ESTIMATING

of COST the

 PREVENTIVE

Abuse Substance and Health Mental in SERVICES

Care Managed Under 
and Health of Department .S.U

Services Human

Health Mental and Abuse Substance

Administration Services

Services Health Mental for Center

Care Managed of Office

Lane Fishers 5600

20857 MD ,Rockville

BROSKOWSKI ANTHONY

SMITH SHELAGH

Report Technical

ESTIMATING

of COST the

 PREVENTIVE

Health Mental in SERVICES

 and 

Abuse Substance 

Care Managed Under 
Report Technical ii

Acknowledgments

.,C.L ,Solutions Pareto ,President ,PhD ,Broskowski Anthony are report this of authors The

Project Government ,)Specialist Education Health Certified (CHES ,MPH ,Smith Shelagh and

Health Mental and Abuse Substance ,)CMHS (Services Health Mental for Center ,Officer

who people several thank to like would authors The .)SAMHSA (Administration Services

Organization of Director Associate ,PhD ,Buck Jeffrey including ,suggestions helpful made

;SAMHSA ,Care Managed of Office ,Director ,PhD ,Goplerud Eric; CMHS ,Financing and

.SAMHSA ,Prevention Abuse Substance for Center ,MHS ,Williams Charlie and

Disclaimer

.,C.L ,Solutions Pareto by D0056801M99 # Requisition under prepared was report This

,Smith Shelagh); HHS (Services Human and Health of Department .S.U ,SAMHSA for

reflect necessarily not does publication this of content The .Officer Project Government

.HHS or SAMHSA of policies or views the

Notice Domain Public

reproduced be may and domain public the in is report this in appearing material All

Services Health Mental and Abuse Substance the from permission without copied or

not may publication this ,However .appreciated is source the of Citation .Administration

the of authorization written ,specific the without fee a for distributed or reproduced be

.HHS ,SAMHSA ,Communications of Office

Publication to Access

 at and gov.samhsa.www at electronically accessed be can publication This

copies Additional .asp.pubs/ManagedCare/cmhs/org.mentalhealth.www://http

1-800-789-2647. ,Clearinghouse CMHS the calling by obtained be can

Office Originating

Financing and Organization for Director Associate

Services Health Mental for Center

Administration Services Health Mental and Abuse Substance

15-87 ,Lane Fishers 5600

20857 MD ,Rockville

Citation Suggested

Health Mental in Services Preventive of Cost the Estimating .S ,Smith and .,A ,Broskowski

:MD ,Rockville .R-02-3617SMA .No .Pub DHHS .Care Managed Under Abuse Substance and

Services Health Mental and Abuse Substance ,Services Health Mental for Center

2001. ,Administration
Contents of Table

iii Services Preventive of Cost The

vii . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary Executive

1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Background and Introduction .I

4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Interventions Six These of Models Cost

4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Modeling Based-Cost of Method General

5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Basis Annualized an on Costs Service Ongoing

6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Variation for Accounting

6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Scenarios for Accounting

9 . . . . . . . . . . . . . . . Mothers Risk-High for Visits Home Infancy and Prenatal :One Model .II

10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Model the in Used Values Input and Design

10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Assumptions

11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Results

11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Discussion

13 . . . . . . . . . . . . . . . . . . . . . Women Pregnant at Targeted Cessation Smoking :Two Model .III

13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Results

13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Model the in Used Values Input and Design

15 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Discussion

17 . . . . . . . . . . . . . . . . . . . . . . Therapy Health Mental Term-Short Targeted :Three Model .IV

17 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Results

17 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Model the in Used Values Input and Design

19 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Discussion

21 . . . . . . . . . . . . . . . . . . . . . Education Care-Self Through Promotion Health :Four Model .V

21 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Results

21 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Model the in Used Values Input and Design

22 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Discussion

23 . . . . . . . . . . . . . . . . . . . . . Adults With Intervention Educational Presurgical :Five Model .VI

23 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Results

23 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Model the in Used Values Input and Design

24 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Discussion
25 . . . . . . . . . . . . . . . . . . . . . . . . . . . . Use Alcohol Reduce to Counseling Brief :Six Model .VII

25 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Results

25 . . . . . . . . . . . . . . . . . . . . . . . . . . . . Model the in Used Values Input and Design

27 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Discussion

29 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Discussion and Summary .VIII

33 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bibliography .IX

37 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appendix Technical .X

37 . . . . . . . . . . . . . . . . . . . . . “Averages of Flaw “the and Simulation Carlo Monte

43 . . . . . . . . . . Mothers Risk-High for Visits Home Infancy and Prenatal 1: Model

48 . . . . . . . . . . . . . . . . . Women Pregnant at Targeted Cessation Smoking 2: Model

52 . . . . . . . . . . . . . . . . . . . Therapy Health Mental Term-Short Targeted 3: Model

56 . . . . . . . . . . . Adults Older and Adults for Education Health Care-Self 4: Model

59 . . . . . . . . . . . . . . . . Adults With Intervention Educational Presurgical 5: Model

62 . . . . . . . . . . . . . . . . . . . . . . . Use Alcohol Reduce to Counseling Brief 6: Model

Report Technical iv
v Services Preventive of Cost The

Tables of List

7 . . . . . . . . . . . . . . . . scenarios cost four the of each for assumed values relative The 1 Table

 the and Scenario Expensive Least the between costs PMPM Midpoint 2 Table

30 . . . . . . . . . . . . . . . . . . . intervention preventive each for Scenario Expensive Most

HMO 1997 of percentage a as interventions preventive of costs PMPM 3 Table

31 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . individuals single for premiums

38 . . . . . . . . . . . . . . . scenarios cost four the of each for assumed values relative The .1A Table

44 . . . . . . . . . . . . . scenarios four under costs PMPM :visits home postnatal and -Pre .2A Table

 :women pregnant at targeted counseling/education cessation Smoking .3A Table

49 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . scenarios four under costs PMPM

under values PMPM of Range :psychotherapy term-short Targeted .4A Table

53 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . scenarios four

under values PMPM of Range :care-self through promotion Health .5A Table

57 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . scenarios four

 promotion Health 4: Model in variables for values input Assumed .6A Table

60 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . care-self through

 :adults older and adults with interventions educational Presurgical .7A Table

61 . . . . . . . . . . . . . . . . . . . . . . . . . . . . scenarios four under values PMPM of Range

 :labor and ,supplies ,materials ,participation for values input Assumed .8A Table

63 . . . . . . . . . . . . . . . . . elderly and adults with intervention educational Presurgical

under values PMPM of Range :abuse alcohol reduce to counseling Brief .9A Table

64 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . scenarios four
Report Technical vi

Figures of List

5 . . . . . . . . . . . . . MCO an in costs PMPM understanding for formulas critical Two 1 Figure

 under costs PMPM of Distributions :visits home postnatal and -Pre .1A Figure

45 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . scenarios four

:women pregnant at targeted counseling/education cessation Smoking .2A Figure

50 . . . . . . . . . . . . . . . . . . . . . . . . . scenarios four under costs PMPM of Distribution

54 . . scenarios four under costs PMPM of Distribution :psychotherapy brief Targeted .3A Figure

 PMPM of Distribution :education care-self through promotion Health .4A Figure

58 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . scenarios four under costs

 of Distribution :elderly and adults with interventions educational Presurgical .5A Figure

62 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . scenarios four under values PMPM

65 . . . . . . . . . . . . . use alcohol reduce to counseling brief for costs PMPM of Range .6A Figure
vii Services Preventive of Cost The

and review literature a through identified previously ventionsinter preventive six for estimates cost presents document This

mental in research published ,reviewed-peer of analysis

was report That .)2000 ,Dorfman (services abuse substance or health

a yielded and Services Health Mental for Center the by commissioned

studies those of one-Twenty .studies research designed-well of number

benefits patient demonstrated that interventions preventive six supported

report The .care medical of cost and use lower or) outcomes better .,e.i(

,report this to companion a as reader the to useful be should Dorfman by

screening for methodology and ,criteria ,background the provides it as

recommended six the support directly that articles 21 to field the rowingnar further and ,studies 54 describing and selecting ,articles of hundreds

 .inclusion its support to studies lishedpub ,reviewed-peer ,rigorous two least at had intervention Each .services

presented are models ,report technical this In

the for cost potential of range the project to

:life later to prenatal from stages opmentaldevel the span services The .)MCO (zationorgani care managed a of members to videdpro are they when interventions following

 for visits home infancy and Prenatal 1.

mothers risk-high

counseling/education cessation Targeted 2.

smokers for

 therapy health mental term-short Targeted 3.

 care-self through promotion Health 4.

 education

with intervention educational Presurgical 5.

 adults

alcohol reduce to advice/counseling Brief 6.

 use

and based-spreadsheet are models The

(variables input (factors various the include

:intervention each of costs the drive that

and supplies ,labor clerical and professional

administrative and general and ,materials

.margin profit as well as overhead) A&G(

research the in published values the on Based

and) 2000 (Dorfman by reviewed studies

each ,surveys or studies published other

per service of units ,users probable s’tioninterven each of estimates included model

 .unit per price and ,user

of method a ,estimates these achieve To

known ,use common in simulation computer

each to applied was” ,Carlo Monte “as

potential the estimate to model spreadsheet

simulation This .variables input of nationscombi and variable input each in variability

variable specific ,single a for allows method

per a as expressed costs of range or tributiondis a in resulted simulation Each .values blepossi all of distribution a by replaced be to

four across cost) PMPM (month per member

vii

Summary Executive
Report Technical viii

Scenario Expensive Least a from” ,scenarios“

higher increasingly represented scenario sivesucces Each .Scenario Expensive Most a to

,variables input assumed the in estimates

the or salaries staff professional the as such

bearing-child of women enrolled of number

run were factors or variables input in tionsvaria the all ,number one achieve To .age

a produce to iterations of thousands across

and median a with costs outcome of range

Monte the on details Further .midpoint

the in presented are simulation Carlo

to application its and ,Appendix Technical

reviewed be can costs and use estimating

.(1998) Harshbarger and Broskowski in

this in reported cost PMPM single The

value midpoint the represents publication

the of cost median the and scenario siveexpen least the of cost median the between

relative their In .scenario expensive most

costs PMPM median the between pointsmid calculated the are here ,cost of order

 :interventions six the for

Care-Self Through Promotion Health ,tionsinterven these of expensive most the Even

to percent 1 than less add would ,Education

organization maintenance health average the

rates 1997 on based ,premium) HMO(

and ,Long ,Cantor ,Baker by reported

increase average the ,fact In .)2000 (Marquis

interventions six all across premium in

.percent 0.5 than less be would

survey) 2000 (Robertson and Milliman A

response third-one a with ,HMOs 591 of

a for month a $187.49 as 2000 in miumspre HMO average national estimated ,rate

of cost PMPM average The .employee single

is combined interventions preventive six all

that of percent 0.41 only is which $0.77,

 .premium average

have interventions cost-low these Since

,outcomes medical improve to shown been

would they that given and ,cost and use icalmed reduce and ,satisfaction patient increase

percent 0.5 than less of increase an require

MCOs ,premiums current typical the of

refer should reader The .interventions ioralbehav such implementing consider should

(2000) s’Dorfman ,studies original the to

,studies published 54 original the of review

which ,Appendix Technical attached the and

cost regarding details the of many provides

.intervention each for used assumptions

Intervention Preventive Behavioral

Cost PMPM Median Midpoint

/Education Cessation Targeted

$0.03 Smokers for Counseling

Educational Presurgical

$0.26 Adults With Intervention

 to Advice/Counseling Brief

$0.58 Use Alcohol Reduce

 Visits Home Infancy and Prenatal

$0.76 Mothers Risk-High for

 Mental Term-Short Targeted

$1.48 Services Health

 Through Promotion Health

$1.54 Education Care-Self
.I

the by commissioned ,)2000 (review literature s’Dorfman

and Abuse Substance ,Services Health Mental for Center

than more screened ,Administration Services Health Mental

to link a with interventions preventive of types effective documenting iesstud research published of) 54 (number large a yielded and studies 800

that health mental or) drugs illicit and ,tobacco ,alcohol (use substance

in outlined studies 54 the Of .1interventions the of impact cost the ingaddress those including ,journals reviewed-peer in published been have

as and service per studies supporting two of minimum a with ,ventionsinter recommended six the of basis the form to used were 21 ,report the

.services some supporting studies six as many

and Introduction

Background

:review literature that in article an inginclud for used were criteria following The

definition the within fit intervention The• 

classifications three the of one or ,tionpreven secondary ,prevention primary of

Model s’Medicine of Institute the in) tionsinterven indicated or ,selective ,universal(

.Prevention of

or one reviewed or evaluated study The• 

a prevent to designed interventions more

or ,tobacco ,alcohol .,e.i (abuse substance

a or problem health mental or) drug illicit

to designed intervention health behavioral

—problem health associated an prevent

resulting—baby birthweight-low a as such

.tobacco of use from

with implemented was intervention The• 

model intervention the or; subjects human

of group hypothetical a to applied was

.subjects human

a in implemented was intervention The• 

.setting referral or care medical

in result to shown was intervention The• 

impact neutral or ,offset cost ,savings cost

intervention the or; care of cost the on

the with ,effective be to shown was

,offset cost ,savings cost of result potential

.care of cost the on impact neutral or

1964 from published was study The• 

,language English the in 1999 through

.journal reviewed-peer a in

1 Services Preventive of Cost The

Internet through located were review this for obtained studies the of majority the “that reported Dorfman 1

,AIDSLINE ,PREMEDLINE ,HealthSTAR ,MEDLINE :databases 11 includes which 2.3.2,V Med Grateful

evaluation ,savings cost ,effectiveness-cost ,analysis benefit-cost ,behavior cost :used were terms search ingfollow The .SDILINE and ,OLDMEDLINE ,HSRPROJ ,HISTLINE ,DIRLINE ,AIDSTRIALS ,AIDSDRUGS

,studies intervention ,promotion health ,)HMOs (organizations maintenance health ,education health ,studies

preventive ,services health preventive ,prevention ,education patient ,health mental ,programs care managed

.(12–11 .pp” (abuse substance and ,economics/prevention primary ,medicine
the against screened were that studies lishedpub 54 yielded criteria these of use The

included be to criteria additional following

by consideration for recommendations the in

:MCO an

been has effectiveness s’intervention The• 

studies more or two by demonstrated

.review this in included

for appropriateness s’intervention The• 

referral or care managed a in provision

is or stated explicitly been has setting

.apparent

MCO for feasibility s’intervention The• 

been has perspective cost a from coverage

,Dorfman (suggested or documented

.(19 .p 2000,

criteria final these of application The

21 by supported interventions six yielded

review s’Dorfman in articles the All .articles

preventive of outcomes positive document“

or health mental to relation in interventions

articles 54 the of Thirteen .abuse substance

. . . .intervention the of cost the address

of body the represent studies these ,Overall

interventions that evidence based-science

and abuse substance prevent to designed

some as well as [problems health mental

net produced have ,cases some in ,and tiveeffec proven been have] problems medical

would that costs offset have or savings cost

preventive the absent incurred been have

.(13 .p” (intervention

a (studies 21 and criteria these on Based

Dorfman ,)intervention per two of minimum

stages developmental the spanning ,tionsinterven six following the recommended

:(21–19 .pp (age old to birth from

for Visits Home Infancy and Prenatal 1.

 Mothers Risk-High

women on focused articles These

who ,pregnancies risk-high with

19 under women pregnant included

low of or ,unmarried ,age of years

The .prematurely born infants weightbirth-low and; status socioeconomic

,varied visits home periodic of timing

age to period prenatal the from ranging

in nurses by made were visits Home 3.

in aide Act Training Education siveComprehen a with teamed student ategradu psychology a by and project one

visits home focused study One .another

other and functioning maternal on

to mothers of training the on studies

spacing greater ,pregnancies quentsubse Fewer .infants their stimulate

drug and alcohol less ,births between

and abuse child less and ,impairment

home received who mothers for ingsfind significant the among were neglect

on scores better ,weight Higher .visits

reduced and ,tests developmental motor

were retardation mental of incidence

for findings significant the among

 received mothers whose infants

.intervention

Counseling/Education Cessation Targeted 2.

Smokers for

a included articles these in Subjects

smoked who women of” cohort birth“

smokers pregnant ,pregnancy during

maternity county through recruited

of group hypothetical a and ,clinics

session counseling minute15- a of sistedcon Interventions .care medical tinerou receiving smokers female and male

two and materials written by mentedsupple educator health or nurse a with

minute15- a; calls telephone followup

counselor health trained a with sionses development skill and counseling

newsletter ,support social ,forcementrein patient clinical by supplemented

prenatal a in mention and ,information

a and booklet help-self a by mentedsupple smoking quit to advice cianphysi of minutes 4 and; class education

cohort birth The .visit followup year1-

Report Technical 2
$3.31 of savings estimated study model

birthweight-low for caring of cost the in

care intensive neonatal a in infants

smoking on spent dollar every for unit

advice physician brief ,group patient calhypotheti the In .intervention cessation

cessation the increase to estimated was

the In .percent 2.7 by year 1 at rate

in rate quit percent8.5- an with paredcom ,rate quit percent14.3- a ducedpro intervention the ,clinics maternity

.group control the

Therapy Health Mental Term-Short Targeted 3.

15 age to up children of study a In

parents their with sessions therapy ioralbehav targeted six to one received who

psychology clinical predoctoral or gistspsycholo pediatric level-doctoral from

problems behavioral with those ,interns

,noncompliance ,aggression as such(

or sleep or ,fears excessive ,tantrums

their reduced) disturbances mealtime

,third-one almost by encounters medical

problems toileting with those while

by encounters medical their reduced

of group another In .half-one almost

term-short sought who individuals

or psychiatrist a from psychotherapy

an on psychotherapist registered other

decreased significantly cases index ,erspractition community of list approved

.controls matched with paredcom hospitalization medical of days

Care-Self Through Promotion Health 4.

Education

were studies cited six the of Five

;settings care managed in conducted

The .based-worksite was sixth the

.health mental and use substance passedencom that issues care-self and tionpromo health addressed interventions

education group included Interventions

practitioner nurse a by led workshops

guide care-self a by supplemented and

a ,materials written; videotapes and

by staffed service information telephone

individual an and ,coordinator nurse a

risk-health personal ,serial ,basedcomputer; nurse trained a with enceconfer planning and evaluation health

individualized by supplemented reports

written and letters recommendation

;center care-self a to access; materials

with sessions education one-on-one

The .shows tape-slide and; physicians

percent28- estimated an were results

24- and costs laboratory in savings

between costs ray x in savings percent

and; groups control and experimental

medical total in decrease percent17- a

in decrease percent35- a and visits

experimental in visits illness minor

significant ,Also .groups control versus

in decreases :noted were improvements

;stress reported and ,use alcohol ,ingsmok including ,behaviors risk-health

and; visits physician ambulatory in centper 24 to 7.2 from ranging decreases

group experimental the in visits icalmed total in percent 15 of decrease a

,study one In .controls with compared

in saved was $5 estimated an ,grampro the on expended dollar every for

physician for costs care health direct

.days hospital and visits

Intervention Educational Presurgical 5.

Adults With

to workshop a of consisted ventioninter the ,studies cited the of one In

.patients surgical adult to care ucationalpsychoed provide to nurses staff enable

two other the in described Interventions

skills; expect to what about mationinfor patients giving included articles

provider care health a with support cialpsychoso; anxiety reduce or plicationscom prevent patients help to training

ability enhance or anxiety reduce to

to surgery after and before thetistanes an by patients to visits and; alsmateri taped and printed with mentedsupple ,hospitalization with cope to

3 Services Preventive of Cost The
associated were Interventions .anceguid care-self and information provide

,antiemetics ,sedatives of use less with

as well as narcotics and ,hypnotics

.hospital the from discharge earlier

Reduce to Advice/Counseling Brief 6.

Use Alcohol

studies 47 reviewed articles four The

and States United the in conducted

included Interventions .internationally

advice of minutes 15 and 5 between

alcohol reducing on counseling or

,physicians by provided consumption

also subjects ,studies some In .sionalsprofes other or ,psychologists ,nurses

informational or workbook a received

followup included components tioninterven Other .materials help-self or

alcohol in reductions Significant .mentreinforce for calls telephone or visits

:documented were consumption

,percent 14 ,men aged-middle among

;percent 31 ,women aged-middle and

percent40- ,older and 65 adults among

.reduction

Six These of Models Cost

Interventions

of results the on reports publication This

modeled were interventions The .ventionsinter of types six these of simulations cost

an to cost potential their for specifically

;members enrolled to provided when MCO

or offsets cost include not does cost the

a on Based .plan the to savings potential

with dealing studies the all of review careful

financial ,intervention of category each

reflect to created were models spreadsheet

of cost the drive would that variables the

 .intervention of type each

summarizes report this of part first The

useful be to intended is and calculations the

report previous the in given ommendationsrec the implementing considering MCOs to

Under Interventions Preventive ,Dorfman by

Substance and Health Mental :Care Managed

for Center the by published ,Services Abuse

It .SAMHSA at Services Health Mental

public ,employers ,organizations care agedman ,packages benefits covered of chaserspur and decisionmakers to useful be should

 .financing in researchers services health talmen and ,administrators health State ,payers

supporting studies multiple the of Because

one no that fact the and intervention each

design the in details the of all provided study

intervention of kind each of operation and

model generic a ,category overall each within

Infancy and Prenatal “of category the ,pleexam For .study one than more from cationsspecifi using category each for designed was

was” Mothers Risk-High for Visits Home

of out publications different 11 by supported

11 These .reviewed Dorfman 54 overall the

of training job-the-on to interventions basedclassroom to visits home from ranging ,tionsinterven of variety wide a described studies

provide not did 7 ,studies 11 these Of .tercen care-day child a within mothers young

the of cost the to specific information any

detail enough specify not did 4 ,intervention

clear a establish to done was what about

final the for basis the formed 3 ,model cost

most the with 2 only and ,recommendation

model cost the design to used were details

.intervention visit home the for

Based-Cost of Method General

Modeling

three the on based created was model Each

any of cost the drive that variables primary

defined a within service or intervention

:population

persons eligible of percentage The 1.

intervention the by served are who

(“Users “or ,Participants(

Report Technical 4
within Service of Units or ,intensity The 2.

provided services of ,Time of Period a

participant each to

Unit (service of units these of cost The 3.

(Cost

these of each of value the Multiplying

total the by divided cost total The .ventioninter the of” Cost Total “the yields variables

or ,lives covered (persons eligible of number

Eligible per Cost “the yields) members

plans care managed most Because” .Person

on benefits care health of cost their calculate

their determine to order in (basis PMPM a

each of cost total the ,)premium monthly

a on calculated was intervention of type

 .basis PMPM

.variables three these summarizes 1 Figure

used be can relationship multiplicative Their

PMPM .cost annual total the calculate to

annual total on based calculated are costs

number annual average the by divided ,cost

.months 12 by divided ,members of

other still of result the be may variables marypri these of each of values the ,course Of

of unit a of cost the ,example For .variables

depend will employee an by delivered service

:following the as such variables on

benefit-fringe and salary s’employee The• 

 costs

the that year the in hours average The• 

service” productive “in spends employee

 of hour productive a of cost the .,e.i(

(service

to necessary expenses direct of cost The• 

.,g.e (service particular that establish

(supplies ,equipment

to necessary expenses A&G of cost The• 

that and organization general the support

,utilities ,insurance .,g.e (service particular

(salaries’ administrators

broken be may variables these ,Again

another one to related and further down

:following the as such formulas through

Service of Hour s’Person Staff a of Cost

Direct (+) Benefits Fringe (+) Salary= [(

Total /) expenses A&G (+) Expenses

[Hours Productive

an on Costs Service Ongoing

Basis Annualized

a on operate plans care managed Because

through enroll members and budget year1-

was model every ,annually employers their

if as and model cost” year1- “a as designed

an on intervention each provides MCO the

carry commonly Researchers .basis ongoing

interventions preventive on research their out

defined-well a over collection data tematicsys for designed environment controlled a in

of method This .period time limited but

plan care managed a way the than ferentdif somewhat is understandably operation

 .services similar provide would

how involves difference major Another

.delivered and organized is intervention the

as offered were interventions these of Some

limited but defined-well a to service group a

.period time defined a over cases of group

are ,however ,services health clinical Most

intermittently occur they as basis ingongo an on patients individual to provided

 .year the throughout

5 Services Preventive of Cost The

formulas critical Two 1: Figure

 costs PMPM understanding for

MCO an in

X) User/Units (X) /1000Users = (Cost Total 1.

(Unit/Cost(

(PMPM (Month per Member per Cost 2.

/ (Members Total (/) costs Total) = (PMPM $(

months 12
interventions the of many ,Furthermore

,organized were literature the in described

a during terminated then and ,out carried

managed a If .year 1 than less of time fixed

an such offering undertake to were plan care

an on service the offer would it ,intervention

new a up starting probably ,basis ongoing

the receive to persons of cohort or” class“

other ,Still .intervals month6- at intervention

being to themselves lend do interventions

,basis case-by-case ,ongoing an on offered

of use the reduce to advice brief as such

.alcohol

is plan care managed a ,example either In

startup time-one incur to want to unlikely

its among expectations some establish ,costs

the terminate then and ,members enrolled

the ,Therefore .time short a after program

plan care managed a for cost the for model

offered be will intervention the that assumes

the ,time same the At .year the throughout

that costs startup the include do models cost

first the during incurred be to have would

such ,year first the After .service the of year

less cost would intervention the that so tionscalcula cost the in omitted be could costs

initial the in did it than year ensuing the in

were models the which on studies The .year

;evaluations with research all were based

with associated costs extra the ,obviously

tracking as such ,research the out carrying

were ,members group control on outcomes

.models cost the in incorporated not

Variation for Accounting

model the how of discussion detailed a For

chance to due variation account into took

.Appendix Technical the to refer ,)taintyuncer (values unknown and) probability(

Scenarios for Accounting

preventive these of each of model cost A

one At .scenarios different four under latedsimu then and designed was interventions

,Scenario Expensive Least the was extreme

least the assumed that scenario the as defined

reasonable a among from values expensive

.,g.e (driver cost each for values of range

intervention the of intensity ,prevalence

other the At .)salaries staff ,period time/units

,Scenario Expensive Most the was extreme

values expensive most the assumed which

reasonable of range same the among from

 .values

of values relative the summarizes 1 Table

.model each in drivers cost various the

each for variable dependent critical The

the is which ,cost PMPM the was model

per membership average (months bershipmem annual total the by divided cost total

the of) 12 by multiplied ,year the over month

was that) MCO (organization care managed

.intervention the sponsor to assumed

1,000 over simulated was model Each

simulation Carlo Monte using iterations

distribution a in resulting ,)1996 ,Winston(

each for values cost PMPM possible 1,000 of

.intervention

the presents Appendix Technical The

distributions cost PMPM four the of details

the of details the and intervention each for

as used drivers cost the of values assumed

.model each to inputs

Report Technical 6
7 Services Preventive of Cost The

scenarios cost four the of each for assumed values relative The 1: Table

Scenario

 Least Intermediate Intermediate Most Drivers Cost

Expensive Low High Expensive

 Many ,Public Many

Primarily ,Commercial Some Primarily Plan the in Covered Enrollees

Commercial Public Some Commercial* Public

Low Very Low High High Very Condition Target of Prevalence

Low Very Low High High Very Rate Participation

Short Very Short Long Long Very Intervention per Period Time

Low Very Low High High Very) Intervention per Units Service (Intensity

Staff Few Very Staff Few Staff Many Staff Many Very Pattern Staffing

Lowest Low High Highest Benefits Fringe and Salaries Staff

Lowest Low High Highest Expenses Variable and ,Fixed ,Startup

13% 12% 11% 10% Profit and Overhead Administrative

.(Medicaid .,g.e (funds sector public through financed is coverage care health whose persons means enrollees Public*

.II

9 Services Preventive of Cost The

of amalgamation an on based designed was intervention This

and ,Kitzman ,Phelps ,Henderson ,Olds—publications two

reviewed and)—1992 (Ramey and Ramey and) 1993 (Hanks

5. and 2 numbered respectively references in) 2000 (Dorfman by

to necessary was it ,another of replication strict a was study no Because

would that variables major on based model intervention each build

.study each for model separate a building than rather ,costs drive clearly

additional an used It .model cost this in included not was ,mendationsrecom final the supported that and Dorfman by reviewed ,study third A

separate a required have would thus and intervention based-classroom

.(1982 .,S ,Stoller & .,R ,Greenberg .,S ,Widmayer .,T ,Field (model cost

Prenatal :One Model

Home Infancy and

Risk-High for Visits

Mothers

studies two these between differences Further

and mothers of population target the in were

and Ramey 19. age under women marriedun on focused) 1993 (.al et Olds .infants

because subjects their selected) 1992 (Ramey

premature or birthweight low’ infants the of

types the in differences these While .delivery

impact some had have may participants of

a have to considered not were they ,tionsinterven the of effectiveness relative the on

participant a “.,e.i (cost the on impact major

 .(“participant a is

intervention the design to important is It

possible reasonably as generically as models

care managed given any allow to order in

For .circumstances of variety a under tioninterven the of cost likely the assess to plan

its target to wish may plan one ,example

enrolled of category narrow a to intervention

while ,)only mothers teenage .,g.e (members

women older ,mothers teenage .,g.e (goriescate multiple target to wish may another

mothers all and ,age to due risk prenatal at

 .(outcome birth adverse an for risk at

number the of estimate an get to order In

was model the ,participants potential of

the among from participants of categoriessub different three support to designed

 :members eligible

mothers Teenage 1.

babies birthweightlow potentially of mothers Nonteenage 2.

risk-high other with mothers Nonteenage 3.

pregnancies
model this for reported costs PMPM The

 .participants of categoriessub three all for cost total the on based are

 Used Values Input and Design

Model the in

of range wide a incorporated model This

order in values assumed their and variables

a is following The .cost PMPM a estimate to

.structure general s’model the of description

values the and variables input the on Details

provided are variables these populate to used

.Appendix Technical the in

Assumptions

Managed the by Covered Lives of Number

Plan Care

enrolled 100,000 assumed models the All

 .MCO the in) members (lives

Served Cohorts Intervention of Number

Cycle Operational Month12- a Within

intervention the that assumes model The

that so ,weeks 26 than more no last would

served be would cohorts independent two

.year 1 in

in Participates That Cohort the of Size

Cycle Intervention Each

model the ,members enrolled the on Based

of number average the of estimate an used

be would who females pregnant risk-high

In .intervention the in participate to likely

populate to use to values what determining

data Bureau Census .S.U 1998 ,variables these

population general the of percentages the on

group age each of females by represented

children bear to able potentially were who

20 ages = adults 19, to 14 ages = teens .,e.i(

on tables separate were as ,used were) 44 to

rate The .groups age these of rates birth the

Report Technical 10

from estimated was babies birthweight-low of

“Card Report HEDIS “plan care managed the

.NCQA the for 1996 to 1995 from developed

Attrition

of number the for included were Estimates

,intervention the complete would who bernum the and begin would who participants

.attrition to due being difference the

Services and Time

,private initial an undergo would ticipantspar all that assumed model particular This

visit orientation and assessment one-on-one

1 of average an lasting ,worker social a with

participants that assumed model The .hour

and week other every visit one receive would

attempted be would visits home some that

.(“shows no (“completed not but

of Number and Hours Staff Required

Employed Staff

,participants of number average the Using

the and ,participation of weeks average their

the from and to driving spent time average

drive and time visit total (hours staff of bernum the of made were calculations ,home

home the do to required be would that) time

allows hours staff necessary total The .visits

have would that staff) FTE (equivalent timefull of number the of calculation the for

required of calculation The .employed be to

adjusted model the ,Therefore .time” ductivepro “are hours these assumes hours staff

would that staff FTE of number the upward

representing factor a by hired be to need

average the that time of percentage the

.,g.e (productive not is member staff FTE

internal or ,vacation ,leave sick of because

the for calls also model The .)meetings

salaries average so hired be to staff of types

 .entered be can rates benefit-fringe and
 Variable and ,Fixed ,Startup :Costs Direct Other

the to attributable directly costs startup timeone the of estimates includes also model The

fixed annual the and program intervention

“visit home per “a on expenses variable and

be would expenses fixed and Startup .basis

of Examples .software and ,equipment putercom ,furniture ,rent of cost as items such

or supplies any are visit per costs variable

visit each at consumed are that items other

mother the for toys stimulation sensory .,g.e(

noncompleted and completed both for tiontransporta staff of cost ,child the with use to

.(visits

Profit and Overhead Administrative

to required are that expenses total of agepercent the is valued be to variable final The

 .margin profit any plus expenses A&G cover

Results

Cost PMPM

simulation cost the ,I Chapter in noted As

of each for done was intervention this of

distributions four producing ,scenarios four

,variable output the of values possible of

reported cost PMPM single The .cost PMPM

the between value midpoint the represents

Scenario Expensive Least the of cost median

Expensive Most the of cost median the and

all for results cost the on Details .Scenario

11 Services Preventive of Cost The

Technical the in presented are scenarios four

 .Appendix

Least the for cost PMPM median The

the and $0.40, only was Scenario Expensive

Scenario Expensive Most the for cost median

two these between midpoint The $1.12. was

 $0.76. is values median

Discussion

reduce to shown been has intervention This

overall produce and outcomes birth adverse

;1993 .,al et Olds (savings cost medical

annual The .)1992 ,Ramey and Ramey

100,000 for PMPM $1.03 of investment

of cost aggregate an to comes members

of sum large a is this Although $1,236,000.

save to expected be could MCO the ,money

savings cost the through amount larger a

births adverse of prevention the by realized

most Although .costs medical high their and

the in accrue would savings medical the of

additional ,life s’child the of years 5 first

child per cost the in savings net icantsignif documented has interventions hoodchild early on research econometric tudinalLongi .adolescence during likely are savings

,Hoube ,Everingham ,Greenwood ,Karoly(

,Chiesa and ,Sanders ,Rydell ,Kilburn

involve savings these of Much .)1998

system justice criminal the to costs reduced

and health adolescent and child as well as

.costs welfare

and ,Hogue ,Koplan ,Marks—publications three of tionamalgama an of basis the on designed was model cost This

,Artz ,Yoder-Smith ,Perkins ,Lowe ,Windsor); 1990 (Dalmat

and ,Rubin ,Cummings and); 1993 (Boyd and ,Amburgy ,Crawford

 26. and 3, 1, numbered tivelyrespec references in) 2000 (Dorfman by reviewed and)—1989 (Oster

extensive most was that intervention The

toward targeted ,)1993 .,al et Windsor(

care prenatal receiving women pregnant

the of consisted ,clinic health public a in

:components following

,session counseling) minute15- (brief A• 

 written of use the by supplemented

materials

prenatal during reminders chart Medical• 

visits

letters and calls phone Followup• 

“contact buddy “A• 

reminder smoking-no minute2- A• 

prenatal minute20- a within embedded

class education

a only using reported) 1990 (.al et Marks

simple ,session counseling minute15- single

followup two and ,materials instructional

reported) 1989 (.al et Cummings .calls phone

administered booklet help-self a and ,lowupfol year1- a ,physician a by session selingcoun minute4- a of effectiveness-cost the on

and male adult of group” hypothetical “a to

.patients female

cost the make to order in ,again Once

designed was it ,possible as generic as model

all across components various the include to

.studies three

Results

Cost PMPM

median a had Scenario Expensive Least The

Most the and $0.02, of cost PMPM

of cost median a had Scenario Expensive

,Again $0.03. of midpoint a with $0.04,

Visits Home Infancy and Prenatal the in as

average the as increased variability ,model

,scenarios four all Across .increased cost

values PMPM estimated the of percent 90

$0.06. to $0.02 of range the within were

 Used Values Input and Design

Model the in

Managed the by Covered Lives of Number

Plan Care

assumed ,models other all like ,model This

(members (lives enrolled 100,000 are there

 .MCO the in

13 Services Preventive of Cost The

Smoking :Two Model .III

Targeted Cessation

Women Pregnant at
Within Served Cohorts Intervention of Number

Cycle Operational Month12- a

one be to assumed was intervention This

basis ongoing an on offered be could that

routine their for in came they as patients to

the in visits prenatal .,e.i (visits medical

.(women pregnant of case

Completing Participants Likely of Number

Intervention the

in women be would who members of bernum the of estimates used also model This

Bureau Census .S.U .years childbearing their

the determine to used were 1998 from data

who group age each of females by sentedrepre population general the of percentages

.,e.i (children bear to able potentially were

to 20 ages = adults 19, to 14 ages = teens

rates birth the on tables separate and) 44

 .groups age these of

21 of average an that estimated was It

a in patients pregnant likely the of percent

by reported as ,smokers be would year

1986–1985” a on based) 1990 (.al et Marks

System Surveillance Factor Risk Behavioral

and states 25 from women American of ...

2000, ,Dorfman” (Columbia of District the

.(31 .p

of percentage the established Having

,smokers and pregnant were who members

such of number the estimated model the

93.7 of figure a on Based .study the in patepartici to willing be would who members

,(1993) .al et Windsor by reported ,percent

the of estimates of range a used model the

who smokers pregnant the of percentage

The .participation start to agree would

of percentage the estimated also model

complete would who smokers pregnant

as were values selected These .program the

Expensive Least the in percent 68 as low

the in percent 78 as high as and Scenario

.Scenario Expensive Most

attrition on based selected were values The

.(1993) .al et Windsor by reported rates

intervention planned s’Windsor left Women

,eligibility benefit losing as reasons such for

.miscarriages having or ,abortions having

Services Related and ,Time Staff ,Materials

model the ,studies three the of each For

undergo would participants all that assumed

lasting ,nurse a with counseling one-on-one

.minutes 15 of average an

received patient each assumed model The

cessation smoking “a and pamphlets two

were Items” .book help-self “or” guidebook

(1989) .al et Cummings $4. cost to assumed

help-self a for $2 of estimate an reported

estimated) 1993 (.al et Windsor and ,booklet

,materials of cost the for patient per $6

.labor and ,reproduction

as same the was time’ nurses of value The

salary a on based ,model first the in used that

by scenario each in incrementing $50,000 of

percent 70 of productivity average an $1,000,

.rate benefitfringe percent 29 a and ,hours payroll of

each that reported) 1993 (.al et Windsor

,cessation smoking of importance the sizingempha” letter medical “a received patient

s’patient the in placed was reminder a and

The .visits prenatal subsequent at tionsques ask could doctor the so chart medical

activities these for required time clerical

.minutes 10 of mean a at estimated was

at start to estimated were salaries Clerical

each for increments $1,000 with ($20,000

productivity a with ,)scenario successive

rate benefit-fringe a and percent 80 of rate

costs postage and letter The .percent 29 of

.patient per $0.41 at estimated were

Report Technical 14
on reported also) 1993 (.al et Windsor

:activities lowingfol the of consisted which” ,supports social“

two including” ,letter buddy “a Sending• 

 patient each to ,pamphlets

each to newsletter quarterly a Sending• 

patient

to assumed were mailings five These

clerical of minutes 10 of average an require

(minutes 3] = SD [deviation standard (time

per postage and reproduction for $0.45 and

.patient

the for cost the in builds also model The

as nurse a by delivered reminder minute2-

.class prenatal minute20- a of part

no were there that assumed model The

costs startup time-one or variable other

/guides cessation smoking the beyond

.pamphlets and booklets help-self

valued be to had that variable final The

required expenses total of percentage the is

profit any plus expenses A&G cover to

10 of amount generous fairly A .margin

.used was percent

Discussion

the in little very entails intervention This

fixed other or costs startup initial of way

,extensive any require it does nor ,costs

.al et Marks .staff for training specialized

for $3.31 of savings a estimated) 1990(

through primarily ,invested dollar every

babies birthweight-low of prevention the

 Windsor .deaths perinatal averted and

medical of range a estimated) 1993 (.al et

adverse fewer through realized savings

for $17.18 to $6.72 from effects birth

.invested dollar every

15 Services Preventive of Cost The

.IV

interventions of basis the on designed was model cost This

(1991) Cataldo and ,Riley ,Finney by research in described

Cook and ,Locke ,Carey ,Kessler ,Allen ,Goldberg and

estimate to ,others the were as ,designed was model This 41. and 15 berednum respectively references in) 2000 (Dorfman by reviewed and) 1981(

.(65–18 ages (members adult its for and) 17 age to birth (members lescentado and child its for) visits 16 to 6 (benefit psychotherapy brief a mentsimple that members 100,000 with plan care managed a for costs PMPM

Targeted :Three Model

Mental Term-Short

Therapy Health

ages children on focused) 1991 (.al et Finney

Goldberg .HMO based-staff a of clinic atricpedi a in therapy brief with treated 15 to 1

the on based research their did) 1981 (.al et

to provided psychotherapy for paid claims

Employees Federal the of members adult

was model cost This .Plan Benefit Health

and children both accommodate to designed

subgroup each of results cost the and ,adults

MCO an that assuming ,combined were

age all with intervention this use would

similar a had categories age Both .groups

.(distributions chasticsto various to assigned values .,e.i (tionsassump input different but structure cost

Results

 Cost PMPM

Least the for cost PMPM median The

median The $1.00. was Scenario Expensive

Scenario Expensive Most the for cost PMPM

value midpoint a in resulting $1.96, was

 $1.48. of

 Used Values Input and Design

Model the in

Prevalence Treated and Membership

membership MCO an assumed model This

census 1990 of basis the On 100,000. of

of percent 32 that assumed model the ,data

age to birth from be would population the

65. to 19 ages be would percent 68 and 18,

would MCO any that assumed model The

as ,psychotherapy brief for need the atingevalu when criteria” necessity medical “use

.al et Goldberg by study the in used was

that assumed model the ,Therefore .)1981(

best would prevalence treated of indicators

would who persons of number the estimate

.therapy brief receive

assumed model the ,subgroup child the For

based percent 12 to 9 of rate prevalence a

analysis-meta a from estimates median on

17 Services Preventive of Cost The
reported research epidemiological the of

,Manderscheid ,Leavy-Katz ,Friedman by

treated on study A .)1996 (Sondheimer and

problems health mental of prevalence

indicated adolescents and children among

children insured privately of percent 23 that

serious (disorder health mental any with

(SED-non or] SED [disturbance emotional

,Burns (therapy outpatient some received

.(1991

model the ,subgroup adult the For

rates prevalence treated outpatient assumed

,Bourdon by reported research demiologicalepi on based percent 15 and 14.5, 14, of

Regier and ,Manderscheid ,Narrow ,Rae

rate prevalence treated average an on) 1994(

prevalence treated of rate That .adults for

rate a ,percent 44 by reduced further is

index of) 1981 (.al et Goldberg by reported

who diagnoses psychiatric with patients

.visits zero received

 ,Provider of Type ,Service of Volume

 Copayments and

assumed model the ,subgroup child the For

et Finney .child per visits 2.75 of average an

visits 6 to 1 of range a reported) 1991 (.al

measure no but ,visits 2.4 of average an and

model The .mean this around variability of

child per session therapy each that assumed

includes which ,minutes 60 lasted participant

et Finney by reported sessions minute50- the

10 and) 1981 (.al et Goldberg and) 1991 (.al

on Based .keeping record clinical for minutes

,(1981) .al et Goldberg by reported data the

of minutes 50 requiring one each ,ticipantpar adult per visits eight assumed model the

record for minutes 10 and time therapist

.keeping

was therapy the that assumed model The

social psychiatric or psychologist (sionalprofes health mental licensed a by provided

$50,000, of salary annual an with) worker

,salary of percent 29 of cost benefit-fringe a

$44.30. of” hour per cost effective “an ingyield ,percent 70 of rate productivity a and

including ,plans insurance most Because

copayment health mental a have ,outscarve care health behavioral and HMOs

,respectively $5, and $10, $15, $20, of mentcopay a assumed model the ,requirement

Expensive Least from scenarios four the for

the ,words other In .Expensive Most to

effective “the reduces effectively copayment

the for $24.30 to $20 by” hour per cost

to $5 by and Scenario Expensive Least

.Scenario Expensive Most the for $39.30

all of percent 100 that assumed model The

.collected were copayments

Expenses Other

to how .,g.e” (guidelines treatment ioralbehav “that reported) 1991 (.al et Finney

cost a assumed model The .treatment in drenchil the of parents the to given were”) outstime “of use the ,wetting bed to respond

of cost the for increments $1 in $5 to $2 of

 these of distribution and reproduction

.guidelines

that reported also) 1991 (.al et Finney

of number a received also families most“

was therapy after contacts telephone planned

of implementation adequate ensure to begun

to and techniques therapeutic recommended

,Therefore .)452 .p” (problems troubleshoot

the of percent 100 that assumed model the

.calls phone two receive each would families

took calls phone the that assumed model The

.therapist the by made were and minutes 5

phone or supply no assumed model The

.adults the for expenses call

by increased also was cost total The

rate profit plus overhead A&G a applying

direct the to percent 13 and 12, 11, 10, of

Report Technical 18
respective four the of each in cost services

Most to Expensive Least from scenarios

.Expensive

Discussion

traditionally use that interventions Unlike

brief in trained professionals requires allygener intervention this ,staff medical trained

but ,psychologists primarily—psychotherapy

social psychiatric and psychiatrists some also

HMOs model-staff some ,Therefore .workers

(IPAs (associations practice independent or

patterns staffing their review to have would

were personnel such whether determine to

,psychotherapy brief in trained and available

An .adolescents and children with especially

be would personnel such hiring to alternative

professional qualified a with subcontract to

.basis rate-case or servicefor-fee a on intervention the out carry to

19 Services Preventive of Cost The

amalgamation an of basis the on designed was model cost This

,Lowry ,Kalmer ,Vickery); 1982 (Kemper—publications six of

,Parcell ,Fries ,Fries); 1983 (Loren and ,Wright ,Constantine

,Leigh); 1993 (Mettler and ,Lorig ,Kemper); 1992 (Harrington and

,Vickery and); 1992 (Fries and ,Parcell ,Harrington ,Kerr ,Beck ,Richardson

Dorfman by reviewed and)—1988 (Kalmer and ,Wright ,Golaszewski

52. and 51, 43, 40, 32, 29, numbered respectively references in ,)2000(

19 ages (adults to provided interventions of variety a described study Each

 .worksite the at offered was one and ,setting care managed a in ductedcon were studies six the of Five .)older and 66 age (adults older or) 65 to

of range wide a ,studies six the Across

in participants to provided was activities

behaviors health positive promote to order

:care-self and

provide to nurses train to Workshops• 

,patients to support psychoeducational

,pamphlets ,materials written including

booklets and

,books ,newsletters ,guidelines care-Self• 

participants for booklets and

care-self covering Videotapes• 

service information telephone a to Access• 

nurse a by staffed

nurse a with conferences health Individual• 

personalized ,serial ,based-Computer• 

reports risk health

and letters recommendation Individualized• 

reports

a with sessions educational one-on-One• 

physician

center in-drop care-self a to Access• 

(21 .p 2000, ,Dorfman(

incorporate to designed was model The

estimate to and activities these of nine all

an for overstated are costs PMPM the ,foreThere .combined nine all of costs PMPM the

.activities the of subset a only uses that MCO

Results

Cost PMPM

Least the for cost PMPM median The

median The $1.06. was Scenario Expensive

Scenario Expensive Most the for cost PMPM

 $1.54. of midpoint a with $2.02, was

 Used Values Input and Design

Model the in

Participation and Membership

of estimation an with begins model The

adults older and adults of number the

21 Services Preventive of Cost The

Health :Four Model .V

Through Promotion

 Education Care-Self
with MCO an of members are who

1990 of basis the On .members 100,000

were percentages these ,figures census

uses then model The .adults older for centper 11 and adults for percent 59 at valued

age each of percentage the of estimate an

participate to agree to likely is that group

a .,e.i (campaign promotion health a in

care-self and promotion health of series

These .)year the throughout activities

percent 45 from ranged adults for estimates

percent 15 of increments in percent 90 to

to Expensive Least (scenario each for

the ,adults older For .)Expensive Most

Least (percent 60 at started percentage

as high as went and) Scenario Expensive

in) Scenario Expensive Most (percent 90

.percent 10 of increments

by out costed are activities some Because

a to mailed videotape a .,g.e (household

for household per members covered of bernum the estimate to necessary is it ,)home

on Based .members adult older and adults

the ,)1983 (.al et Vickery by reported data

(Expensive Least (1.26 from set was holdshouse to participants adult older of ratio

of increments in) Expensive Most (1.20 to

3.0 from ranged ratio this ,adults For 0.02.

(Expensive Most (2.4 to) Expensive Least(

0.20. of increments in

Time Staff and Materials :Expenses Other

types various the reflecting modules ratesepa 10 of consisted model the of rest The

were that activities intervention specific of

reviewed studies various the in described

allowed module Each .)2000 (Dorfman by

,material written of estimation cost the for

labor professional and clerical as well as

activities one-on-one conducting in spent

the ,module each In .activities group or

the for estimate separate a used model

older or adults by participation of level

adults 9,000 although ,example For .adults

of series the in participate to agree may

actually may percent 25 only ,activities

particular a in participate to up show

.workshop educational an as such ,activity

in than 4 Model in assumed were ductivitypro of rates and ,)percent 29 (rates benefitfringe ,salaries staff different Slightly

3: through 1 Models

increments $500 in $20,000 at Clerical• 

productivity percent 80 and

increments $1,000 in $50,000 at Nurses• 

productivity percent 70 and

$1,000 in $50,000 at Psychologists• 

productivity percent 70 and increments

$2,000 in $100,000 at Physicians• 

productivity percent 70 and increments

Discussion

easily integrated be could intervention This

practice-independent or -staff most into

Unlike .HMOs model-)IPA (association

is there ,interventions other the of some

medical professional on reliance heavy a not

visit the of exception the with ,time staff

risk health the review to physician a with

.case any in practice medical ablereason be to seem would which ,appraisal

s’model the that note to important is It

highest the are costs PMPM total estimated

type this because is That .models six all of

were which of all ,activities specific entdiffer many so employ can intervention of

original the read should intervention tivepreven this of implementation the sideringcon MCO Any .model cost the in included

The .implement to wishes it activities blepossi the all of which decide and research

presented is activity each for cost PMPM

.Appendix Technical the in

Report Technical 22
.VI

—publications research three on based was model cost This

,Wenk ,Cook ,Connor’O ,Devine); 1983 (Cook and Devine

Bartlett and ,Welch ,Battit ,Egbert and); 1988 (Curtin and

respectively references in) 2000 (Dorfman by reviewed and)—1964(

(1983 ,Cook and Devine (publication One 38. and 36, 35, numbered

other the and analysis-meta This .studies other 49 of analysis-meta a was

to provided interventions component of variety a described studies two

:procedures surgical inpatient of range wide a undergoing adults

videos and materials written including ,supports choeducationalpsy of benefits the on focus that workshops group conducted-Nurse• 

anesthetist an by visits postsurgical and Presurgical• 

recovery postsurgical promote to training exercise or Skill• 

provider care health a from support Psychosocial• 

:Five Model

Presurgical

Educational

 Intervention

Adults With

Results

Cost PMPM

Least the for cost PMPM median The

median The $0.22. was Scenario Expensive

Scenario Expensive Most the for cost PMPM

$0.26. of cost midpoint a with $0.31, was

 Used Values Input and Design

Model the in

of Level and ,Audience Target ,Membership

Participation

the of estimation an with begins model The

an undergo would who adults of number

number The .procedure operative inpatient

in out carried procedures operative of

was States United the in settings inpatient

23 Services Preventive of Cost The
reported results recent most the in accessed

Survey Discharge Hospital National the by

and Control Disease for Centers; NHDS(

by down adjusted and) 1996 ,Prevention

those only of estimate an for ,percent 71

elderly and adult on done procedures

of number the ,)80 to 18 ages (patients

Census .S.U 1998 on based was which

1,000 per 154 was rate procedure calsurgi inpatient 1996 The .numbers Bureau

population general 1996 the of members

value This .)1998 ,Bureau Census .S.U(

and adult 1,000 per 109 to reduced was

once reduced was rate The .lives elderly

procedures operative of ratio the by again

Health Group the by reported as ,HMOs in

rate the to ,)1995 (America of Association

about had 1995 in members HMO .ulationpop general the for NHDS the by reported

than procedures operative fewer percent 36

rate the ,Therefore .population general the

hypothetical the in members 100,000 per

and adult 1,000 per 70 at set was MCO

of percent 71 at estimated (lives elderly

.(100,000 the

Least the for participation of level The

,percent 50 at set was Scenario Expensive

65 to up increments percent 5 in increasing

.Scenario Expensive Most the for percent

Materials and Staffing

an that reports research original the While

the patients to visits bedside made anesthetist

assumed model the ,surgery the before night

 .task this out carry could thesiologyanes in training specialty with nurse a that

details provides Appendix Technical The

for participation of levels assumed the of

the of costs the ,activity component each

and ,scenario each for supplies and materials

hour per cost effective and time assumed the

.counselor health and ,ologistanesthesi nurse ,psychologists ,nurses the for

Discussion

intervention this 4, Model of case the in As

incorporate to easy relatively seem would

most of procedures operating routine the into

be might barrier biggest The .units inpatient

of effectiveness reported the given ,But .ogistanesthesiol nurse trained a of availability the

(1983 ,Cook and Devine (compliance icalmed’ patients improving in intervention this

the and narcotics of use the reducing and

.,al et Devine (stay inpatient of length average

by offset be could intervention an such mentimple to cost the ,)1964 .,al et Egbert; 1988

.costs surgical tientinpa for risk at is that MCO an for savings

Report Technical 24
Brief :Six Model

to Counseling

Use Alcohol Reduce

.VII

,Barry ,Fleming); 1993 (Tonigan and ,Miller ,Bien—cationspubli research four of basis the on designed was model This

Health World); 1997 (London and ,Johnson ,Manwell

and ,Adams ,Manwell ,Barry ,Fleming and); 1996 (Organization

references in) 2000 (Dorfman by reviewed and)—1999 (Stauffacher

,models other the all with As 53. and 50, 39, 33, numbered respectively

care managed a for costs PMPM estimate to designed was model this

to 18 ages (members adult its by use alcohol excessive reduce to ventioninter brief and screening a implements that members 100,000 with plan

.female and male ,)older and 66 ages (members older its as well as) 65

Results

Cost PMPM

Least the for cost PMPM median The

The $0.36. only was Scenario Expensive

Expensive Most the for cost PMPM median

range midpoint a with $0.82, was Scenario

 $0.59. of

 Used Values Input and Design

Model the in

Screened Audience Target ,Membership

Participation and ,Use Alcohol for

.S.U the from numbers 1998 on Based

that assumed model the ,Bureau Census

persons including ,adults female and male

to 70 of range a represented 65, than older

for percent 1 of increments in (percent 73

.members 100,000 the of) scenario each

Fleming by reported research the on Based

household epidemiological and) 1997 (.al et

Office the by use alcohol and drug of surveys

and Abuse Substance ,Studies Applied of

the ,)1998 (Administration Health Mental

in (percent 17 to 14 that assumed model

(scenario each for percent 1 of increments

alcohol excessive for positive screen would

administered-self a on dependency or use

a by distributed instrument screening health

female excludes percentage This .receptionist

adults all and pregnant were who adults

alcohol or drug be to known) 64 to 19 ages(

for treatment of history a having or abusers

 .abuse alcohol or drug

percent 71 to 68 that assumed model The

(scenario each for percent 1 of increments in(

go to agree would positive screening those of

with interview minute30- initial the through

and participants screen further to nurse a

25 Services Preventive of Cost The
.(exercise ,smoking .,g.e (iorsbehav related-health on data baseline collect

.al et Fleming by reported data on Based

45 to 42 that assumed model the ,)1997(

each for percent 1 of increments in (percent

interview this completing those of) scenario

the in participation start to on go would

95 that assumed model The .intervention

percent 1 of increments in (percent 98 to

the started who those of) scenario each for

 .it complete would intervention

Time Staff and Materials

for time average the that assumed model The

assumed model The .minutes 5 was tionistrecep a by instrument screening health teredadminis-self the of scoring and distribution

would instrument screening health the that

four the in $2 and $1.50, $1, $0.75, cost

.scenarios

.workbook a given was participant Each

and participant the by used workbook The

regarding feedback contained “physician the

the of review a ,behaviors health current

the of list a ,drinking problem of prevalence

on worksheet a ,alcohol of effects adverse

the in agreement drinking a ,cues drinking

diary drinking and ,prescription a of form

model The .)61 .p 2000, ,Dorfman” (cards

to provided was workbook this assumed

model The .participants the of percent 100

of each for workbook per cost the assumed

$8. and $7, $6, $5, was scenarios four the

Interventions Service

the ,)1997 (.al et Fleming by described As

would participants that assumed model

with sessions counseling brief two receive

lasting each ,physician care primary their

few the includes time This .minutes 15

enter to physician the for required minutes

.record medical the in documentation brief

of percent 100 that assumed model The

phone followup a receive would participants

two the of each following nurse a by call

followup Each .physician the with sessions

of average an last to assumed was call

 .minutes 5

clerical by interventions these of cost The

determined was physicians and ,nurses ,staff

staff productive a of cost the multiplying by

and ,benefits fringe ,salary on based (hour

required time the by) time nonproductive

each of salaries annual The .trainers the of

,clerical be to assumed were staff of category

each for increments $500 with $20,000

;productivity percent80- and scenario

increments $1,000 with $50,000 ,nurses

,physicians and; productivity percent70- and

70- and increments $2,000 with $100,000

.productivity percent

at assumed were costs benefit-Fringe

model The .personnel all for percent 29

associated were expenses no that assumed

or supervisory additional for need the with

clinical ongoing the into blend could tioninterven an such because ,staff management

.office s’physician each of operations

Training Staff and Recruitment Physician

.al et Fleming by reported ratios on Based

be to have would who physicians of bernum the ,physicians to participants of) 1997(

.estimated was participate to invited

participate to agreement of rate a Assuming

increments percent5- in percent 95 to 80 at

physicians of number the ,scenario each for

of number the handle to order in patepartici to needed number the and invite to

.calculated be could participants expected

$50 to $35 at estimated were costs Invitation

the ,scenario each For .increments $5 in

1 or 2, 3, 4, be would there assumed model

number the ,way That .site office per doctor

Report Technical 26
physicians and personnel where sites office of

.calculated be could trained be to need would

involved all that assumed model The

training some require would personnel office

office each For .protocol the of use the on

5 = SD (minute20- a assumed model the ,site

who personnel clerical for training) minutes

screening health the scored and distributed

who nurses the for session training) utesmin 5 = SD (minute60- a and ,instrument

the make and interview the administer would

an assumed model The .calls phone followup

= SD (minutes 60 of session training initial

a at working physicians all for) minutes 10

two assumed also model The .site single

of physicians for sessions training” booster“

 .(minutes 10 = SD (each minutes 15

by determined were costs training The

$1,000 in $40,000 (trainer a of costs benefitfringe and salary average the multiplying

(cost benefit-fringe percent 29 and ductivitypro percent 70 ,scenario each for increments

model The .trainers of required time the by

associated were expenses no that assumed

or supervisory additional for need the with

 office ongoing into blend could tioninterven an such because ,staff management

.operations

Fleming by research original the Because

the to payment $300 a reported) 1997 (.al et

to payments assumed model the ,physicians

$500, $300, of physician participating each

the compensate to made be would mentpay This .scenario each for $900 and $700,

related” revenue patient lost “for physician

.training the in patepartici to physician and staff for need the to

expenses A&G for added be should centageper some that assumed model the ,Finally

minimum a assumed model The .profit plus

for percent 1 by increasing ,percent 10 of

 .scenarios four the of each

Discussion

be may one this ,interventions the all Of

model-IPA traditional for problematic most

organizations provider preferred or HMOs

the train to required effort logistical siveexten the of because largely ,implement to

clerical (staff office their and physicians

the out carry to) nurses and workers

likely’ physicians some and ,protocol

drinking problem confront to resistance

 .patient a by

studies published four the of one least At

carried was) 2000 (Dorfman by reviewed

World (countries of number a across out

Intervention Brief Organization Health

screening health or college in) 1996 ,Group

with associated stigma the where clinics

may drinkers problem confronting to anceresist the or lower be may abuse alcohol

reported studies the all while And .lower be

no was there ,drinking reducing in success

term-long likely the of analysis explicit

with associated savings cost and benefits

 .services medical of use reduced

offset-cost medical the of review a In

,Schlesinger ,Mumford ,however ,literature

in 3 ,studies 12 reviewed) 1981 (Glass and

effectiveness significant reported that ,tingsset work based-employee in 9 and HMOs

and ,workdays lost ,costs surgical and icalmed reducing in treatment alcoholism of

bearing-risk A .disabilities and injuries

to incentive an have clearly would MCO

to personnel training of costs the incur

problem or excessive reduce and identify

the on ,membership its among drinking

would membership the that assumption

the for enough long MCO the with remain

and benefits term-long yield to investment

.savings cost

27 Services Preventive of Cost The

the of some restate to important is it ,interventions ventivepre six these of cost PMPM estimated the summarizing Before

.addressed be to had that limitations and assumptions major

and Summary

Discussion

did research published originally the of Most

their of elements various the of costs cificspe the regarding details enough present not

did studies most ,example For .intervention

staff the to paid salaries the indicate not

the indicate not did also studies Most .tioninterven the out carry to required members

,brochures ,booklets various of costs unit

.participants to tributeddis instruments assessment or ,videotapes

published the in limitation serious more A

behavior lifestyle poor or ,disorder ,easedis the of prevalence or incidence the ingregard information of lack the was research

.directed was intervention the which toward

of number the reported studies many While

not did studies most ,out or in screened bernum the and participate to invited persons

from population the of size the describe

.drawn were participants these which

the estimate to necessary was it ,Therefore

MCO 100,000 per participation of rate

interventions these of any offering of bilityfeasi the considers that MCO Any .members

users of volume likely the assess to need will

.intervention the complete and start will who

widely vary to likely are MCOs Because

and demographics the to respect with

,members their among mix case illness/health

to -low of range full the encompass to iosscenar alternative create to necessary was it

the ,example For .assumptions cost-high

the all encompasses Scenario Expensive Least

mix case the about assumptions costly least

,employees of costs salary the ,)insured ciallycommer ,employed ,educated (members of

.travel and material of costs unit the and

encompasses Scenario Expensive Most The

about assumptions of set expensive most the

and supplies and ,levels salary ,membership

possible of range wide fairly A .materials

variables such for assumed be to had values

related-cost the of most that ensure to

be would MCOs most to applicable values

.encompassed

an was model cost intervention Each

specific ,different several of amalgamation

theme common a shared that interventions

.behavior or ,condition ,illness targeted or

a but study published one any on sentationrepre cost exact an not is model each ,Thus

drive would that variables essential the rateincorpo to designed was that model generic

In .interventions similar of cost overall the

Health for model the as such ,cases some

the ,Education Care-Self Through Promotion

the all incorporate to designed was model

average estimated the ,Thus .studies lishedpub all across used interventions component

costs the overstate to likely are costs PMPM

29 Services Preventive of Cost The

.VIII
subset a only implements that MCO an for

.components possible the all of

Term-Short Targeted (model one Only

any assumed) Therapy Health Mental

.costs offset to revenue

value midpoint the summarizes 2 Table

Least the of cost PMPM median the between

PMPM median the and Scenario Expensive

.Scenario Expensive Most the of cost

incremental the that suggest results These

of one any implement to MCO an for costs

to relative small very are interventions these

.premiums monthly existing

between midpoint the expresses 3 Table

Least the of cost PMPM median the

PMPM median the and Scenario Expensive

each of Scenario Expensive Most the of cost

average the of percentage a as intervention

single for rates premium HMO monthly

et Baker by reported as 1997 in individuals

country the of regions in lowest are miumspre HMO monthly average The .)2000 (.al

where) Central South East and Mountain(

community the of percentage highest the

.HMO an in enrolled is population

most the 3, Table in seen be can As

Promotion Health ,intervention expensive

midpoint (Education Care-Self Through

,percent 1.09 add would ,)$1.54 = PMPM

average 1997 estimated the to ,most at

the in HMO an of premium single monthly

to percent 0.84 only and region Mountain

.region England New the in premium the

all across increase percentage average The

only is regions four all in interventions six

.percent 0.5

of effectiveness documented the Given

medical improved in interventions these

,satisfaction patient increased ,outcomes

,cost and ,resources medical of use reduced

MCOs that recommended highly is it ,umspremi existing to relative cost low their and

implementing to consideration serious give

.interventions the

Report Technical 30

and Scenario Expensive Least the between costs PMPM Midpoint 2: Table

intervention preventive each for Scenario Expensive Most the

 Cost PMPM Median Between Midpoint Interventions Preventive Six

($) Scenarios Expensive Most and Least of

0.76 Visits Home Infancy and Prenatal

/Education Cessation Targeted

0.03 Smokers for Counseling

1.48 Therapy Health Mental Term-Short Targeted

1.54 Education Care-Self Through Promotion Health

0.26 Adults With Intervention Educational Presurgical

0.59 Use Alcohol Reduce to Advice/Counseling Brief
31 Services Preventive of Cost The

 of percentage a as interventions preventive of costs PMPM 3: Table

individuals single for premiums HMO 1997

 Premiums HMO 1997 Monthly Single Average

Regions USA Four in

West East Midpoint

New South South Between

England Central Central Mountain PMPM Median Interventions Preventive Six

$183.23 $165.58 $153.31 $141.23 and Least of Cost

 average the to cost percentage Incremental Expensive Most

premium HMO) $ (Scenarios

0.41% 0.46% 0.50% 0.54% 0.76 Visits Home Infancy and Prenatal

/Education Cessation Targeted

0.02% 0.02% 0.02% 0.02% 0.03 Zmokers for Counseling

0.81% 0.90% 0.97% 1.05% 1.48 Therapy Health Mental Term-Short Targeted

0.84% 0.93% 1.00% 1.09% 1.54 Education Care-Self Through Promotion Health

0.14% 0.16% 0.17% 0.18% 0.26 Adults With Intervention Educational Presurgical

0.32% 0.36% 0.38% 0.42% 0.59 Use Alcohol Reduce to Advice/Counseling Brief

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35 Services Preventive of Cost The

.X

by manuscript the supplements Appendix Technical This

information statistical detailed contains It .title same the

following the for costs of simulation a of results the on

:interventions preventive six

Mothers Risk-High for Visits Home Infancy and Prenatal 1.

Smokers for Counseling/Education Cessation Targeted 2.

Therapy Health Mental Term-Short Targeted 3.

Education Care-Self Through Promotion Health 4.

Adults With Intervention Educational Presurgical 5.

Use Alcohol Reduce to Advice/Counseling Brief 6.

Appendix Technical

37 Services Preventive of Cost The

each of description complete a and ventionsinter six these of selection the for rationale The

and ,audience target intended its ,intervention

appear costs and outcomes health on impact its

the in summarized are and) 2000 (Dorfman in

Cost the Estimating “,report this of text main

and Health Mental in Services Preventive of

“.Care Managed Under Abuse Substance

preventive these of each of model cost A

one At .scenarios different four under latedsimu then and designed was interventions

,Scenario Expensive Least the was extreme

least the assumed that scenario the as defined

reasonable a among from values expensive

.,g.e (driver cost each for values of range

intervention the of intensity ,prevalence

other the At .)salaries staff ,period time/units

,Scenario Expensive Most the was extreme

values expensive most the assumed which

reasonable of range same the among from

 .values

values relative the summarizes .1A Table

.model each in drivers cost various the of

each for variable dependent critical The

the is which ,cost PMPM the was model

per membership average (months bershipmem annual total the by divided cost total

of) 12 by multiplied ,year the over month

that) MCO (organization care managed the

.intervention the sponsor to assumed was

1,000 over simulated was model Each

simulation Carlo Monte using iterations

distribution a in resulting ,)1966 ,Winston(

for values cost PMPM possible 1,000 of

.intervention each

the presents Appendix Technical This

distributions cost PMPM four the of details

the of details the and intervention each for

as used drivers cost the of values assumed

.model each to inputs

the and Simulation Carlo Monte

“Averages of Flaw“

the account into take must model cost Each

entered is that value” average “the that fact

represents variables multiple the of any for
,distributions” skewed “are they ,average the

the than greater is value average the wherein

other In .value) likely most .,e.i” (modal“

very of probabilities small are there ,words

of probabilities large very and values large

.values small or moderate

full a allow not do limitations page The

theoretical of types various the of exposition

describe best may that distributions statistical

,User/Units /1,000,Users as variables such

of Some .Year/User/Cost and ,Episode/Cost

skewed extremely be can distributions these

less others and) distributions Pareto .,g.e(

Poisson .,g.e (normal nearly or skewed

reliability the ,Furthermore .)distributions

a is expected be can that average the of

or entities of number total the of function

large very With .considered being events

of numbers large very and populations

skewed some ,units service and episodes

approach to begin will distributions

.shape their in” normality“

even not may value average the ,fact In .uesval possible many of one than more nothing

real the in occur to value likely most the be

values possible all of distribution the if world

 .negatively or positively ,skewed highly is

outpatient of number average .,g.e (value ageaver an of told are people most Whenever

they ,)episode outpatient closed per visits

do they If .value average that around ationvari of impact the consider not do generally

generally they ,variation possible consider

of type This .value average the around tionvaria of distribution symmetrical a assume

when heads their in assume implicitly plepeo most that distribution the is it and ,tiondistribu” normal “a called is distribution

 .variation risky about think they

,thinking of kind that with problem The

health of distributions most that is ,however

small a are there because ,Rather .tributeddis normally not are costs and services care

“up drag “that values high very of number

Report Technical 38

scenarios cost four the of each for assumed values relative The .1:A Table

Scenario

 Least Intermediate Intermediate Most Drivers Cost

Expensive Low High Expensive

 Many ,Public Many

Primarily ,Commercial Some Primarily Plan the in Covered Enrollees

Commercial Public Some Commercial* Public

Low Very Low High High Very Condition Target of Prevalence

Low Very Low High High Very Rate Participation

Short Very Short Long Long Very Intervention per Period Time

Low Very Low High High Very) Intervention per Units Service (Intensity

Staff Few Very Staff Few Staff Many Staff Many Very Pattern Staffing

Lowest Low High Highest Benefits Fringe and Salaries Staff

Lowest Low High Highest Expenses Variable and ,Fixed ,Startup

13% 12% 11% 10% Profit and Overhead Administrative

.(Medicaid .,g.e (funds sector public through financed is coverage care health whose persons means enrollees Public*
average at only look not should one ,metricalsym be to likely not is variation Because

and Understanding .variables such for values

or above variation possible the measuring

both in occur can that average the below

to critical is variables utilization and cost

 .costs of range possible the estimating

Sources Uncontrollable and Controllable

Variation of

.variation the driving are that factors ingunderly the understand to needs one ,ationvari the measure to need one does only Not

managed be may variation of sources Many

upside the reduce to order in controlled or

algorithms formal ,example For .variation

formalized and programs service-to-triage for

that variation reduce can protocols treatment

by made decisions day-to-day the from arises

affect that factors the of Some .clinicians

and managed easily be cannot variation

with associated characteristics to related torsfac ,example For .run short the in changed

members eligible of population particular a

 .changed be easily not may) use menttreat about values learned culturally ,easedis of prevalence underlying ,poverty .,g.e(

between distinction the to related Closely

is variables uncontrollable and controllable

is that variation between distinction the

and randomness of because uncontrollable

represents but controllable is that variation

the of ignorance the to due uncertainty

.builder model

 Chance to Due Variation

(“Variability Probabilistic “or(

chance of effect the is ,variability” bilisticproba “or” stochastic “called ,type first The

such ,Generally .variation uncontrollable and

by controlled directly be cannot variation

variation such :Note (.decisions management

long the in” influenced “be sometimes can

and decisions related-policy through run

variable of type this of Examples) .actions

plan the in mothers of percentage the are

or baby weight-birth-low a deliver will who

who plan the in teenagers of percentage the

of examples are These .pregnant become will

or condition of type certain a with members

preventive a which for factors risk of set

to used are MCOs .intended is intervention

historical using variability such with dealing

demands future of estimate” average “ablereli a derive can they which from values ousprevi of distribution a provide can that data

.use of

systemic have to known variables For

from values sample could software putercom the which from distributions) abilityprob (stochastic used models the ,variability

possible all of distribution defined a within

spreadsheet the in functionality This .values

.simulation Carlo Monte supports that waresoft of type” in-add “an with possible was

“,Risk “@called ,software” in-add “This

variable a of value single specific any allows

teenage of percentage the .,g.e (model the in

to) pregnant become would who members

possible all of distribution a by replaced be

Carlo Monte as known method a ,values

 .(1996 ,Winston (simulation

of percentage “variable the ,example For

teenage become will who members eligible

a by model the in represented is” mothers

:parameters three with distribution triangular

value” possible minimum “The 1.

value” likely most “The 2.

 value” possible maximum “The 3.

,spreadsheet the of simulation the During

among from” sampled “be would value entdiffer a ,model the of” iteration “each with

,example For .values maximum and mummini of range the within values possible all

39 Services Preventive of Cost The
estimate an ,ran iterations of thousands after

lives member of percentage average “the of

be would” mothers teenage be will that

of thousands these of average the on based

The .simulation the during sampled values

parameters the establish to used values initial

best the on based were distributions the of

a had who 19 to 14 ages women of centageper the listing data Bureau Census .S.U ,pleexam For .variable each for data available

which for year recent most the in birth live

,Census the of Bureau (available were data

of number the estimate to used were) 1998

teenage become would who members eligible

 .mothers

“Unknowns “to Due Variation

the to due is variability of type second The

Such .modeler the of knowledge uncertain

s’builder model the represents uncertainty

of value actual the about knowledge of lack

builder model the Although .variables some

values proper the about knowledge lack may

the by controlled or known readily are uesval their ,variables of types these to give to

salary the ,example For .operators system

staff various of costs benefit-fringe and level

plans care managed different within working

not ,model the in variables” unknown “are

fluctuate randomly values these because

the because but MCO given any within

values what certain not is builder model

all of universe the represent fairly would

 .MCOs

uncertain were values whose variables For

specific the about knowledge of lack to due

(nurses of level salary .,g.e (costs operating

may that plan care managed particular a of

four ,intervention an implement to wish

a reflect to used were values fixed alternative

four the of one different A .range reasonable

scenario each during used be would values

per iterations 1,000 of consisting ,simulation

for ,salary s’worker social A .simulation

one for $30,000 at set be could ,instance

for $35,000 ,simulation iteration1,000-

and $40,000 and ,simulation another

1,000- remaining two the for $45,000

during ,example For .simulations iteration

simulations iteration1,000- four the of each

Visits Home Infancy and Prenatal the of

factors cost ,model Mothers Risk-High for

given any within chance by vary could that

plan care managed particular any for year

per births weight-birth-low of rate .,g.e(

stochastic using simulated were) births 100

more be would there Because .distributions

model each in variable uncertain one than

productivity staff average ,level salary .,g.e(

general to due expenses total of percent ,level

the ,)expenses] A&G [administrative and

least from ordered always were values four

 .expensive most to

simulations four the of first the ,Therefore

circumstances of combination the represents

are values expensive least the all when

variables uncertain the of each for assumed

the while ,)Scenario Expensive Least the(

values expensive most the all when stancescircum the represents simulation fourth

The .)Scenario Expensive Most the (ablesvari uncertain the of each for assumed are

for values assumed scenarios two other

intermediate were that variables uncertain

most the and values costly least the between

values assumed of pattern This .values costly

.1.A Table in illustrated was

four s’model the of each of simulation The

PMPM variable output the of values siblepos of distributions four produces scenarios

as expressed be can intervention each of tionsimula cost the of result the ,Therefore .cost

for ,costs PMPM possible of distribution a

single the While .scenarios four the of each

Report Technical 40
between value midpoint the represents tionpublica parent the in reported cost PMPM

Expensive Least the of cost median the

Most the of cost median the and Scenario

Appendix Technical this ,Scenario Expensive

.scenarios four all for tionsdistribu cost the on details greater presents

be can probabilities of continuum a ,tionsimula Carlo Monte the using by ,Thus

possible of continuum a reflecting ,generated

,model a into entered drivers cost the of tiesvariabili potential the on based costs PMPM

drivers cost Such .1.A Table in outlined

participation ,conditions of prevalence ,)vatepri or public (enrollees of types the include

and ,intensity ,time ,intervention the in rate

,intervention the deliver to pattern staffing

,expenses variable and fixed ,staff of salaries

managed Any .overhead administrative and

PMPM likely its that assume can ventioninter an implementing considering plan care

Least the between somewhere is cost

Expensive Most the and Scenario Expensive

.Scenario

Managed Specific a for Cost the Assessing

Organization Care

models cost these design to important was It

operating MCO of variety wide a over tiongeneraliza and application broad allow to

populations covered of range a and ,agespack benefit of range wide a ,circumstances

,(Medicare/Medicaid ,commercial .,g.e(

might plans care managed different because

could differences the and ,ways ferentdif slightly in intervention similar a provide

might one ,example For .costs affect directly

workers social used another while nurses use

assist to aides employ might one or ,staff as

might another while staff professional these

of types identical employing when Even .not

,costs benefit-fringe ,levels salary in encesdiffer of because costs PMPM different enceexperi could plans care managed two ,staff

profit targeted or ,costs overhead indirect

very a in intervention particular A .margin

of use make might plan membership large

plan small a while ,)space .,g.e (costs tionaladdi no at available already resources slack

for costs additional incur to have would

.space rented

most is scenarios cost four the of Which

would MCO specific any to applicable

the as such ,factors of number a on depend

the and membership its of demographics

each by targeted conditions the of prevalence

with ,example For .intervention preventive

Home Infancy and Prenatal the to reference

of population eligible-Medicaid dominantlypre a has MCO the if ,intervention Visits

teenage of prevalence high a with ,members

it ,pregnancies risk higher and mothers

that scenarios end higher the consider should

members educated-well and employed of tionpopula commercial a predominantly is shipmember its If .prevalence higher a assume

and rate birth average-than-lower a with

MCO the ,pregnancies risk-high of incidence

.Scenario Expensive Least the choose should

the affect should consideration Another

a of basis the on designed was model tioninterven preventive Each .scenario of choice

specific studies published different of number

was study each; intervention of type that to

most In .other the of replication strict a not

of specifics the in variations were there ,cases

the among ,example For .intervention each

Promotion Health on studies various

research the ,Education Care-Self Through

.components specific of variety a used teams

following the used have might study One

:components

classes education health based-Group 1.

booklets and guidelines care-Self 2.

41 Services Preventive of Cost The
Videotapes 3.

where hotline care-self a to Access 4.

trained a by answered be would questions

counselor health or nurse

care primary a from letters Individualized 5.

changes behavior relatedhealth certain recommending physician

used have might care-self of study Another

:components different

appraisal risk health individualized An 1.

assessment

recommended on reports Personalized 2.

risk the on based behaviors related-health

appraisal

health or nurse a with sessions Individual 3.

counselor

center in-drop health a to Access 4.

only use to wish may MCO particular A

.studies both of components the of some

incorporates model Care-Self the ,Therefore

the estimates and components nine all

as well as component each for cost PMPM

.combined nine all for costs PMPM total the

Most and Expensive Least the provide dixappen this in tables ,circumstances such For

separate each for cost PMPM Expensive

.component

MCO any that recommended highly is It

of any of implementation the considering

the read interventions preventive six these

by used components specific the of cabilityappli the assess to studies research original

.researchers the

Assumptions General Other

that assumption general the to addition In

an on offered be would interventions such

were costs of assumptions ,basis ongoing

toward or conservative fiscally generally

hand to receptionist a required ventionsinter some ,example For” .side high “the

arriving patients to form assessment an out

labor and time The .room waiting the in

added and estimated were task this for costs

and ,time ,effort such ,however ,stancescircum most In .estimates cost total the to

incremental be actually not would costs

incorporated be readily could they because

related-patient regular s’receptionist the into

.duties

cost s’intervention each ,addition In

training of cost the included assumptions

that To .intervention the out carry to staff

year-first the on based are costs the ,extent

costs PMPM effective The .costs startup

years subsequent in down go likely would

each retrained be to have not did staff the if

 .year

for provided is information following The

 .interventions recommended six the of each

Results

an assumed model the ,intervention each For

PMPM The 100,000. of membership MCO

cost aggregate total its as calculated is tioninterven each within scenario each of cost

median the between midpoint the as latedcalcu ,cost PMPM single a reports licationpub This 12. by divided 100,000, by divided

the and Scenario Expensive Least the of cost

.Scenario Expensive Most the of cost median

details statistical provides appendix This

,medians ,means ,maximums ,minimums(

the of) values percentile th95 and th5 and

each for scenarios all of distributions cost

.intervention

PMPM the that note to important is It

on calculated is intervention each of cost

just not 100,000, of membership entire the

to corresponds that members of subset the

For .intervention the for group target the

total a costing intervention an if ,example

,children toward targeted is $520,000 of

Report Technical 42mem 100,000 the of 26,000 represent who
as calculated be would PMPM the ,bers

not ,)$0.43 = $520,000/100,000/12(

other In .)$1.66 = $520,000/26,000/12(

are costs intervention preventive the ,words

amount the representing rate a at calculated

every to add to have would MCO an that

.premium s’member

Model the in Used Values Input and Design

cost the calculating for inputs as used ablesvari of set the identifying means” Design“

are” Values “.calculations in used and izedorgan were inputs these how and drivers

variables input the to assigned figures the

,example For .simulation each during used

input an was salary s’worker social when

the for values four used model the ,variable

high to value low a from ranging ,salary

$40,000, $35,000, $30,000, .,g.e (value

values the ,cases most In .)$45,000 and

actually were variable input an to assigned

a ,example For .values of distribution a

may activity staff a for minutes 15 of value

a with distribution normal a represent

 .minutes 5 of tiondevia standard a and minutes 15 of mean

relevant no was there when ,general In

the in available information benchmark

best “,sources other or research published

.values reasonable of basis the were” guesses

always model the ,guesses best using When

direction the in biased was that value a used

the ,Therefore .up costs drive would that

—result conservative a producing are models

on probably are that estimates cost ,is that

.side high the

 Discussion

to specific issues any of discussion brief A

of presentation the follows MCO an in tionimplementa its affect could that model that

.results cost

Results

Visits Home Infancy and Prenatal 1: Model

 Mothers Risk-High for

an on based designed was model cost This

,Olds—publications two of amalgamation

Hanks and ,Kitzman ,Phelps ,Henderson

and)—1992 (Ramey and Ramey and) 1993(

references in) 2000 (Dorfman by reviewed

third A 5. and 2 numbered respectively

not was ,recommendations final the portedsup that and Dorfman by reviewed ,study

thus and intervention based-classroom tionaladdi an used It .model cost this in included

model cost separate a required have would

& .,R ,Greenberg .,S ,Widmayer .,T ,Field(

.(1982 .,S ,Stoller

Cost PMPM

for values PMPM of distribution the of tersparame statistical the summarizes .2A Table

Scenario Expensive Least The .scenario each

the and $0.58 of cost PMPM mean a has

PMPM mean a has Scenario Expensive Most

all in cost PMPM median The $1.49. of value

because cost mean the than lower is scenarios

was scenarios four all in value mean the

.values lierout cost-high few a by” up dragged “being

of interpretation the with assist further To

of percentile th95 the at ,respectively ,lishedestab were limits lower and upper ,results the

at and) $1.47 (Scenario Expensive Most the

Expensive Least the of percentile th5 the

the ,scenarios four all Across .)$0.30 (Scenario

is limit upper the and $0.51 is limit lower

4,000 estimated the of percent 90 with $1.68,

falling scenarios four the across values PMPM

it ,words other In $1.17. of range this within

the that certainty percent 90 with said be can

While $1.47. and $0.30 between be will tioninterven of type this for costs PMPM actual

43 Services Preventive of Cost The
relatively seem may $1.17 of range that

will range the that likely more is it ,large

the of which on depending smaller much be

cost the of representative is scenarios four

Table in shown as ,example For .MCO ularpartic a of) overhead ,salaries .,g.e (structure

of cost PMPM average the in range the .2,A

a to $0.46 of minimum a from is 1 Scenario

.($0.27 of range a .,e.i ($0.73 of maximum

($0.72) range greatest the has 4 Scenario

PMPM maximum and minimum the between

.(maximum $1.89 to minimum $1.17 .,e.i(

distributions the illustrates .1A Figure

four the of each for values simulated of

.scenarios

mean the as .1,A Figure in seen be can As

PMPM mean These .mean the around ityvariabil the does so ,higher gets cost PMPM

iterations 1,000 the of average the are values

for used values the and ,scenario each within

higher progressively got variables uncertain

the reveal results These .scenario each with

coupled variability of effects amplification

 .uncertainty with

Report Technical 44

scenarios four under costs PMPM :visits home postnatal and -Pre .2:A Table

4 Scenario 3 Scenario 2 Scenario 1 Scenario

Most Intermediate Intermediate Least

($) Expensive) $ (Expenses) $ (Expenses) $ (Expensive

1.17 0.85 0.63 0.46 Minimum

1.49 1.05 0.78 0.58 Mean

1.12 0.76 0.55 0.40 (Percentile th50 (Median

1.89 1.32 0.98 0.73 Maximum

0.12 0.08 0.06 0.05 Deviation Standard

0.01 0.01 0.00 0.00 Variance

1.56 1.08 0.87 0.57 Mode

1.29 0.92 0.68 0.51 Percentile th5

1.68 1.18 0.88 0.66 Percentile th95

Scenarios All

0.51 Limit Lower

1.68 Limit Upper

1.17 Limit Upper and Lower Between Difference

 and Lower Between Values of Percent

90 Limit Upper
Model the in Used Values Input and Design

the by Covered Lives of Number

Plan Care Managed

,models other all as well as ,model This

lives enrolled 100,000 are there assumed

 .MCO the in) members(

Served Cohorts Intervention of Number

Cycle Operational Month12- a Within

the ,year full a than less required tionsinterven preventive the of many Because

as) year a half .,e.i (weeks 26 used model

and start to required weeks of number the

a for intervention preventive a complete

model The .participants of cohort single

run would program the that assumed also

number total the so ,year the throughout

the if doubled be could participants of

.year one in twice offered was intervention

in Participates That Cohort the of Size

Cycle Intervention Each

first the ,members enrolled the on Based

average the estimate must calculation crucial

in participate will who persons of number

published the often Most .intervention the

who persons the all among from rate tionparticipa the of calculation a allow to tioninforma enough provide not does but pantspartici of number some specifies research

were or intervention the to access had

.participate to invited and” approached“

to use to values what determining In

Bureau Census .S.U ,variables these populate

of females by represented population eralgen the of percentages the for 1998 for data

adults 19, to 14 ages = teens (group age each

able potentially were who) 44 to 20 ages= 

as well as reviewed were children bear to

age these of rates birth the on tables separate

45 Services Preventive of Cost The

$1.68 = %th95 $.51 = %th5

Cost PMPM 

Probability

$1.65 $1.45 $1.25 $1.05 $0.85 $0.65 $0.45

0

1

3

4

5

6

2

4: Scenario

$1.49 = Mean

3: Scenario

$1.05 = Mean

1: Scenario

$.58 = Mean

2: Scenario

$.78 = Mean

costs PMPM of Distributions :visits home postnatal and -Pre .1:A Figure

scenarios four under
babies weight-birth-low of rate The .groups

plan care managed the from estimated was

1995 from developed” Card Report HEDIS“

Quality on Council National the for 1996 to

no is measure This (.)NCQA (Assurance

HEDIS s’NCQA by monitored longer

percentages large Conservatively) .Reports

(“Starters (“participation of rates initial for

(“Completers (“completion of rates for and

adult that assumed model The .used were

starting of rate higher a have would women

.teens than program the completing and

the with Starting .required was culationscal and assumptions of series a ,ticipantspar of number average the establish To

the ,)100,000 (lives enrolled of number

:calculated were variables following

intended is intervention the which for buteattri the having members of Percentage 1.

above the of percentage the :”Starters “2.

participation start to agree who number

the of percentage the :”Completers “3.

program the complete who Starters

as ,participants of number Average 4.

:formula this by estimated

2 / [COMPLETERS + STARTERS[

Attrition

rate the that assumes calculation above The

the of period time the throughout attrition of

number the is participants of number ageaver the ,Therefore .uniform is intervention

and start the between midpoint the at active

Average “This .program the of end the

Average ,example For .costs of culationscal further for used is value” Participants

number the calculate to used is Participants

to were class each if needed classrooms of

for week a days Y meet and hours X last

of limit a have and weeks consecutive Z

participants) of number (N than more no

.classroom each in meeting

Services and Time

all that assumed model the ,setting each For

,private initial an undergo would participants

visit orientation and assessment one-on-one

1 of average an lasting ,worker social a with

.(minutes 15] = SD [deviation standard (hour

to was calculations critical of set next The

participant each time average the determine

used is which ,program the in spend would

of units the of calculations subsequent for

.receive would participant each that service

participant average the if ,example For

and program week26- a in weeks 24 spends

but participation of week per visit 1 receives

can model the ,rate show-no percent 5 a has

23 receive will participant this that calculate

in used were factors following The .visits

:calculations these making

:week per visits scheduled of Frequency 1.

or 0.5 of value a assumed model The

 .week other every visit 1

were that visits scheduled of Percentage 2.

home not is mother .,g.e (completed not

assumed model The :)arrive staff the when

.completed not were percent 10

:visit per time driving trip-round Average 3.

round per minutes 20 assumed model The

.trip

model The :home the in time visit Average 4.

.literature the on based hours 2 assumed

and driving in spent hours staff the culatecal can model the ,estimates these Using

 .home the within services ventioninter the providing in spent hours staff the

of costs variable the requires model The

of because visits incomplete but scheduled

,gas ,expenses variable .,g.e (incurred cost the

well as home a to out driving by) time staff

costs their of because visits completed as

.(time staff ,gas ,supplies .,g.e(

,levels salary for asks also model The

,productivity staff ,rates benefit-fringe

Report Technical 46
plus expenses A&G and ,staff supervisory

for used were values same The .margin profit

.version classroom the in used were as these

the in variability inherent is there Because

all across” participant per weeks average“

“subjective-beta “a establish will that tersparame four for asks model the ,participants

:simulation a during values siblepos sample will it which from ,weeks of bernum average the for distribution stochastic

weeks of number minimum The 1.

which (weeks of number maximum The 2.

the weeks of number the exceed cannot

(operational is program

the .,e.i (weeks of number modal The 3.

most of characteristic weeks of number

 (participants

added participant each for weeks of bernum the (weeks of number average The 4.

of number the by divided and together

(participants

along ,participant per weeks average The

maximum the as such estimates other with

later is ,classroom a using group a of size

,calculations” downstream “further for used

per active participants average the as such

to needed classrooms of number the ,week

the and ,participants of number this support

.classroom each of costs fixed

classrooms required of number the Once

each for present staff of number the of matesesti have to necessary was it ,calculated was

.classroom each in held being meeting group

the on based ,hours staff necessary total The

and week per meetings classroom of number

that staff) FTE (equivalent time-full of bernum the of calculation the for allows ,tionalopera is program the weeks of number the

also model The .employed be to have would

Total Because .entered be can salaries ageaver so hired be to staff of types the for calls

hours these assumes Required Hours Staff

FTE of number the ,time” productive “are

adjusted be must hired be to needing staff

not is staff FTE average the that time of agepercent the representing factor a by upward

very a ,Again .)meetings internal or ,tionvaca ,leave sick of because .,g.e (productive

of rate the estimating for range optimistic

90 of high a from (used was productivity

to Scenario Expensive Least the for percent

Expensive Most the for percent 60 of low a

.(Scenario

well as ,fixed annual and costs startup timeone the of entries for asks also model The

 .expenses ,variable as

as items such be would expenses Fixed

and equipment computer ,furniture ,rent

would that supplies other any and ,software

for toys stimulation sensory .,g.e (required be

Direct .)children the with use to mothers the

“classroom per “a on entered are expenses

“shared “is that equipment any with ,basis

amounts generous relatively ,Again .roomclass each to assigned proportionately being

.items such for entered were

variable the for asked also model The

a or basis” meeting class per “a on expenses

variable of Examples .basis” visit home per“

certain any be would meeting class per cost

at consumed are that items other or supplies

and mother for snacks .,g.e (meeting each

home per “A .)vouchers transportation ,child

the to transportation be would cost” visit

.home s’participant

staff of type and number the has it Once

asks model the ,modality each within ventioninter each for demand the meet to needed

time s’employee each of percentage the for

assumed model The .program this to devoted

staff service direct each for percent 100

a at but ,manager a for percent 50; member

out sending .,g.e (duties clerical for staff portsup FTE for percent 25 and; salary higher

47 Services Preventive of Cost The
The .)supplies necessary ordering ,danceatten recording ,participate to invitations

and salary average their required also model

fringe on spent salary of percentage the

 .benefits

is valued be to had that variable final The

to required expenses total of percentage the

.margin profit any plus expenses A&G cover

,percent 10 of amount generous fairly A

four the of each for percent 1 by increasing

Most to Expensive Least from scenarios

.entered was ,Expensive

at Targeted Cessation Smoking 2: Model

Women Pregnant

basis the on designed was model cost This

—publications three of amalgamation an of

;1990 ,Dalmat and ,Hogue ,Koplan ,Marks

,Artz ,Yoder-Smith ,Perkins ,Lowe ,Windsor

and; 1993 ,Boyd and ,Amburgy ,Crawford

and—1989 ,Oster and ,Rubin ,Cummings

references in) 2000 (Dorfman by reviewed

 26. and 3, 1, numbered respectively

extensive most was that intervention The

toward targeted ,)1993 .,al et Windsor(

care prenatal receiving women pregnant

the of consisted ,clinic health public a in

:components following

,session counseling) minute15- (brief A• 

written of use the by supplemented

materials

prenatal during reminders chart Medical• 

visits

letters and calls phone Followup• 

“contact buddy “A• 

reminder smoking-no minute2- A• 

prenatal minute20- a within embedded

class education

.,al et Marks (publication second The

minute15- single a only using reported) 1990

The .calls phone followup two and ,rialsmate instructional simple ,session counseling

(1989 .,al et Cummings (publication third

4- a of effectiveness-cost the on reported

a ,physician a by session counseling minute

booklet help-self a and ,followup year1-

of group” hypothetical “a to administered

.patients female and male adult

cost the make to order in ,again Once

designed was it ,possible as generic as model

component of types various the all include to

.studies three all across interventions

 Cost PMPM

Windsor (intervention cessation smoking siveexpen most the for costs PMPM the of tersparame statistical the summarizes .3A Table

publications three the of) 1993 .,al et

Least The .)2000 (Dorfman by reviewed

average an estimates Scenario Expensive

Expensive Most the with $0.02, of PMPM

.($0.06) more much not totaling Scenario

Home Infancy and Prenatal the in as ,Again

,scenarios four all Across .increases cost ageaver the as increases variability ,model Visits

values PMPM estimated the of percent 90

$0.06. to $0.02 of range the within are

range the portrays graphically .2A Figure

mean the around variability the and costs of

with as ,Again .scenario each of costs PMPM

the of costs assumed the as ,model first the

variability the ,increases variables unknown

.well as increases

Model the in Used Values Input and Design

the by Covered Lives of Number

Plan Care Managed

,models other all as well as ,model This

lives enrolled 100,000 are there assumed

.MCO the in) members(

Report Technical 48
49 Services Preventive of Cost The

at targeted counseling/education cessation Smoking .3:A Table

scenarios four under costs PMPM :women pregnant

4 Scenario 3 Scenario 2 Scenario 1 Scenario

Most Intermediate Intermediate Least

($) Expensive) $ (Expenses) $ (Expenses) $ (Expensive

0.02 0.02 0.02 0.02 Minimum

0.04 0.03 0.03 0.02 Mean

0.04 0.03 0.03 0.02 (Percentile th50 (Median

0.06 0.05 0.04 0.04 Maximum

0.01 0.00 0.00 0.00 Deviation Standard

0.00 0.00 0.00 0.00 Variance

0.04 0.03 0.03 0.02 Mode

0.03 0.03 0.02 0.02 Percentile th5

0.05 0.04 0.04 0.03 Percentile th95

Scenarios All

0.02 Percentile th5

0.06 Percentile th95

0.04 Percentile th95 and th5 Between Difference

 and th5 Between Values of Percent

90 Percentile th95
Served Cohorts Intervention of Number

Cycle Operational Month12- a Within

one be to assumed was intervention This

basis ongoing an on offered be could that

routine their for in came they as patients to

case the in ,visits prenatal .,e.i (visits medical

.(women pregnant of

Completing Participants Likely of Number

Intervention the

the for used was that information same The

,model this populate to used was model first

members of number the of estimates ,namely

childbearing their in women be would who

to use to values what determining In .years

Bureau Census .S.U ,variables these populate

by represented population general the of agespercent the for reviewed were 1998 for data

14 ages = teens (children bear to able tiallypoten were that group age each of females

separate and ,)44 to 20 ages = adults 19, to

 .groups age these of rates birth the on tables

pregnant likely of number the Once

of average an ,estimated was year a in patients

be to estimated be could them of percent 21

(1990) .al et Marks by reported as ,smokers

Risk Behavioral 1986–1985 “a on based

American of . . . System Surveillance Factor

of District the and states 25 from women

the In .)31 .p 2000, ,Dorfman” (Columbia

21 of estimate this around values of) mummaxi ,likely most ,minimum (distribution lartriangu a used model the ,calculations actual

 :scenarios four the of each for percent

Report Technical 50

$.06 = %th95 $.02 = %th5

0

10

20

30

40

50

60

70

80

90

100

$.06 $.05 $.04 $.03 $.02 $.01

PMPM 

Probability

$.02 = Mean 1: Scenario

$.03 = Mean 2: Scenario

$.03 = Mean 3: Scenario

$.04 = Mean 4: Scenario

pregnant at targeted counseling/education cessation Smoking .2:A Figure

scenarios four under costs PMPM of Distribution :women

Scenario Scenario Scenario Scenario

(%) 4 (%) 3 (%) 2 (%) 1

21 20 19 18 Minimum

23 22 21 20 likely Most

26 24 23 22 Maximum
of Number Average the 1, Model in As

:formula this by estimated was Participants

 2. / [COMPLETERS + STARTERS[

Services Related and ,Time Staff ,Materials

model the ,studies three the of each For

undergo would participants all that assumed

counseling one-on-one a ,component first the

.(minutes 3 = SD (utesmin 15 of average an lasting ,nurse a with

received patient each assumed model The

smoking “a and pamphlets two person in

“.book help-self “or” guidebook cessation

Cummings $4. cost to assumed were Items

for $2 of estimate an reported) 1989 (.al et

.al et Windsor and ,booklet help-self a

the for patient per $6 estimated) 1993(

.labor and ,reproduction ,materials of cost

same the was time’ nurses of value The

on based ,model first the in used that as

each in incrementing $50,000 of salary a

productivity average an $1,000, by scenario

29 a and ,hours payroll of percent 70 of

.rate benefit-fringe percent

.al et Windsor ,component second the In

received patient each that reported) 1993(

medical “a through reinforcements patient

in placed reminder a had and cessation ingsmok of importance the emphasizing” letter

could doctor the so chart medical her or his

.visits prenatal subsequent at questions ask

activities these for required time clerical The

= SD (minutes 10 of mean a at estimated was

estimated were salaries Clerical .)minutes 3

increments $1,000 with ($20,000 at start to

benefit-fringe a and percent 80 of rate tivityproduc a with) scenario successive each for

postage and letter The .percent 29 of rate

.patient per $0.41 at estimated were costs

by reported component third The

on reported also) 1993 (.al et Windsor

model the 1 Scenario in ,words other In

smoking of prevalence minimum a assumed

a ,percent 18 at women pregnant among

likely most a with ,percent 22 of maximum

scenario successive Each .percent 20 of value

three these of each for values higher assumed

.percent 1 by increasing ,parameters

of percentage the established Having

pregnancy of attributes the having members

willing be would who members such of bernum the estimated model the ,smoking and

the ,)1993 (.al et Windsor by reported centper 93.7 of figure a on Based .participate to

the of estimates of range a used model

of percentage the :”Starters “of percentage

start to agree that smokers pregnant the

:participation

the estimate to had model the ,Next

pregnant of percentage the :”Completers“

:program the complete would that smokers

.(1993) .al et Windsor by reported rates tionattri on based selected were values These

intervention planned s’Windsor left Women

,eligibility benefit losing as reasons such for

.miscarriages having or ,abortions having

51 Services Preventive of Cost The

Scenario Scenario Scenario Scenario

(%) 4 (%) 3 (%) 2 (%) 1

96 94 92 90 Minimum

98 96 94 92 likely Most

100 98 96 94 Maximum

Scenario Scenario Scenario Scenario

(%) 4 (%) 3 (%) 2 (%) 1

74 72 70 68 Minimum

76 74 72 70 likely Most

78 76 74 72 Maximum
the of consisted which” ,supports social“

:activities following

contract a with” letter buddy “a Sending• 

patient each to tipsheet and

each to newsletter quarterly a Sending• 

patient

patient each to pamphlets two Giving• 

to assumed were mailings five These

clerical of minutes 10 of average an require

.patient per postage and ductionrepro for $0.45 and) minutes 3 = SD (time

the for cost the in builds also model The

as nurse a by delivered reminder minute2-

.class prenatal minute20- a of part

other no were there assumed model The

the beyond costs startup time-one or variable

booklets help-self/guides cessation smoking

.pamphlets and

is valued be to had that variable final The

to required expenses total of percentage the

of Each .margin profit any plus A&G cover

13 and 12, 11, 10, used scenarios four the

.respectively ,percent

Health Mental Term-Short Targeted 3: Model

 Therapy

basis the on designed was model cost This

by research in described interventions of

and) 1991 (Cataldo and ,Riley ,Finney

,Locke ,Carey ,Kessler ,Allen ,Goldberg

Dorfman by reviewed and) 1981 (Cook and

numbered respectively references in) 2000(

,models other the all with As 41. and 15

PMPM estimate to designed was model this

100,000 with plan care managed a for costs

members adult its for and 17 to 0 age bersmem its for benefit) visits 16 to 6 (therapypsycho brief a implements that members

.(65 to 18 ages(

children on focused) 1991 (.al et Finney

therapy brief with treated 15 to 1 ages

based-staff a of clinic pediatric a within

.(HMO (organization maintenance health

research their did) 1981 (.al et Goldberg

psychotherapy for paid claims the on based

(65 to 18 ages (members adult to provided

Benefit Health Employees Federal the of

,categories age adult and child both modateaccom to designed was model cost The .Plan

were subgroup each of results cost the and

use would MCO an assuming ,combined

Both .group either with intervention this

design cost similar a had categories age

values .,e.i (assumptions input different but

.(distributions stochastic various to assigned

 Cost PMPM

statistics primary the summarizes .4A Table

.scenario each for costs PMPM for generated

Least the for cost PMPM average The

average The $1. was Scenario Expensive

Scenario Expensive Most the for cost PMPM

the ,scenarios four all Across $1.96. was

the and $0.17 is) percentile th5 (limit lower

with $3.60, is) percentile th95 (limit upper

PMPM 4,000 estimated the of percent 90

within falling scenarios four the across values

$3.43. of range this

unusual is costs of pattern statistical This

The .models previous the all to compared

.3.A Figure in tratedillus well is costs potential of distribution

PMPM estimated of distributions The

considerably are scenarios four all for costs

ranging ,large quite is costs PMPM of butiondistri s’scenario each of variability The .ityvariabil more with ,shape in uniform more

range average The $1.12. to $0.29 from

minimum minus cost PMPM maximum(

is scenarios four all across) cost PMPM

estimated the of percent Ninety $2. almost

$3.60, and $0.17 between are values 4,000

$3.43. of range a

Report Technical 52
53 Services Preventive of Cost The

values PMPM of Range :psychotherapy term-short Targeted .4:A Table

scenarios four under

4 Scenario 3 Scenario 2 Scenario 1 Scenario

Most Intermediate Intermediate Least

($) Expensive) $ (Expenses) $ (Expenses) $ (Expensive

0.08 0.07 0.06 0.05 Minimum

1.96 1.62 1.30 1.00 Mean

1.96 1.62 1.30 1.00 (Percentile th50 (Median

3.88 3.20 2.56 1.98 Maximum

1.06 0.87 0.70 0.54 Deviation Standard

1.12 0.76 0.49 0.29 Variance

0.77 0.63 1.33 0.76 Mode

0.33 0.27 0.22 0.17 Percentile th5

3.60 2.97 2.38 1.84 Percentile th95

3.27 2.69 2.16 1.66 Percentile th95 and th5 Between Difference

Scenarios All

0.17 Percentile th5

3.60 Percentile th95

3.43 Percentile th95 and th5 Between Difference

 th95 and th5 Between Values of Percent

90 Percentile
each of shape” uniform “relatively The

of range wide a that implies distribution

likelihood equal about have values PMPM

Expensive Most the ,Clearly .occurring of

greatest the with one the also is Scenario

 .variability

distributions these of shape uniform The

the values and distributions the to due is

the on based ,design its in assumed model

to According .literature the in reported data

of proportion the ,)1981 (.al et Goldberg

,visits 15 to 6 ,visits 5 to 1 receiving persons

.same the about was visits 15 than more and

this ,costs total of driver primary the As

participant per visits of distribution uniform

final the of uniformity the for accounts

.distributions PMPM

Model the in Used Values Input and Design

Prevalence Treated and Membership

Census .S.U on Based 100,000. of shipmember MCO an assumed also model This

assumed model the ,data) 1990 (Bureau

from be would population the of percent 32

be would percent 68 and 18 age to birth

65. to 19 ages adults

use would MCO any assumed model The

evaluating when criteria” necessity medical“

used was as ,psychotherapy brief for need the

.(1981) .al et Goldberg by study the in

indicators that assumed model the ,Therefore

the estimate best would prevalence treated of

brief receive would who persons of number

.therapy

Report Technical 54

0.4

0

0.1

0.2

0.3

0.5

0.6

$4.00 $3.50 $3.00 $2.50 $2.00 $1.50 $1.00 $0.50 $0.00

PMPM

$3.60 = %th95 $0.17 = %th5

Probability

1: Scenario

$1.00 = Mean

2: Scenario

$1.30 = Mean

$1.62 = Mean 3: Scenario

4: Scenario

$1.96 = Mean

costs PMPM of Distribution :psychotherapy brief Targeted .3:A Figure

scenarios four under
assumed model the ,subgroup child the For

on based) scenario each in increments centper 1 in (percent 12 to 9 of rate prevalence a

the of analysis-meta a from estimates median

by reported research epidemiological

and ,Manderscheid ,Leavy-Katz ,Friedman

any with children insured privately of centper 23 that indicated adolescents and drenchil among problems health mental of lencepreva treated on study A .)1996 (Sondheimer

some received) SED-non or] SED [turbancedis emotional serious (disorder health mental

.(1991 ,Burns (therapy outpatient

model the ,subgroup adult the For

prevalence treated outpatient an assumed

epidemiological on based adults for rate lencepreva treated average an on based) mentsincre percent 0.5 in (percent 15 to 14 of rate

,Narrow ,Rae ,Bourdon by reported research

rate That .)1994 (Regier and ,Manderscheid

by reduced further is prevalence treated of

et Goldberg by reported rate a ,percent 44

.visits zero received who diagnoses atricpsychi with patients index of ,)1981 (.al

and ,Provider of Type ,Service of Volume

 Copayments

“triangular “a assumed subgroup child The

visits 2.75 of average an with distribution

1.25, = likely most 1, = minimum (child per

of frequency the describe to) 6 = maximum

a reported) 1991 (.al et Finney .visits therapy

2.4 of average an and visits 6 to 1 of range

around variability of measure no but ,visits

.mean this

session therapy each assumed model The

,minutes 60 lasted participant child per

sessions minute50- the includes which

and) 1991 (.al et Finney by reported

for minutes 10 and) 1981 (.al et Goldberg

data the on Based .keeping record clinical

the ,)1981 (.al et Goldberg by reported

of distribution uniform a assumed model

one each ,participant adult per visits eight

and time therapist of minutes 50 requiring

.keeping record for minutes 10

was therapy the that assumed model The

social psychiatric or psychologist (sionalprofes health mental licensed a by provided

$50,000, of salary annual an with) worker

a and ,percent 29 of cost benefit-fringe a

an yielding ,percent 70 of rate productivity

$44.30. of” hour per cost effective“

including ,plans insurance most Because

carve “care health behavioral and HMOs

copayment health mental a have” ,outs

,respectively $5, and $10, $15, $20, of mentcopay a assumed model the ,requirement

Expensive Least from scenarios four the for

the ,words other In .Expensive Most to

effective “the reduces effectively copayment

the for $24.30 to $20 by” hour per cost

to $5 by and Scenario Expensive Least

.Scenario Expensive Most the for $39.30

all of percent 100 assumed model The

.collected were copayments

Expenses Other

to how .,g.e” (guidelines treatment ioralbehav “that reported) 1991 (.al et Finney

a assumed model The .treatment in drenchil the of parents the to given were”) outstime “of use the ,wetting bed to respond

the for increments $1 in $5 to $2 of cost

of distribution and reproduction of cost

.guidelines these

that reported also) 1991 (.al et Finney

of number a received also families most“

therapy after contacts telephone planned

techniques therapeutic recommended of tionimplementa adequate ensure to begun was

.(452 .p” (problems troubleshoot to and

of percent 100 assumed model the ,Therefore

phone two receive each would families the

55 Services Preventive of Cost The
with distribution triangular a using .,e.i (calls

phone the assumed model The .)3 = mummaxi and 2, = likely most 1, = minimum a

and) minutes 2 = SD (minutes 5 took calls

.therapist the by made were

phone or supplies no assumed model The

.adults the for expenses call

by cost total the increased also model The

rate profit plus overhead A&G a applying

direct the to percent 13 and 12, 11, 10, of

.scenarios four the of each in cost services

for Education Health Care-Self 4: Model

Adults Older and Adults

basis the on designed was model cost This

—publications six of amalgamation an of

,Lowry ,Kalmer ,Vickery); 1982 (Kemper

;(1983) Loren and ,Wright ,Constantine

;(1992) Harrington and ,Parcell ,Fries ,Fries

,Leigh); 1993 (Mettler and ,Lorig ,Kemper

,Parcell ,Harrington ,Kerr ,Beck ,Richardson

,Golaszewski ,Vickery and); 1992 (Fries and

reviewed and)—1988 (Kalmer and ,Wright

respectively references in) 2000 (Dorfman by

Each 52. and 51, 43, 40, 32, 29, numbered

interventions of variety a described study

of Five .adults older or adults to provided

a within conducted were studies six the

the within one and setting care managed

 .worksite

wide a was there ,studies six the Across

to provided were that activities of range

positive promote to order in participants

:care-self and behaviors health

provide to nurses train to Workshops 1.

,patients to support psychoeducational

,pamphlets ,materials written including

booklets and

,books ,newsletters ,guidelines care-Self 2.

participants for booklets and

care-self covering Videotapes 3.

service information telephone to Access 4.

nurse a by staffed

a with conferences health Individualized 5.

nurse

personalized ,serial ,based-Computer 6.

reports risk health

and letters recommendation Individualized 7.

reports

a with sessions educational one-on-One 8.

physician

“center in-drop care-self “a to Access 9.

(21 .p 2000, ,Dorfman(

all incorporate to designed was model The

costs PMPM the estimate and activities nine

PMPM the ,Therefore .combined nine all of

may that MCO any for overstated are costs

.activities all of subset a only use to wish

 Cost PMPM

cost PMPM the summarizes .5A Table

cost PMPM average The 4. Model of lationsimu a in generated were that parameters

$1.06. was Scenario Expensive Least the for

Most the for cost PMPM average The

all Across $2.02. was Scenario Expensive

th95 (limit upper the and $0.99 was) centileper th5 (limit lower the ,scenarios four

of percent 90 with $2.14, was) percentile

across values PMPM 4,000 estimated the

range this within falling scenarios four the

$1.15. of

in graphically presented are results The

PMPM of distributions The .4.A Figure

this of scenarios four the of each for values

of any than separated more clearly are model

assumed of range wide the to due is rationsepa of degree large This .models other the

.scenario each of values input the for values

Model the in Used Values Input and Design

of estimation an with begins model The

who adults older and adults of number the

Report Technical 56
57 Services Preventive of Cost The

values PMPM of Range :care-self through promotion Health .5:A Table

scenarios four under

4 Scenario 3 Scenario 2 Scenario 1 Scenario

Most Intermediate Intermediate Least

($) Expensive) $ (Expenses) $ (Expenses) $ (Expensive

1.78 1.46 1.18 0.93 Minimum

2.02 1.66 1.34 1.06 Mean

2.02 1.66 1.34 1.06 (Percentile th50 (Median

2.28 1.88 1.52 1.20 Maximum

0.07 0.06 0.05 0.04 Deviation Standard

0.01 0.00 0.00 0.00 Variance

1.95 1.64 1.29 1.02 Mode

0.99 0.99 0.99 0.99 Percentile th5

2.14 2.14 2.14 2.14 Percentile th95

1.15 1.15 1.15 1.15 Percentile th95 and th5 Between Difference

Scenarios All

0.99 Percentile th5

2.14 Percentile th95

1.15 Percentile th95 and th5 Between Difference

 th95 and th5 Between Values of Percent

90 Percentile
100,000 with MCO an of members are

Bureau Census .S.U 1990 on Based .members

59 at valued were percentages these ,figures

older for percent 11 and adults for percent

the of estimation an for calls then It .adults

to likely is that group age each of percentage

Promotion Health “a in participate to agree

promotion health of series a .,e.i” (Campaign

.(year the throughout activities care-self and

to 45 from ranged adults for estimates These

for percent 15 of increments in percent 90

Most to Expensive Least (scenario each

percentage the adults older For .)Expensive

Expensive Least (percent 60 at started

percent 90 as high as went and) Scenario

increments in) Scenario Expensive Most(

.percent 10 of

by out costed are activities some Because

a to mailed videotape a .,g.e (household

number the estimate to necessary is it ,)home

adults for household per members covered of

data on Based .members adult older and

ratio the ,)1983 (.al et Vickery by reported

households to participants adult older of

1.20 to) Expensive Least (1.26 from set was

0.02. of increments in) Expensive Most(

Least (3 from ranged ratio this ,adults For

in) Expensive Most (2.4 to) Expensive

0.20. of increments

ten of consisted model the of rest The

types various the reflecting modules separate

were that activities intervention specific of

by reviewed studies various the in described

for allowed module Each .)2000 (Dorfman

as material written of estimation cost the

spent labor professional and clerical as well

group or activities one-on-one conducting in

a used model the ,module each In .activities

,example For .adults older or adults by tionparticipa of level the for estimate separate

Report Technical 58per 25 only ,activities of series the in patepartici to agree may adults 9,000 although

1: Scenario

2: Scenario $1.06 = Mean

$1.30 = Mean

3: Scenario

$1.62 = Mean

$0.99 = %th5 $2.14 = %th95

5%

0

1

2

3

4

5

6

7

8

$1.90 $2.20 $2.10 $2.00 $1.80 $1.70 $1.60 $1.50 $1.40 $1.30 $1.20 $1.10 $1.00 $0.90

Costs PMPM 

Probability

4: Scenario

$1.96 = Mean

of Distribution :education care-self through promotion Health .4:A Figure

scenarios four under costs PMPM
in participate to up show actually may cent

educational as such ,activity particular a

.workshops

Materials and Staffing

benefit-fringe ,salaries staff different Slightly

productivity of rates and ,)percent 29 (rates

were than 4 Model in assumed were

3: through 1 Models in assumed

increments $500 in $20,000 at Clerical• 

productivity percent 80 and

increments $1,000 in $50,000 at Nurses• 

productivity percent 70 at

$1,000 in $50,000 at Psychologists• 

productivity percent 70 at increments

$2,000 in $100,000 at Physicians• 

productivity percent 70 and increments

assumed values the summarizes .6A Table

.activity the of description summary a is umncol first The .model the in module each for

total of percentage the is column second The

each in participate to assumed participants

four the are columns four next The .activity

scenario successive each for assumed values

reproducing or purchasing of cost the for

seventh The .activity each of required is rialmate written or ,booklets ,supplies whatever

staff professional of type the notes column

.activity the out carries who member

and mean assumed the are 9 and 8 Columns

time assumed the of deviations standard

last-to-third The .activity each for required

total the reflect columns last-to-second and

,adults older and adults for costs aggregate

costs PMPM the shows column last the and

.combined groups age both for

Intervention Educational Presurgical 5: Model

Adults With

basis the on designed was model cost This

and Devine—publications research three of

59 Services Preventive of Cost The

,Cook ,Connor’O ,Devine); 1983 (Cook

,Egbert and); 1988 (Curtin and ,Wenk

and)—1964 (Bartlett and ,Welch ,Battit

references in) 2000 (Dorfman by reviewed

One 38. and 36, 35, numbered respectively

was) 1983 ,Cook and Devine (publication

This .studies other 49 of analysis-meta a

studies two remaining the and analysis-meta

wide a undergoing adults to provided tionsinterven component of variety a described

:procedures surgical inpatient of range

,workshops group conducted-Nurse• 

including ,supports choeducationalpsy of benefits the on focus which

videos and materials written

by visits postsurgical and Presurgical• 

anesthetist an

promote to training exercises or Skills• 

recovery postsurgical

care health a by support Psychosocial• 

provider

 Cost PMPM

cost PMPM the summarizes .7A Table

PMPM average The 5. Model of lationsimu a in generated were that parameters

was Scenario Expensive Least the for cost

the for cost PMPM average The $0.22.

$0.31. was Scenario Expensive Most

limit lower the ,scenarios four all Across

upper the and $0.16 was) percentile th5(

with $0.40, was) percentile th95 (limit

PMPM 4,000 estimated the of percent 90

falling scenarios four the across values

.5A Figure $0.24. of range this within

.graphically results the presents

Model the in Used Values Input and Design

Participation and Membership

the of estimation an with begins model The

an undergo would who adults of number
60

$0.02 $6,217 $12,958 $44.30 15 90 Nurse $1.75 $1.50 $1.25 1.00 4 Workshops Education Group 1 Costs Adults Adults Hour/Cost Deviation Minutes Staff) $ (4) $ (3) $ (2) $ (1 Participation PMPM Older for Sum Effective Standard Mean Scenario Scenario Scenario Scenario % Activity Total for Sum Cost Unit Reproduction or Purchase :Materials care-self through promotion Health 4: Model in variables for values input Assumed .6:A Table Report Technical

$0.03 $13,065 $27,230 $15.50 1 5 Clerical $4.00 $3.00 $2.00 1.00 100 Participant per Guides Care-Self 2

$0.03 $19,416 $16,997 $15.50 1 5 Clerical $6.00 $5.00 $4.00 3.00 100 Household per Videotapes 3

Center Info Telephone Staffed 4

$0.08 $29,876 $62,267 $44.30 12,480 124,800 Nurse $0.00 $0.00 $0.00 0.00 100) 1 Note) (52/5/8(

 and Evaluation Health Individual 5

$0.25 $96,115 $200,324 $44.30 5 45 Nurse $1.00 $0.75 $0.50 0.25 100 Conference Planning

 Computerized Personalized 6

$0.11 $43,230 $90,100 $15.50 1 10 Clerical $8.00 $7.00 $6.00 5.00 50 Reports Risk Health

$15.50, ,Clerical and Recommendations Individualized 7

 $0.19 $73,035 $152,221 $44.30, 5, 3, 30, 10, ,Nurse $1.75 $1.50 $1.25 1.00 50 MD by Signed Letters

$86.60 and 1 and 5 and MD and

$0.03 $12,625 $26,314 $88.60 2 20 MD $0.00 $0.00 $0.00 0.00 15 MD With Sessions Educational Individual 8

$0.73 $881,989 Components Eight All for Costs Total

Consumable Phone Monthly

PMPM Total per Supplies Operating and Monthly Square Care-Self to Access 52/5/8

Costs Costs Participant Equipment) $ (Costs) $ (Lease Footage Center In-Drop

$0.23 $272,900 $5.00 $100,000 $7.00 15.00 625

$0.96 $1,154,889 Components Eight All for Costs Total

$0.25 10% Profit and Expenses Administrative and General for Margin Components All for Total

$1.06 $1,270,377 Profit and A&G with Costs Total

day a hours 8 and ,week a days 5 ,weeks 52 Staffed Center Telephone 1: Note
number The .procedure operative inpatient

in out carried procedures operative of

United entire the within settings inpatient

recent most the in accessed was States

National the by reported) 1996 (results

and ,)NHDS (Survey Discharge Hospital

patients elderly and adult on done duresproce those only of estimate an for ,centper 71 by down adjusted was number that

Census .S.U the on based ,)80 to 18 ages(

in persons for 1998 for figures Bureau

1,000 per 154 was rate procedure gicalsur inpatient 1996 The .category age that

This .)1998 ,Bureau Census .S.U (ulationpop general 1996 the of) NHDS (members

adult 1,000 per 109 to reduced was value

reduced was rate This .lives elderly and

Group the by reported as ,HMOs in duresproce operative of ratio the by again once

,(1995) America of Association Health

the for NHDS the by reported rate the to

in members HMO .population general

operative fewer percent 36 about had 1995

.population general the than procedures

members 100,000 per rate the ,Therefore

per 70 at set was MCO hypothetical the in

61 Services Preventive of Cost The

and adults with interventions educational Presurgical .7:A Table

scenarios four under values PMPM of Range :adults older

4 Scenario 3 Scenario 2 Scenario 1 Scenario

Most Intermediate Intermediate Least

($) Expensive) $ (Expenses) $ (Expenses) $ (Expensive

0.18 0.16 0.15 0.13 Minimum

0.31 0.28 0.25 0.22 Mean

0.31 0.28 0.25 0.22 (Percentile th50 (Median

0.50 0.45 0.41 0.36 Maximum

0.05 0.05 0.04 0.04 Deviation Standard

0.00 0.00 0.00 0.00 Variance

0.32 0.27 0.24 0.25 Mode

0.16 0.16 0.16 0.16 Percentile th5

0.40 0.40 0.40 0.40 Percentile th95

0.24 0.24 0.24 0.24 Percentile th95 and th5 Between Difference

Scenarios All

0.16 Percentile th5

0.40 Percentile th95

0.24 Percentile th95 and th5 Between Difference

 th95 and th5 Between Values of Percent

90 Percentile
at estimated (lives elderly and adult 1,000

.(100,000 the of percent 71

for participate to agreement of level The

50 at set was Scenario Expensive Least the

increments percent 5 in increasing ,percent

Expensive Most the for percent 65 to up

.Scenario

Materials and Staffing

an that reports research original the While

the patients to visits bedside made anesthetist

assumed model the ,surgery the before night

 .task this out carry could thesiologyanes in training specialty with nurse a that

levels assumed the summarizes .8A Table

,activity component each for participation of

for supplies and materials the for costs the

and time assumed the and ,scenario each

health and ,anesthesiologist nurse ,chologistspsy ,nurses the for hour per cost effective

.counselor

cost component postsurgical The .surgerypost and -pre spent time the be would nentcompo expensive most the ,expected As

component presurgical the than more

patients most that assumed was it because

before visits postsurgical two receive would

.discharge their

Reduce to Counseling Brief 6: Model

Use Alcohol

four of basis the on designed was model This

and ,Miller ,Bien—publications research

,Manwell ,Barry ,Fleming); 1993 (Tonigan

Health World); 1997 (London and ,Johnson

,Barry ,Fleming and); 1996 (Organization

—(1999) Stauffacher and ,Adams ,Manwell

and 50, 39, 33, numbered respectively encesrefer in) 2000 (Dorfman by reviewed and

model this ,models other the all with As 53.

a for costs PMPM estimate to designed was

members 100,000 with plan care managed

Report Technical 62

$0.40 = %th95 $0.16 = %th5

0

1

2

3

4

5

6

7

8

9

10

$0.42 $0.37 $0.32 $0.27 $0.22 $0.17 $0.12

Costs PMPM 

Probability

$0.22 = Mean 1: Scenario

$0.28 = Mean 3: Scenario

$0.25 = Mean 2: Scenario

 4: Scenario

$0.31 = Mean

:elderly and adults with interventions educational Presurgical .5:A Figure

scenarios four under values PMPM of Distribution
63 Services Preventive of Cost The

 educational Presurgical :labor and ,supplies ,materials ,participation for values input Assumed .8:A Table

elderly and adults with intervention

:Materials

Total Cost Unit Reproduction or Purchase %

PMPM Total Effective Standard Mean Scenario Scenario Scenario Scenario Patients of Activity

Costs Costs Hour/Cost Deviation Minutes Staff) $ (4) $ (3) $ (2) $ (1 Participating

and Nurses Provide to Nurses Train

0.00 1,865 53.16 15 180 Psychologist 5678 NA Support Psychoeducational

 Visit Presurgery Individualized

0.03 37,925 88.60 5 20 NAnesth 1234 50 Anesthetist Nurse by

and 50 Visit Postsurgery Individualized

0.05 22,024 88.60 5 15 NAnesth 0000 visits 2 Anesthetist by

and Nurses Reduction Pain Provide to Nurses Train

0.00 1,819 53.16 15 180 Psychologist 5678 NA Patients to Exercises and Skills

 by Provided Support Psychosocial

0.12 146,732 35.44 5 50 Coun H 0 0 0 0 100 Counselor Health a

$243,365 Components All for Total

$0.20 Services Direct for PMPM

$0.22 Profit and A&G with PMPM
by use alcohol excessive reduce to ventioninter brief and screening a implements that

as well as) 65 to 18 ages (members adult its

male ,)older and 66 age (members older its

.female and

 Cost PMPM

statistics primary the summarizes .9A Table

.scenario each for costs PMPM for generated

Least the for cost PMPM average The

The $0.36. only was Scenario Expensive

Expensive Most the for cost PMPM average

$0.31 is) percentile th5 (limit lower the ,iosscenar four all Across $0.85. was Scenario

is) percentile th95 (limit upper the and

estimated the of percent 90 with $0.93,

$0.62. of range this within falling iosscenar four the across values PMPM 4,000

their at were variables input the all If

would cost PMPM the that probability centper 90 a is there ,values possible maximum

.less be probably would it although $0.93, be

of representation graphic a is .6A Figure

costs PMPM average of distribution the

the as 1, Model with As .scenario each for

Report Technical 64

PMPM of Range :abuse alcohol reduce to counseling Brief .9:A Table

scenarios four under values

4 Scenario 3 Scenario 2 Scenario 1 Scenario

Most Intermediate Intermediate Least

($) Expensive) $ (Expenses) $ (Expenses) $ (Expensive

0.70 0.50 0.35 0.26 Minimum

0.85 0.63 0.47 0.36 Mean

0.82 0.62 0.47 0.36 (Percentile th50 (Median

1.01 0.77 0.59 0.47 Maximum

0.05 0.04 0.04 0.03 Deviation Standard

0.00 0.00 0.00 0.00 Variance

0.85 0.64 0.47 0.37 Mode

0.77 0.57 0.41 0.31 Percentile th5

0.93 0.70 0.53 0.41 Percentile th95

0.15 0.13 0.12 0.10 Percentile th95 and th5 Between Difference

Scenarios All

0.31 Percentile th5

0.93 Percentile th95

0.62 Percentile th95 and th5 Between Difference

 th95 and th5 Between Values of Percent

90 Percentile
the does so ,increases cost PMPM average

 .average the surrounding variability

Model the in Used Values Input and Design

Use Alcohol for Screening

information Bureau Census .S.U on Based

and male that assumed model the 1998, for

than greater persons including ,adults female

the on Based .members 100,000 the of) nariosce each for percent 1 of increments in (centper 73 to 70 of range a represented 65, age

,Barry ,Fleming by reported research

and ,)1997 (London and ,Johnson ,Manwell

drug of surveys household epidemiological

Applied of Office the by use alcohol and

Health Mental and Abuse Substance ,Studies

assumed model the ,)1998 (Administration

percent 1 of increments in (percent 17 to 14

for positive screen would) scenario each for

a on dependency or use alcohol excessive

instrument screening health administered-self

percentage This .receptionist a by distributed

pregnant were who adults female excludes

be to known) 64 to 19 ages (adults all and

history a having or abusers alcohol or drug

The .abuse alcohol or drug for treatment of

administered-self the of scoring and tiondistribu for time average the assumed model

receptionist a by instrument screening health

model The .)minute 1 = SD (minutes 5 was

in $2 and $1.50, $1, $0.75, cost would mentinstru screening health each that assumed

.scenario each

in (percent 71 to 68 assumed model The

of) scenario each for percent 1 of increments

go to agree would positive screening those

with interview minute30- initial the through

and participants screen further to nurse a

related-health on behavior baseline collect

.(exercise ,smoking .,g.e (behaviors

.al et Fleming by reported data on Based

percent 45 to 42 assumed model the ,)1997(

(scenario each for percent 1 of increments in(

65 Services Preventive of Cost The

reduce to counseling brief for costs PMPM of Range .6:A Figure

use alcohol

2

1

3

4

5

6

7

8

9

$0.93 = %th95 $0.31 = %th5 10

$1.000 $0.900 $0.800 $0.700 $0.600 $0.500 $0.400 $0.300

Costs PMPM

Probability

$0.36 = Mean 1: Scenario

$0.47 = Mean 2: Scenario

$0.63 = Mean 3: Scenario

 4: Scenario

$.0.85 = Mean
go would interview this completing those of

.intervention the in participation start to on

in (percent 98 to 95 assumed model The

(scenario each for percent 1 of increments

 “.Completers “be would” Starters “the of

Interventions Service

the ,)1997 (.al et Fleming by described As

receive would participants assumed model

minutes 15 lasting each ,physician care marypri their with sessions counseling brief two

few the includes time This .)minutes 3 = SD(

enter to physician the for required minutes

.record medical the in documentation brief

feedback contained “physician the and pantpartici the by used workbook The” .bookwork “a given was participant Each

review a ,behaviors health current regarding

list a ,drinking problem of prevalence the of

worksheet a ,alcohol of effects adverse the of

in agreement drinking a ,cues drinking on

drinking and ,prescription a of form the

The .)61 .p 2000, ,Dorfman” (cards diary

provided was workbook this assumed model

The .participants the of percent 100 to

for workbook per cost the assumed model

$7, $6, $5, was scenarios four the of each

.most to least from ,respectively $8, and

of percent 100 that assumed model The

call phone followup a received participants

sessions two the of each following nurse a by

= SD ,minutes 5 = mean (physician the with

 .(minutes 2

clerical by interventions these of cost The

determined was physicians and ,nurses ,staff

staff productive a of cost the multiplying by

and ,benefits fringe ,salary on based (hour

to spent hours against) time nonproductive

annual The .time travel including ,train

were staff of category each of salaries

with $20,000 ,clerical :follows as assumed

80 and scenario each for increments $500

with $50,000 ,nurses; productivity percent

.productivity of rate percent 70 a and mentsincre $2,000 with $100,000 ,physicians; ityproductiv percent 70 and increments $1,000

29 at assumed were costs benefit-Fringe

model The .personnel all for percent

associated expenses no were there assumed

or supervisory additional for need the with

clinical ongoing the into blend could tioninterven an such because staff management

.office s’physician each of operations

Training Staff and Recruitment Physician

physicians to participants of ratios on Based

be to have would that physicians of bernum the ,)1997 (.al et Fleming by reported

.estimated was participate to invited

participate to agreement of rate a Assuming

increments percent 5 in percent 95 to 80 at

physicians of number the ,scenario each for

of number the handle to order in patepartici to needed number the and invite to

.calculated be could participants expected

$50 to $35 at estimated were costs Invitation

from ,scenario each For .increments $5 in

the ,Expensive Least to Expensive Most

1 or 2, 3, 4, be would there assumed model

number the ,way That .site office per doctor

 be could trained be to need would ciansphysi and personnel where sites office of

.calculated

involved all that assumed model The

training some require would personnel office

office each For .protocol the of use the on

5 = SD (minute20- a assumed model the ,site

who personnel clerical for training) minutes

screening health the scored and distributed

who nurses the for session training) utesmin 5 = SD (minute60- a and instrument

the make and interview the administer would

an assumed model The .calls phone followup

= SD (minutes 60 of session training initial

Report Technical 66
two assumed model The .site single a in ingwork physicians agreeing all for) minutes 10

minutes 15 of sessions training” booster“

 .physicians for) minutes 10 = SD (each

by determined were costs training The

.,e.i ,salary” (trainer “a of costs benefitfringe and salary average the multiplying

each for increments $1,000 in $40,000

productivity percent 70 with ,scenario

against) costs benefit-fringe percent 29 and

.time travel including ,train to spent time

expenses no were there assumed model The

additional for need the with associated

because staff management or supervisory

into blend could intervention an such

.operations office ongoing

Fleming by research original the Because

the to payment $300 a reported) 1997 (.al et

to payments assumed model the ,physicians

$500, $300, of physician participating each

the compensate to made be would mentpay This .scenario each for $900 and $700,

related” revenue patient lost “for physician

.training the in patepartici to physician and staff for need the to

some assumed model this 1, Model in As

plus A&G for added be should percentage

the of each for percent 1 by increasing centper 10 of amount generous fairly A .profit

Most to Expensive Least from scenarios four

.entered was Expensive

67 Services Preventive of Cost The

ESTIMATING

of COST the

 PREVENTIVE

Abuse Substance and Health Mental in SERVICES

Care Managed Under