per year).

    -   Additional State and Federal reimbursement to hospitals and
        clinics (\$10M per year.).

    -   Earlier federal disability assistance for COUNTY residents (\$3M
        to \$5M per year.)

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```
-   Improved program participants' ability to maintain employment (Value
    of over \$15M per year.)

**[DESIRED ACTION:]{.underline}**

Reauthorization of the enabling legislation on a continuing basis.