In a recent Health Affairs Blog post titled “Project ECHO: Enthusiasm Overtakes Evidence,” Christopher Langston questions the value of investing in Project ECHO® (Extension for Community Healthcare Outcomes), a technology-enabled collaborative learning model originally developed by Sanjeev Arora, a physician at the University of New Mexico, to train primary care clinicians in rural communities to treat patients with hepatitis C virus (HCV) infection.
Over the past few years, an increasing number of philanthropic organizations (the New York State Health Foundation, GE Foundation, Greater Rochester Health Foundation, Health Foundation for Western and Central New York, Robert Wood Johnson Foundation, Leona M. and Harry B. Helmsley Charitable Trust, and others) have invested resources to support the development of new Project ECHO programs—and their evaluation—in other health care delivery settings and for different health conditions.
The interest in telementoring programs such as Project ECHO has grown to the point that, on December 14, 2016, former President Barack Obama signed into law the Expanding Capacity for Health Outcomes (ECHO) Act. The ECHO Act calls for “studies and reports examining the use of, and opportunities to use, technology-enabled collaborative learning and capacity building models to improve programs of the Department of Health and Human Services (DHHS), and for other purposes.” The new law requires the department to examine how technology-enabled collaborative learning models could be used to address health care challenges such as how best to deliver complex specialty care, tackle health care workforce issues, and provide access to health care programs and services in rural and/or medically underserved areas. The ECHO Act emphasizes the assessment of the potential benefits of such models and the development of recommendations to define their use, rather than the allocation of specific resources for new programs.
Langston expresses skepticism about the effectiveness and generalizability of Project ECHO. His concerns include limitations in the evidence base for the model, challenges inherent in incorporating it into the current fee-for-service health system, and the fact that the model is likely to function differently depending on the targeted condition and the community being served.
Reasons To Be Cautiously Enthusiastic
While Langston raises some valid concerns, we are more optimistic about the potential of Project ECHO. A prospective cohort study published in 2011 in the New England Journal of Medicine found that patients treated for HCV by ECHO-participating primary care clinicians in New Mexico fared better than those who were treated at the University of New Mexico’s HCV clinic. Since then, ECHO programs have been implemented in more than thirty states and eighteen countries. Health care interventions are unlikely to have grown in the way that Project ECHO has over the past few years if they did not offer at least some value.
Our own experience implementing and evaluating Project ECHO GEMH, a program focused on geriatric mental health care, suggests that technology-enabled collaborative learning models can enhance the capacity of the health care workforce while improving health care access and delivery. Preliminary findings from our evaluation of Project ECHO GEMH—which connected a multidisciplinary team of specialists (medicine including geriatric psychiatry, nursing, social work, psychology, and pharmacy) to fifty-four primary care practices and case management sites in ten counties in the state of New York between 2014 and 2016—suggest that Project ECHO GEMH led to substantial improvements in geriatric mental health care knowledge and treatment practices among the physicians, nurse practitioners, and social workers participating in the program. Moreover, health insurance claims data available for patients six months before and six months after the sites started participating in the program point to reductions in emergency department visits for patients with mental health diagnoses, and, generally, a more efficient utilization of the health care delivery system.
Also telling is the fact that health professionals spearheading different ECHO programs across the United States and abroad are implementing the model to address obvious health gaps in their communities, and they have done so with few resources. Compared with other efforts to transform pieces of the delivery system, Project ECHO implementations are relatively inexpensive. The average cost of implementing an ECHO program is around $200,000 per year—much less on a per capita basis than, for example, care coordination models that can only reach the patient population targeted by individual health care providers and that do not have the added benefit of building a collaborative learning environment for ongoing education and mentorship in geographic areas that are traditionally underserved by the health care system.
The experience of Project ECHO GEMH and other Project ECHO programs across the country and abroad suggest that greater support, and not less, is needed to evaluate whether technology-enabled collaborative learning models can improve workforce capacity, increase health care access and quality, and reduce costs. Ongoing and increased investment in high-quality demonstration projects and evaluations is essential to learning more about the conditions under which this promising model works and fails, and about its potential for improving health care delivery and health outcomes.
Showing The Value of Project ECHO
Still, it is one thing to assume there is value, and another to actually show value—which, ironically, can be difficult to do for many Project ECHO implementers because of their limited resources for program implementation and evaluation activities. Demonstrating and proving the value of the program is essential if it is to continue growing, and it will be increasingly important as the health system continues to shift from fee-for-service to value-based care. In general, programs operating in a value-based system will be judged on whether they improve quality of care (and health outcomes) as well as reduce per capita costs (or are at least cost neutral).
Project ECHO and similar models are low cost and have the potential to achieve both of these goals, and only modest improvements in key health care utilization indicators are needed to demonstrate this value. For argument’s sake, suppose that we implement a particular ECHO program for a given health condition at a cost of $250,000 per year—a figure higher than the average cost of ECHO programs. Assume that thirty-five primary care practices with 1,000 patients each participate in this ECHO program with the goal of reducing hospital admissions by just 1 percent per year. If hospitalizations per patient decrease from .318 one year before implementation to .315 one year after implementation, and each hospitalization costs $10,000, then the health system would save about $1.1 million because of the program. This means that for every dollar spent on this ECHO program, the health system would save $4.45 in hospitalization costs alone. Clearly, the upside of this specific hypothetical ECHO implementation, if we were able to rigorously show that it reduces hospitalizations, would be very large.
Benefits Beyond Health Care Cost Reductions
The example above is undoubtedly an oversimplification and, in fact, it is entirely possible that some Project ECHO programs could lead to higher health care costs by providing care to people who otherwise would have forgone treatment. However, preliminary evidence suggests that there are benefits beyond reductions in such costs.
At the patient level, evaluation findings indicate that the model has the potential to improve access to and quality of care while reducing costs (direct and indirect) related to traveling for care. At the practice level, the model has been shown to improve professional satisfaction and reduce isolation among providers while fostering an interdisciplinary approach to care not often seen or encouraged in our current health care delivery system. These findings are vitally important as rising expectations of primary care providers (PCPs) related to new health care initiatives increase the risk of job dissatisfaction and burnout. It has been estimated that family medicine physician turnover costs nearly $250,000 per physician (and likely costs even more now). That is financially unsustainable for a small primary care practice. Improving the work life of those who deliver care through participation in Project ECHO might overcome the “substantial costs in expert and PCP time” to which blogger Chris Langston refers.
Where There’s Smoke, There’s Fire
As Langston notes, Project ECHO is not a “silver bullet” that can fix all of the problems with our health care delivery system—indeed, it is unlikely that any program can do so. However, early evidence and consistent enthusiasm for Project ECHO among those implementing and participating in it—together with the interest of government agencies and philanthropic organizations that are now funding ongoing, more rigorous evaluations and even an evaluation toolkit for programs with limited resources—means that it would be wiser to try to understand the value of Project ECHO rather than to simply disregard its potential.