Is IPS value for money? Research update, Eric Latimer

Is IPS value for money? Research

update

Eric Latimer, Ph.D. Douglas Mental Health

University Institute McGill University

Montreal, Canada

Evidence-Based Supported Employment ConferenceDexter House, London, England

March 3 2011

£

Overview of presentation

• Methods• What can it mean to say that IPS is value for money?

– Department of Health perspective• Benefits to IPS participants• IPS program costs• Healthcare cost offsets

– Government perspective• Effects on tax revenues• Effects on government benefits

– Societal perspective• Effects on value of economic production

• Factors that influence cost-effectiveness of IPS• Conclusions

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

* Remaining errors are my own!

What can it mean to say that IPS is value for money?

What can it mean to say that IPS is value for money?

a) IPS generates significant health/QOL benefits at reasonable cost to NHS / D of H

b) IPS generates so much savings in health and social care costs that the net cost to D of H is almost 0 (or almost)

c) IPS programs result in such large reductions in benefits payments and increases in tax revenues that they are cost-neutral for the government (or almost so)

d) IPS generates so much economic production through people returning to work that society is better off with IPS programs (or almost so)

e) A combination of some or all of the above

IPS program costsOther health and social care costs

Other government-borne personal services (e.g., prisons)

Tax revenues

Personal income/wages

Government-borne disability benefit payments

Department of Health perspective



Tax revenues



Government perspective



Tax revenues



Societal perspective



Tax revenues




Transfer payments – no resources added or lost beyond administrative expenses

Department of Health perspective

Percentages of clients who obtained a competitive job, experimental studies, IPS and pre-IPS

SE or pre-IPS

(Adapted from Gary Bond)94

NY

(SE)

95 IN

(SE)

00 N

Y (S

E)97

CA

(SE)

96 N

H (IP

S)07

IL (I

PS)

04 C

T (IP

S)08

HK

(IPS)

07 A

US (I

PS)

06 S

C (IP

S)99

DC

(IPS)

08 C

A (IP

S)07

EUR

(IPS

)09

HK

(IPS)

06 C

AN (I

PS)

02 M

D (IP

S)09

UK

(IPS)

09 H

K (IP

S+)

0

10

20

30

40

50

60

70

80

90

IPS or SEControl

IPS + SST

Salyers et al. 04 Becker et al. 07

Sample NH pre-post study (94 & 96)

NH randomized trial (96)

Original subjects found & recruited for follow-up

36/68 (52%) 38/78 (49%)

Worked during follow-up (8 to 12 years)

33/36 (92%) 38/38 (100%)

% of jobs that were comp. 70% 78%

Received supported employment during follow-up

“Large majority involved in MH program

emphasizing SE over many years”

14/38 (37%) receiving SE at follow-up, 4 other VR

services, 20 no employment services

Duration of employment Avg duration of most recent job: 32 months

Median between ½ and ¾ of the time

Hours per week Avg hours per week of most recent job: 14.4

Median between 11 and 20 hrs/wk

Long-term vocational outcomes of IPS

$0

$500

$1,000

$1,500

$2,000

$2,500

IN 95(SE)

NH 96(IPS)

DC 99(IPS)

CT 04(IPS)

HK 08(IPS)

SC 06(IPS)

CAN06

(IPS)

RI 01(IPS)

Ear

nin

gs

per

clie

nt

per

yea

r

SE or IPS

Control/comp

Competitive earnings per client per year, SE or IPS vs control/comparison groups

Non-RCT designn.s.

p<0.05

medians

p<0.001 except where otherwise indicated

Typical increase in competitive earnings of about $500 - $1,500

Being in IPS per se does not seem to improve non-vocational outcomes in short term, on average, but working does

IPSSome work a good bit

Some work little or not at all

Higher income, non-vocational benefits

No such benefits

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)

Health care cost offsets

1. Other vocational rehabilitation services2. IPS vs other services

Hospitalization: Use and costsOther services: Use and costsOverall costs

3. Workers vs non workers (5 studies)

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$8,000

$9,000

$10,000

IN 95 (SE) NH 96(IPS)

CA 97(SE)

DC 99(IPS)

NH 94(IPS)

NH 96(IPS)

Study

Co

st p

er p

erso

n p

er y

ear

SE or IPS

Control

Costs of SE/IPS Programs vs Control or Comparison Vocational Programs

Pre-post studies (not RCTs)

n.s.Not tested

Not tested

n.s.

(Differences not tested)

Location

Authors and year

Reported differences concerning hospitalisations

IN Bond, Dietzen et al. (95a & 95b)

Accelerated approach : 0,32 admissions and 5.8 days per client per year, Usual care: 0,28 admissions and 5,3 days per client per year(n.s.)

DC Drake et al.99 ; Dixon et al. 02

IPS: 30.3 to 20,9 days per client per year; PSR: 17.4 to 12,1 (difference in differences not significant)

NY McFarlane et al. 00

Statistically significant reduction in both groups, combining groups 0.48 to 0.32 admissions per client per year (no stat. significant difference between groups)

EUR Burns et al. 07 Percent clients admitted : 20% (IPS) vs. 31% (Difference : -11.2%, C.I. : -21,5 – -0,9)Percent time spent in hospital : 4.6% (IPS) vs 8.9% (Difference : -4.3%, C.I : -8,4 – -0,6)(Fewer admissions and days with IPS)

Effects of IPS (or SE) on hospital use – from RCTs

Loca tion

Authors and year


NH Drake, Becker et al., 94; Clark et al., 96

Admissions : 28.2% (IPS) vs 25% (ns); LOS : drop from 2.63 to 2.00 (after IPS) vs increase from 20.04 to 24.81 (continued day treatment) (not tested)

NH Drake, Becker et al., 96; Clark et al., 96

Admissions : drop from 25% to 14,3% (after IPS) (p <0,025) LOS : drop from 24.81 to 23,68 after IPS (not tested) → Drop in admissions following IPS

NH Bailey et al., 98 Hospital days « did not change » (no numbers given)

RI Becker, Bond et al., 01

Admissions : Drop from 16.4% to 9.6% (after IPS), vs. 26.8% to 22% (program x time interaction not significant)

MA Henry, Lucca et al. 04

Admissions : 0.66 (SE) vs 1.98 (matched controls; LOS same) p=0,0003However SE group had more outpatient MH use at baseline and was higher functioning ; additional analyses suggest SE reduces hospitalisations among people with higher outpatient mental health svc use (p=0.05 for interaction)

Effects of IPS (or SE) on hospital use –studies with non-RCT designs

$0

$2,000

$4,000

$6,000

$8,000

$10,000

$12,000

$14,000

$16,000

NH 96 (IPS) DC 99 (IPS) NH 94 (IPS) NH 96 (IPS)

Study

Co

st p

er c

lien

t p

er y

ear

SE or IPS

Control

Costs of hospitalisations: IPS vs control or comparison condition

Pre-post comparisons (not tested)

n.s.

n.s.

Location

Authors and year

Reported differences concerning other mental health service use

DC Lehman et al 02 (RCT)

No difference in proportions receiving other clinical MH services

NH Drake et al 94; Clark et al 96

EM/Crisis hours: 1.2 to 1.4 after IPS, vs 1.7 to 1.7CM + Outpatient hours: 57 to 88 after IPS, vs 67 to 85→ No evidence of effect

NH Drake et al 96; Clark et al 96

EM/Crisis hours: 1.7 to 1.9 after IPS, vs 1.4 to 1.1 CM + Outpatient hours: 85 to 124 after IPS, vs 88 to 90→ No evidence of effect

NH Bailey et al 98 EM/Crisis and outpatient svc use “did not change”

MA Henry et al 04 EM Visits : Highly significant interaction (p=0,003) with use of MH services: 2,24 (IPS) vs 0,66 for low users, 0,36 vs 3,55 for high users

IN Perkins et al. 05

Lower use of MH services associated with receiving SE services (see graph)

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

Costs of emergency, case management and out-patient services, SE or IPS vs control/ comparison

$0

$2,000

$4,000

$6,000

$8,000

$10,000

$12,000

IN 95 (SE) NH 96 (IPS) DC 99 (IPS) NH 94 (IPS) NH 96 (IPS)

Co

st p

er c

lien

t p

er y

ear

SE or IPS

Control/comp.

n.s.

n.s.

Not tested


TOTAL (mental health + VR) costs, SE or IPS vs control or comparison group


Not tested

n.s.

n.s.

n.s.

Hosp. costs not

included

$0

$5,000

$10,000

$15,000

$20,000

$25,000

$30,000

$35,000

$40,000

$45,000

IN 95(SE)

NH 96(IPS)

DC 99(IPS)

HK 05(IPS)

NH 94(IPS)

NH 96(IPS)

Co

st p

er c

lien

t p

er y

ear

SE or IPS

Control/comp

Workers vs non-workers

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)

0

10

20

30

40

50

60

70

80

Pre-S

E

Job

sear

ch

Stable

em

pl.

Inte

rrupt

ed

Close

d

Stage

Ho

urs

per

mo

nth

Hours of work

Hours receiving MH services

Overall service costs (VR + MH) by stage with respect to SE services

(1997 to 2001 Indiana data, N=2,998, Perkins et al. 05)

$0

$200

$400

$600

$800

$1,000

$1,200

$1,400

Pre-SE Job search Stable empl. Interrupted Closed

Stage

Co

st o

f V

R+

MH

ser

vice

s

*Some longer hospitalisations may be missed

Loca- tion

Authors and year


NH Becker et al. (07)

« A large majority reported that they went to the hospital less often when they were working » (p. 925)

NH Salyers et al. (04)

39% reported that they went to the hospital less because of working (42% same – more n.s.) (p. 305)

Effects of working on hospital use –long-term retrospective studies

Costs 3-0 months before and 9-12 months after entry into supported employment,

by work status

Schneider, Boyce et al. (2009)

N=77N=32

N=32(Subset of all health and social care input)

Long-term effects of working – qualitative reports – NH dually-disordered clients

• For those who did work – “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)

10-year follow-up of dually-disordered clients in NH: Hours of work

Source: Bush et al. 2009

10-year follow-up of dually-disordered clients in NH: Cost trends by work involvement

Source: Bush et al. 2009

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

IPSMore people work more

Some work little or not at all

Lower healthcare costs

No such benefits

Government perspective

$0

$500

$1,000

$1,500

$2,000

$2,500

IN 95(SE)

NH 96(IPS)

DC 99(IPS)

CT 04(IPS)

HK 08(IPS)

SC 06(IPS)

CAN06

(IPS)

RI 01(IPS)

Ear

nin

gs

per

clie

nt

per

yea

r

SE or IPS

Control/comp


$251 reduction in welfare payments, and $125 increase in taxes paid (only study with such results)


$0

$500

$1,000

$1,500

$2,000

$2,500

IN 95(SE)

NH 96(IPS)

DC 99(IPS)

CT 04(IPS)

HK 08(IPS)

SC 06(IPS)

CAN06

(IPS)

RI 01(IPS)

Ear

nin

gs

per

clie

nt

per

yea

r

SE or IPS

Control/comp


Non-RCT designn.s.

p<0.05

medians

p<0.001 except where otherwise indicated

Typical increase in competitive earnings of about $500 - $1,500

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

Modulators of effectiveness and/or cost-effectiveness

– Client characteristics?– Program fidelity – Unemployment rate– ‘Benefits trap’

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 those who say they want to work – akin to offering cancer treatment

M

odua

ltors

of (

cost

-) e

ffecti

vene

ss

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-fidelity implementation not documented, but likely to be modest – If so, higher fidelity could prove more cost-effective

Mod

ulat

ors

of (c

ost-

) effe

ctive

ness

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 where unemployment rates are lower

M

odul

ator

s of

(cos

t-) e

ffecti

vene

ss

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

M

odul

ator

s of

(cos

t-) e

ffecti

vene

ss

Conclusions• Many people with severe mental illness desire help in finding

competitive work 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

Health & Medicine

Is IPS value for money? Research update, Eric Latimer