The Massachusetts Prevention and Wellness Trust Fund (PWTF) is a unique state model that supports community-based partnerships, including municipalities, healthcare systems, businesses, regional planning organizations, and schools, to work together to provide research-based interventions that will improve health outcomes and reduce costs. In 2012, the PWTF was established through the state’s health care cost-containment legislation, with a four year and $60 million dollar commitment to population-based health promotion efforts. In January 2014, PWTF awarded close to $43 million in grants to nine community-based partnerships to implement evidence-based interventions that would likely lead to overall savings for the state.
In designing the program, the Massachusetts Department of Public Health (MDPH) wanted to define the number and size of awards that would produce the most benefit over cost, and identify the health conditions these investments should target. Because there is no universally-accepted methodology for determining a return on investments (ROI) for these interventions, MDPH developed a model to calculate optimal population size and optimal per capita funding in the partnerships. We spoke with one of the authors of the model, Thomas Land, PhD, Director of the Office of Data Management and Outcomes Assessment at MDPH, to learn more about its development.
Q: What was your initial process to develop a model?
A: The first step was to prioritize conditions where there was evidence that interventions could result in short-term improvements in health outcomes and cost savings. We collected studiesacross various conditions and interventions, and their associated ROI if available. In order to identify priority conditions, we presented this information to the state Prevention and Wellness Advisory Board and asked them to rank order the strength of the evidence, while considering disease burden in Massachusetts. In addition, a non-profit group specializing in developing social finance bonds weighed in on whether an investor would support interventions for the priority conditions. Ultimately, the PWTF decided to fund awards in four priority areas: pediatric asthma, hypertension, tobacco use, and falls among the elderly.
Next, in order to determine how many grants to award and what the characteristics of those grant awards should be, we developed a model to estimate optimal population size and per capita funding for interventions focused on the priority conditions.
Q: How would you describe the model to calculate the appropriate population size for the PWTF grants?
A: MDPH considered three factors, which are laid out in the graph below.
1. Percent reduction in healthcare costs necessary to recoup the $60 million total PWTF investment along with total population potentially served by PWTF programs (Heavy black line)
- The more people in PWTF funded programs, the less healthcare costs would have to be reduced per capita in order to recoup the $60 million.
2. The cost per person of effective interventions (Blue and Orange Lines)
- The best studies that helped determine these values were worksite wellness programs because they focus across multiple interventions and conditions.
- Programs that spent more per person ($500 vs. $50) affected a smaller number of the populations.
3. The effectiveness of interventions (Green and Red Lines)
- Wellness programs vary in effectiveness. Based on the evidence, the best case for a well-implemented intervention would be about 1% ROI across a full population.
- This 1% ROI decreases as the population size increases because there is less money invested on a per capita basis.
The key to the model is the light gray area indicating that the peak for ROI occurs when the total population covered by all grantees reaches approximately 150,000-1.2 million people. MDPH therefore proposed a cap of no fewer than six awards and no more than 12. Each award would focus on a population between 30,000 and 120,000 people.
Q: What challenges did you face in developing the model?
A: The greatest challenge was the incompleteness of the literature. There were no direct studies to base the model on, and this made it difficult to identify target population size and choose priority conditions.
A continuous challenge for us in development of the model and for PWTF awardees is the requirement to bring together community and clinical partners to work together for an extended period of time. This is one of the long-term goals of the PWTF and hopes to make the interventions sustainable after the PWTF. All applicants were required to have community, clinical and municipal partners included in their official partnerships and had to describe how the community and clinical partners will work together. That partnership structure must be maintained for continued funding.
Q: How are you evaluating the program to understand its impact?
The outcome measures for the PWTF evaluation align with the outcome measures for the entire cost-containment legislation including reduction of preventable health conditions, reduction in health care costs and who benefited from the cost reduction, and employee health impact of workplace wellness. As a first step in measuring outcomes, the MDPH has identified baseline data for the prevalence of diabetes within each of the 9 communities using local clinical, claims and community data (BRFSS). We are also in the process of hiring a contactor for a PWTF evaluation.
Q: What advice do you have for other states as they design and implement state and community level prevention and wellness programs?
A: First, always keep the goals of the project in mind as you continuously monitor and revise the program along the way.
Secondly, operate the program for longer than four years because it will allow states to recruit more people into interventions and give more time to evaluate outcomes of the interventions. States could also select priority conditions and interventions that take longer to realize a positive ROI.
Interested in learning more about the PWTF? Read the 2013 Legislative Report or see this presentation from the preconference session at NASHP’s 2014 Annual State Health Policy Conference. Share your state’s population-based health promotion efforts in a comment below or on our population health discussion page.