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

1. Is IPS value for money? Researchupdate Eric Latimer, Ph.D. Douglas Mental Health University Institute McGill University Montreal, Canada Evidence-BasedSupportedEmployment Conference Dexter House, London, England March 3 2011 £

2. Overview of presentation Methods Whatcanitmean to saythat IPS is value for money? Department of Health perspective Benefits to IPS participants IPS program costs Healthcarecost offsets Government perspective Effects on tax revenues Effects on governmentbenefits Societal perspective Effects on value of economic production Factorsthatinfluence cost-effectiveness of IPS Conclusions

3. Based on (attempted!) exhaustive literaturereview, with input from Gary Bond, Bob Drake – and insights gained from many others in U.S., Canada and U.K.* * Remainingerrors are myown!

4. Whatcanitmean to saythat IPS is value for money?

5. Whatcanitmean to saythat IPS is value for money? IPS generatessignificanthealth/QOL benefitsatreasonablecost to NHS / D of H IPS generatessomuchsavings in health and social care coststhat the net cost to D of H isalmost 0 (or almost) IPS programs result in such large reductions in benefitspayments and increases in tax revenues thatthey are cost-neutral for the government (or almostso) IPS generatessomucheconomic production through people returning to workthatsociety isbetter off with IPS programs (or almostso) A combination of some or all of the above

6. Department of Health perspective IPS program costs Otherhealth and social care costs Othergovernment-borne personal services (e.g., prisons) Personalincome/wages Tax revenues Government-borne disabilitybenefitpayments

7. Government perspective IPS program costs Otherhealth and social care costs Othergovernment-borne personal services (e.g., prisons) Personalincome/wages Tax revenues Government-borne disabilitybenefitpayments

8. Societal perspective IPS program costs Otherhealth and social care costs Othergovernment-borne personal services (e.g., prisons) Personalincome/wages Tax revenues Government-borne disabilitybenefitpayments

9. Societal perspective IPS program costs Otherhealth and social care costs Othergovernment-borne personal services (e.g., prisons) Personalincome/wages Tax revenues Transfer payments – no resourcesadded or lostbeyond administrative expenses Government-borne disabilitybenefitpayments

10. Department of Health perspective

11. Percentages of clients whoobtained a competitive job, experimentalstudies, IPS and pre-IPS SE or pre-IPS (Adapted from Gary Bond)

12. Long-term vocational outcomes of IPS

13. Competitive earnings per client per year, SE or IPS vs control/comparison groups Typical increase in competitive earnings of about $500 - $1,500 p<0.05 medians n.s. Non-RCT design p<0.001 except where otherwise indicated

14. Being in IPS per se does not seem to improve non-vocational outcomes in short term, on average, but working does Higherincome, non-vocationalbenefits Somework a good bit IPS Someworklittle or not at all No suchbenefits

15. How much does an SE program cost? Approximate rule of thumb (based on US cost structure): Cost per active place = (Compensation of ES/18)*1.37 Example (Community OT compensation plus oncosts)): Compensation = £ 37,000 Then C = (37,000/18) * 1.37 ≈ £ 2,800 10 active places mean 18 clients get service in a year, on average (based on US experience)

16. How much does an SE program cost? Large-scale Indiana study reports, using charges to Medicaid: Thosewhowork: Median : 3.2 months of job development, 4 hours per month, $480 Median: 6 months of work, 8 hours per month of support, $1,800 Total: $2,280 to support an episode of SE taking 9.2 months. Those who don’t end up working: Median : 7.5 months in program, 2.3hours per month, $675. (Perkins et al. 05)

17. Health care cost offsets 1. Othervocationalrehabilitation services 2. IPS vs other services Hospitalization: Use and costs Other services: Use and costs Overallcosts 3. Workers vs non workers (5 studies)

18. Costs of SE/IPS Programs vs Control or ComparisonVocational Programs Pre-post studies (not RCTs) n.s. (Differences not tested) Not tested Not tested n.s.

19. Effects of IPS (or SE) on hospital use – fromRCTs

20. Effects of IPS (or SE) on hospital use –studieswith non-RCT designs

21. Costs of hospitalisations: IPS vs control or comparison condition Pre-post comparisons (not tested) n.s. n.s.

22. IPS and Emergency/Crisis services, case management and outpatient services (RCTs and other designs)

23. Costs of emergency, case management and out-patient services, SE or IPS vs control/ comparison Pre-post comparisons (not tested) n.s. n.s. Not tested

24. TOTAL (mental health + VR) costs, SE or IPS vs control or comparison group n.s. Pre-post comparisons (not tested) n.s. Hosp. costs not included n.s. Not tested

25. Workers vs non-workers

26. Hours of work and hours receiving MH (non-VR) services, by stage with respect to receipt of SE services (1997 to 2001 Indiana data, N=2,998, Perkins et al. 05)

27. Overall service costs (VR + MH) by stage with respect to SE services (1997 to 2001 Indiana data, N=2,998, Perkins et al. 05) *Some longer hospitalisations may be missed

28. Effects of working on hospital use –long-termretrospectivestudies

29. Costs 3-0 monthsbefore and 9-12 monthsafter entry intosupportedemployment, by workstatus (Subset of all health and social care input) N=77 N=32 N=32 Schneider, Boyce et al. (2009)

30. Long-termeffects of working – qualitative reports – NH dually-disordered clients For thosewhodidwork – “the business and structure of work also tended to diminish the salience of symptoms” (p. 264) “Working or not working appeared to be reinforcing over time” (p. 266) (Strickler et al. 2009)

31. 10-yearfollow-up of dually-disordered clients in NH: Hours of work Source: Bush et al. 2009

32. 10-yearfollow-up of dually-disordered clients in NH: Cost trends by workinvolvement Source: Bush et al. 2009

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 Lowerhealthcarecosts More people work more IPS Someworklittle or not at all No suchbenefits

34. Government perspective

35. Competitive earnings per client per year, SE or IPS vs control/comparison groups $251 reduction in welfare payments, and $125 increase in taxes paid (only study with such results)

36. Societal perspective

37. Competitive earnings per client per year, SE or IPS vs control/comparison groups Typical increase in competitive earnings of about $500 - $1,500 p<0.05 medians n.s. Non-RCT design p<0.001 except where otherwise indicated

38. Summing up this part of presentation Department of Health perspective: IPS helps more people enter into competitive jobs than other vocational services – and this is what we favour In US, increases in personal income are modest on average Those who do work experience improvements in self-esteem and better symptom management, satisfaction with income IPS can replace equally costly traditional services Evidence is growing that those who enter into work and become steady workers tend to reduce their use of mental health services Data suggest a good investment from D of H perspective but no QALY data Government perspective Almost no evidence, but earnings are low on average thus impacts on benefits and taxes may be small (US-dependent?) Societal perspective Increases in economic production modest on average

39. Studies that have looked at cost-effectiveness of IPS No study appears to have used a measure such as QALYs Dixon, Hoch et al. (02) calculated (based on DC 99 trial) that one extra hour of competitive employment cost $13 (in 1995 US$) 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 Cost-effec./CB studies

40. Studies that have looked at cost-benefit of IPS Clark et al. (98) using NH 96 RCT data, find no significantoveralldifference in net economicbenefit Emergedfromearlier graphs Chalamat et al. (05) use a modelingapproachadapted to Australiancontext. Assuming no benefitsfrom IPS otherthanemploymentitselftheyconclude: Implementing IPS for those not currently receiving any VR services would cost A$10.3 million (95% confidence interval: 7.4 – 13.6) Benefits would be only A$4.7 (95% C.I.: 3.1 – 6.5). 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. Cost-effec/CB studies

41. Modulators of effectiveness and/or cost-effectiveness Client characteristics? Program fidelity Unemployment rate ‘Benefitstrap’

42. Client characteristics and cost-effectiveness Clients who are more actively interested in working more likely to do well in supported employment (Alverson et al. 06; Campbell et al. 10) 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) Additional support for offering SE to thosewhosaytheywant to work – akin to offering cancer treatment Modualtorsof (cost-) effectiveness

43. Greater fidelity more competitive work Several studies examine link between fidelity and outcomes 1 study in US Veterans Administration system finds mixed evidence, but implementation not well carried out (Rosenheck et al. 07) 4 other studies find significant association (Becker et al. 01, 06; McGrew et al. 05; Burns et al. 07) Cost of high-fidelityimplementation not documented, but likely to bemodest If so, higherfidelitycouldprove more cost-effective Modulators of (cost-) effectiveness

44. SE and the unemployment rate 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) Thus SE likely to be more cost-effective whereunemployment rates are lower Modulators of (cost-) effectiveness

45. SE and the “benefits trap” 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 Challenge is to design benefit systems for disabled that are equitable overall, yet provide net incentive to work Protect health and other benefits over a long period of time (48 months of continuous employment in Quebec, Canada) Allow a portion of earned income to be kept - as in current proposed reforms in UK Modulators of (cost-) effectiveness

46. Conclusions Many people with severe mental illness desire help in finding competitivework and this is preferred on grounds of social inclusion Supported employment is more effective than known alternatives at attaining this goal 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 A similar result appears to obtain with regards to health care cost offsets – can be significant for those who become steady workers More work needed to explore long-term cost-effectiveness – implications of persistence of IPS effects