Moving Health "Upstream": Getting More from Return-on-Investment Evidence

Is government spending on public health a good financial investment, or a drain on civic budgets?  Can health plans and businesses reap financial returns on investments in cross-sector collaboration, or should resulting health gains simply be considered a contribution to the communities in which they operate?  Moving the health system “upstream” requires answers, but emerging evidence may not be having maximum impact.

Evidence is Growing, but Impact is Lacking

Evidence of economic return on investment (ROI) for public health spending is an important adjunct to advocacy based on health outcomes and equity, and the move toward value-based purchasing in health care requires a “business case” for addressing patient-specific needs for social supports.  Broader investments in addressing social and economic determinants, including through multi-sector partnerships, are also advanced by evidence that they reduce costs and improve health outcomes.

Evidence is growing on multiple fronts:

• A recent AcademyHealth study concluded that higher total public health spending is associated with better health outcomes – often with returns to society that exceed initial financial investments.
• The clinical care system is turning to evidence compiled and disseminated by the Social Interventions Research and Evaluation Network (SIREN) at UCSF, and others, to address health-related social risks of their patients.
• Federal and state programs (Medicare Advantage, Medicaid managed care, accountable health plans) are responding to emerging evidence through waivers and program guidance as well as providing new opportunities for expanding the evidence base on the financial and health impact of steps both inside and outside the clinical setting.

But is this emerging evidence making as much of a difference as it should? 

Three Common Characteristics Among those Using ROI-Related Evidence

To find out, I joined colleagues at AcademyHealth in an exploration of how ROI and related evidence is used in “real world” public and private decision-making.  We searched the literature and interviewed experts across a broad spectrum including public health, research, health systems, government, and the private sector to identify what we missed, and to better understand limitations and inhibitions on using ROI-related evidence. (See our full report, “How Evidence Drives Policy Change: A Study of Return on Investment in Public Health and Multi-Sector Collaborations.”)

We found published examples where ROI-related evidence was being used to guide decision-making, and found common characteristics among those making direct use of ROI-related evidence: 

1. Empowerment.  Those with existing legal and administrative authority are better positioned to act on evidence than those who might use evidence in support of new legislative or regulatory authority.  Private sector decision-makers may lack legislative constraints but similarly work within degrees of freedom dictated by contracts or funding agreements. 
2. Capital.  Access to investment capital, or control of large enough budgets to consider tradeoffs, is a key factor as even compelling evidence of returns is irrelevant to decision-makers without the means to invest. 
3. Expertise.  In-house expertise, or access to consultants, is important to identifying and customizing evidence relevant to pending decisions. 

These commonalities suggest that researchers can more effectively target evidence to willing decision-makers, and also learn more about the real-world decisions they face to design studies more effectively.

Barriers to Use of Evidence Range from the Philosophical to the Practical

Overall, though, we were underwhelmed by the volume of what we found, and it’s hard to escape the impression that ROI hasn’t taken hold as a force in advocacy or decision-making in public and population health.  Our interviews led us to several possible explanations:

• Advocates are reluctant to “monetize” public health and fear that focusing on “business cases” could distort priorities by emphasizing short-run savings over steps that tackle more fundamental social and economic determinants of health.

• Evidence may not overcome ideology or constituent interests of appropriators and other budget decision-makers, and some may be dubious of projected budget savings or simply fatigued by demands for any new funding, regardless of the justification.
• Many public health investments are limited by the “wrong pocket” problem – investments sometimes come from limited discretionary public health appropriations, while savings end up in the “pockets” of health systems, businesses, or other agencies. 
• Even the most motivated decision-makers cannot make investments if they lack up-front capital.  Most public agencies lack flexibility in their appropriations, so even if long-term returns can be demonstrated they are often unable to free up initial investments.  Private organizations that lack access to capital are similarly limited.
• Many agencies and organizations lack access to current research, have limited insight into how others have used evidence, and have limited analytic ability to adapt available information to pending decisions.  There are few dedicated forums for users of ROI research, and limited opportunities to share successes or failures.  Public health agencies are unlikely to be able to invest in staff skilled in interpreting ROI research, or to engage consultants; many have only have limited access to professional journals.
• Finally, there is often a mismatch between the specificity of evidence generated by ROI researchers and the real-world decisions faced by public agencies, health plans, and health systems.  For example, policymakers need evidence that can be modeled to the unique aspects of their jurisdiction, and businesses and health plans need to understand the extent to which they can capture returns on their investments.  AcademyHealth’s previous work notes that despite a growing body of evidence it remains uncommon for this work to focus on the preferences or perspectives of specific payers or stakeholders. 

Four Next Steps to Advance the Use of ROI-Related Evidence

Decisions on public funding for public health continue to need strong justification, and the growing range of public and private decisions on health care, social services, and other partnerships point to a continuing need to join public and population health advocacy with evidence of economic returns.  So how can we advance this work?  Our interviews with experts helped identify several steps that can help:

1. Create forums and mechanisms for researchers and decision-makers to collaborate in ROI research priority setting.  Better connections between sources and uses of evidence can help ensure that research is relevant and actionable.
2. Improve access, visibility, and delivery of evidence to lower the cost of finding and applying relevant information.  Communities of practice and stronger academic-public health partnerships, for example, can help link users aspiring to pursue investments with those who have successfully found resources and strategies to pursue them.  
3. Broaden efforts to identify and share real-world applications of ROI-related research – promoting the sharing of case studies of uses of evidence in order to demonstrate the relevance of ROI to multiple decisions and partnerships.
4. Reinforce efforts to help researchers translate their work and maximize its usefulness in policy and practice contexts.  This starts with designing studies that address real-world decisions and continues throughout the cycle to ensure that results are written to highlight real-world applications, placed in appropriate channels to get attention from key audiences, and amplified over time as evidence is used in decision-making.

To advocates of “upstream” population health, public health remains chronically underfunded and underappreciated, and health systems don’t fully embrace steps that can save money and improve health outcomes.  New partners and a stronger “business case” for investments in public health and upstream health initiatives can help change this reality.  Additional steps can help bridge the gap between emerging evidence of returns on “upstream” investments and real-world decision-making.