Is IPS value for money? Research update, Eric Latimer

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Professor Eric Latimer, Associate Professor, Department of Psychiatry; McGill University, Canada

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  • This presentationisbased on a systematicreviewreported in a 2008 monographcarried out for Québec’sHealthTechnology and Intervention Assessmentagency, with the set of studiesrecentlyupdated in preparation for this talk.
  • a)And b) reflect a D of H perspectiveC) reflects a government perspectiveD) refelcts a societal perspective
  • Many people withsevere mental illnesswant a job, and mostprefer a job in competitive settings. IPS is more effective thanotherapproaches (with the possible exception of IPS + SST) athelping people obtaincompetitive jobs. This canbeviewed as an intrinsicbenefit for (many) people whoreceive IPS services. In the UK, a decision has been made to favourcompetitiveemployment over sheltered on the grounds thatitfavours social inclusion. This iswhat people experiencing first psychoticepisodeswant, beforethey have been conditionedintobelievingitis not possible for them.
  • Long-termstudies, as well as otherstudies (e.g. Strickler et al. 09) suggestthatwithcontinuedsupportedemployment people will continue to work. People mayalsotakesome time beforetheyeventuallystartworking.
  • This slideindicatesthat,typically, individualswhoreceive IPS services, at least over the relativelynearterm, experienceonlymodestincreases in competitiveearnings.It does not show the reductions in welfarebenefits people may have experienced as a result, whichwouldpartially offset the increases in earnedincome. Thereis of course individual variation. Someindividualsmayexperience more significantincreases in income, particularlygiven more time to find a job thatis a good fit, and time to developbetterworkskills.
  • Short-term studies usually find no difference between groups on:SymptomsSelf-esteemQuality of lifeBut 2 long-term studies find majority of IPS clients who worked say program improved on variables such as self-esteem, self-confidence, hopefulness; one on symptoms (Salyers et al. 04; Becker et al. 07). Third more recent study (Strickler et al. 09), also finds many self-reported benefits for those who work (sense of belonging, of accomplishment if new skills learnt, satisfaction with extra income), not for those who do not.Also, when clients who do enter intocompetitiveemployment are grouped, such variables as quality of life tend to show greaterimprovementthanwith clients who do not enter competitiveemployment (Twamley et al. 08; Bond et al. 01; Mueser et al. 97)These results suggestthat limited work experience of many IPS clients in short-term studies “dilutes” effect of intervention
  • Community OT compensation plus oncostscomesfromSection 9.6, Communityoccupationaltherapist (local authority) http://www.pssru.ac.uk/pdf/uc/uc2009/uc2009_s09.pdf
  • Thisslide shows that SE/IPS costsmaybegreater or lessthan control or comparisonvocational programs. This ishardlysurprisinggiven the range of possible alternative vocational programs, and the factthat SE/IPS services are of moderatecost.
  • As we can see, RCTs and pre-post comparisons give mixed evidence concerning effects of IPS on use and costs of health care services.
  • In this non-experimentalstudy, weseethatthosewhoremainedunemployeddid not experienceanydecline in eitherhealth and social care costs, or mental health services
  • The steady-work group sawrapidincreases in amount of work and thenstabilization.Theyaveraged 5,060 hours per person over 10 years, thus about 10 hours per week on average.The steadywork group tended to include people whohad more education, a bipolardisorderDx (vs. Schizophrenia or schizoaffectivedisorder), work in the pastyear, and fewersymptoms on the BPRS.
  • Over a 10-yearperiod (1989 to 2001), the steady-work group accumulated $166,350 less in outpatient services and institutionalstaysthan the minimum work (no work or latework) group. (Using unit costsfrom a recentyear). In only one MH center (out of 7) wereauthors able to distinguish SE services fromother services. In that center, the steadyworkers made greatest use of SE services in years 1 to 5. But, thisis not a long-termfollow-up of SE services study; many of theseindividualsdid not everwant to work and neverused SE services. Evidencethatrelationshipis causal fromwork to reduced MH costs:Statisticalcontrols for variables listed in notes for previousslidedid not strongly affect relationshipbetweenwork and costsCostreductionsfollowed engagement in workIn a separate, qualitative study of the same clients (Strickler et al. 2009) clients saidworkingenabledthem to manage theirsymptomsbetterEmploymentoutcomesminimallyrelated to mental illness or SA outcomes over time. Thus suggestion that the keyis change in self-definitionfrom mental health services user to worker.
  • These results suggestthat limited work experience of many IPS clients in short-term studies “dilutes” effect of intervention on costs. As with non-vocational outcomes, it appears more and more likely that people who do work experience reductions in health care costs.
  • Cost offsets mightoccurbecause:Employmentspecialist passes on information about state of client to clinicians in more timelymannerEmploymentspecialist substitutes for clinician (e.g., helps to reframeevents)Clients have less time to obtain servicesClient feelbetter about themselvesAlternatively, someclinicianswouldexpect stress of work to provoke crises and thus extra service costsConsiderevidence for potentialreductions in costfrom:Replacement of existing VR programsReduction in hospitalisationsReduction in other MH services (emergency/crisis, outpatientclinics, case management)
  • These results may be dependent on system context. In our high-fidelity program in Montreal, which has had 3 to 4 employment specialists, over 10 years, according to the program coordinator, more than 40 individuals have started on welfare and left it altogether. (Daniel’s story.)
  • Cost offsets mightoccurbecause:Employmentspecialist passes on information about state of client to clinicians in more timelymannerEmploymentspecialist substitutes for clinician (e.g., helps to reframeevents)Clients have less time to obtain servicesClient feelbetter about themselvesAlternatively, someclinicianswouldexpect stress of work to provoke crises and thus extra service costsConsiderevidence for potentialreductions in costfrom:Replacement of existing VR programsReduction in hospitalisationsReduction in other MH services (emergency/crisis, outpatientclinics, case management)
  • This slideindicatesthat,typically, individualswhoreceive IPS services, at least over the relativelynearterm, experienceonlymodestincreases in competitiveearnings.Thereis of course individual variation. Someindividualsmayexperience more significantincreases in income, particularlygiven more time to find a job thatis a good fit, and time to developbetterworkskills.
  • Is IPS value for money? Research update, Eric Latimer

    1. 1. Is IPS value for money? Researchupdate<br />Eric Latimer, Ph.D.<br /> Douglas Mental Health<br />University Institute<br /> McGill University<br />Montreal, Canada<br />Evidence-BasedSupportedEmployment Conference<br />Dexter House, London, England<br />March 3 2011<br />£<br />
    2. 2. Overview of presentation<br />Methods<br />Whatcanitmean to saythat IPS is value for money? <br />Department of Health perspective<br />Benefits to IPS participants<br />IPS program costs<br />Healthcarecost offsets<br />Government perspective<br />Effects on tax revenues<br />Effects on governmentbenefits<br />Societal perspective<br />Effects on value of economic production<br />Factorsthatinfluence cost-effectiveness of IPS<br />Conclusions<br />
    3. 3. Based on (attempted!) exhaustive literaturereview, with input from Gary Bond, Bob Drake – <br />and insights gained from many others in U.S., Canada and U.K.*<br />* Remainingerrors are myown!<br />
    4. 4. Whatcanitmean to saythat IPS is value for money?<br />
    5. 5. Whatcanitmean to saythat IPS is value for money?<br />IPS generatessignificanthealth/QOL benefitsatreasonablecost to NHS / D of H<br />IPS generatessomuchsavings in health and social care coststhat the net cost to D of H isalmost 0 (or almost)<br />IPS programs result in such large reductions in benefitspayments and increases in tax revenues thatthey are cost-neutral for the government (or almostso)<br />IPS generatessomucheconomic production through people returning to workthatsociety isbetter off with IPS programs (or almostso)<br />A combination of some or all of the above<br />
    6. 6. Department of Health perspective<br />IPS program costs<br />Otherhealth and social care costs<br />Othergovernment-borne personal services (e.g., prisons)<br />Personalincome/wages<br />Tax revenues<br />Government-borne disabilitybenefitpayments<br />
    7. 7. Government perspective<br />IPS program costs<br />Otherhealth and social care costs<br />Othergovernment-borne personal services (e.g., prisons)<br />Personalincome/wages<br />Tax revenues<br />Government-borne disabilitybenefitpayments<br />
    8. 8. Societal perspective<br />IPS program costs<br />Otherhealth and social care costs<br />Othergovernment-borne personal services (e.g., prisons)<br />Personalincome/wages<br />Tax revenues<br />Government-borne disabilitybenefitpayments<br />
    9. 9. Societal perspective<br />IPS program costs<br />Otherhealth and social care costs<br />Othergovernment-borne personal services (e.g., prisons)<br />Personalincome/wages<br />Tax revenues<br />Transfer payments – no resourcesadded or lostbeyond administrative expenses<br />Government-borne disabilitybenefitpayments<br />
    10. 10. Department of Health perspective<br />
    11. 11. Percentages of clients whoobtained a competitive job, experimentalstudies, IPS and pre-IPS<br />SE or pre-IPS<br />(Adapted from Gary Bond)<br />
    12. 12. Long-term vocational outcomes of IPS<br />
    13. 13. Competitive earnings per client per year, SE or IPS vs control/comparison groups<br />Typical increase in competitive earnings of about $500 - $1,500<br />p<0.05<br />medians<br />n.s.<br />Non-RCT design<br />p<0.001 except where otherwise indicated<br />
    14. 14. Being in IPS per se does not seem to improve non-vocational outcomes in short term, on average, but working does<br />Higherincome, non-vocationalbenefits<br />Somework a good bit<br />IPS<br />Someworklittle or not at all<br />No suchbenefits<br />
    15. 15. How much does an SE program cost?<br />Approximate rule of thumb (based on US cost structure): <br />Cost per active place = (Compensation of ES/18)*1.37<br />Example (Community OT compensation plus oncosts)):<br />Compensation = £ 37,000<br />Then C = (37,000/18) * 1.37 ≈ £ 2,800<br />10 active places mean 18 clients get service in a year, on average (based on US experience)<br />
    16. 16. How much does an SE program cost?<br />Large-scale Indiana study reports, using charges to Medicaid:<br />Thosewhowork:<br />Median : 3.2 months of job development, 4 hours per month, $480<br />Median: 6 months of work, 8 hours per month of support, $1,800<br />Total: $2,280 to support an episode of SE taking 9.2 months. <br />Those who don’t end up working: <br />Median : 7.5 months in program, 2.3hours per month, $675.<br />(Perkins et al. 05)<br />
    17. 17. Health care cost offsets<br />1. Othervocationalrehabilitation services<br />2. IPS vs other services<br />Hospitalization: Use and costs<br />Other services: Use and costs<br />Overallcosts<br />3. Workers vs non workers (5 studies)<br />
    18. 18. Costs of SE/IPS Programs vs Control or ComparisonVocational Programs<br />Pre-post studies (not RCTs)<br />n.s.<br />(Differences not tested) <br />Not tested<br />Not tested<br />n.s.<br />
    19. 19. Effects of IPS (or SE) on hospital use – fromRCTs<br />
    20. 20. Effects of IPS (or SE) on hospital use –studieswith non-RCT designs<br />
    21. 21. Costs of hospitalisations: IPS vs control or comparison condition<br />Pre-post comparisons (not tested)<br />n.s.<br />n.s.<br />
    22. 22. IPS and Emergency/Crisis services, case management and outpatient services (RCTs and other designs)<br />
    23. 23. Costs of emergency, case management and out-patient services, SE or IPS vs control/ comparison<br />Pre-post comparisons (not tested)<br />n.s.<br />n.s.<br />Not tested<br />
    24. 24. TOTAL (mental health + VR) costs, SE or IPS vs control or comparison group<br />n.s.<br />Pre-post comparisons (not tested)<br />n.s.<br />Hosp. costs not included<br />n.s.<br />Not tested<br />
    25. 25. Workers vs non-workers<br />
    26. 26. Hours of work and hours receiving MH (non-VR) services, by stage with respect to receipt of SE services <br />(1997 to 2001 Indiana data, N=2,998, Perkins et al. 05)<br />
    27. 27. Overall service costs (VR + MH) by stage with respect to SE services<br /> (1997 to 2001 Indiana data, N=2,998, Perkins et al. 05)<br />*Some longer hospitalisations may be missed<br />
    28. 28. Effects of working on hospital use –long-termretrospectivestudies<br />
    29. 29. Costs 3-0 monthsbefore and 9-12 monthsafter entry intosupportedemployment, by workstatus<br />(Subset of all health and social care input)<br />N=77<br />N=32<br />N=32<br />Schneider, Boyce et al. (2009)<br />
    30. 30. Long-termeffects of working – qualitative reports – NH dually-disordered clients <br />For thosewhodidwork – “the business and structure of work also tended to diminish the salience of symptoms” (p. 264)<br />“Working or not working appeared to be reinforcing over time” (p. 266)<br />(Strickler et al. 2009)<br />
    31. 31. 10-yearfollow-up of dually-disordered clients in NH: Hours of work<br />Source: Bush et al. 2009<br />
    32. 32. 10-yearfollow-up of dually-disordered clients in NH: Cost trends by workinvolvement<br />Source: Bush et al. 2009<br />
    33. 33. Being in IPS per se does not seem to reduce health care costs at least in the short term, on average, but working appears to do so<br />Lowerhealthcarecosts<br />More people work more<br />IPS<br />Someworklittle or not at all<br />No suchbenefits<br />
    34. 34. Government perspective<br />
    35. 35. Competitive earnings per client per year, SE or IPS vs control/comparison groups<br />$251 reduction in welfare payments, and $125 increase in taxes paid (only study with such results)<br />
    36. 36. Societal perspective<br />
    37. 37. Competitive earnings per client per year, SE or IPS vs control/comparison groups<br />Typical increase in competitive earnings of about $500 - $1,500<br />p<0.05<br />medians<br />n.s.<br />Non-RCT design<br />p<0.001 except where otherwise indicated<br />
    38. 38. Summing up this part of presentation<br />Department of Health perspective:<br />IPS helps more people enter into competitive jobs than other vocational services – and this is what we favour<br />In US, increases in personal income are modest on average<br />Those who do work experience improvements in self-esteem and better symptom management, satisfaction with income<br />IPS can replace equally costly traditional services<br />Evidence is growing that those who enter into work and become steady workers tend to reduce their use of mental health services<br />Data suggest a good investment from D of H perspective but no QALY data<br />Government perspective<br />Almost no evidence, but earnings are low on average thus impacts on benefits and taxes may be small (US-dependent?)<br />Societal perspective<br />Increases in economic production modest on average <br />
    39. 39. Studies that have looked at cost-effectiveness of IPS<br />No study appears to have used a measure such as QALYs<br />Dixon, Hoch et al. (02) calculated (based on DC 99 trial) that one extra hour of competitive employment cost $13 (in 1995 US$)<br />Wong et al. (05), in an unpublished report from Hong Kong, calculate that IPS reduces overall costs, so that a reduction in cost of HK$462 produces one more competitive job<br />Cost-effec./CB studies <br />
    40. 40. Studies that have looked at cost-benefit of IPS<br />Clark et al. (98) using NH 96 RCT data, find no significantoveralldifference in net economicbenefit<br />Emergedfromearlier graphs<br />Chalamat et al. (05) use a modelingapproachadapted to Australiancontext. Assuming no benefitsfrom IPS otherthanemploymentitselftheyconclude:<br />Implementing IPS for those not currently receiving any VR services would cost A$10.3 million (95% confidence interval: 7.4 – 13.6)<br />Benefits would be only A$4.7 (95% C.I.: 3.1 – 6.5). <br />Drake et al. (09) use a modeling approach for US context. They estimate that widespread implementation of IPS in US would increase personal incomes by $1.6 billion, but taking SE program costs into account ( and modest $5,000 per year savings in healthcare costs for a subgroup) net government savings are reduced to $368 million. <br />Cost-effec/CB studies <br />
    41. 41. Modulators of effectiveness and/or cost-effectiveness<br />Client characteristics?<br />Program fidelity<br />Unemployment rate<br />‘Benefitstrap’<br />
    42. 42. Client characteristics and cost-effectiveness<br />Clients who are more actively interested in working more likely to do well in supported employment (Alverson et al. 06; Campbell et al. 10)<br />Recent meta-analysis suggests that given access to high-fidelity SE, this and to small extent receiving SSI are about only factor that matters (Campbell 10)<br />Additional support for offering SE to thosewhosaytheywant to work – akin to offering cancer treatment<br />Modualtorsof (cost-) effectiveness<br />
    43. 43. Greater fidelity more competitive work<br />Several studies examine link between fidelity and outcomes<br />1 study in US Veterans Administration system finds mixed evidence, but implementation not well carried out (Rosenheck et al. 07)<br />4 other studies find significant association (Becker et al. 01, 06; McGrew et al. 05; Burns et al. 07)<br />Cost of high-fidelityimplementation not documented, but likely to bemodest<br />If so, higherfidelitycouldprove more cost-effective<br /> Modulators of (cost-) effectiveness<br />
    44. 44. SE and the unemployment rate<br />Recent studies suggest that higher unemployment rates in the overall economy make it more difficult to achieve high employment rates for SE clients (Becker et al. 06; Burns et al. 07)<br />Thus SE likely to be more cost-effective whereunemployment rates are lower<br />Modulators of (cost-) effectiveness<br />
    45. 45. SE and the “benefits trap”<br />EQOLISE study finds that where the penalty (in terms of lost benefits and/or income) from working is greater, it is harder to motivate clients to work<br />Challenge is to design benefit systems for disabled that are equitable overall, yet provide net incentive to work<br />Protect health and other benefits over a long period of time (48 months of continuous employment in Quebec, Canada)<br />Allow a portion of earned income to be kept - as in current proposed reforms in UK<br />Modulators of (cost-) effectiveness<br />
    46. 46. Conclusions<br />Many people with severe mental illness desire help in finding competitivework and this is preferred on grounds of social inclusion<br />Supported employment is more effective than known alternatives at attaining this goal<br />Short-term benefits in self-esteem, quality of life not demonstrated but some evidence of long-term benefits for those who become steady workers - at least 1/3 of clients<br />A similar result appears to obtain with regards to health care cost offsets – can be significant for those who become steady workers<br />More work needed to explore long-term cost-effectiveness – implications of persistence of IPS effects<br />

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