Introduction 1 2 This paper discusses the potential economic benefits of preconception care due to the prevention of adverse pregnancy outcomes with a focus on the data that would be needed to assess costs and benefits. Currently, the needed data and analyses are largely lacking. In the absence of information about the costs and benefits of comprehensive preconception care, which should ideally include nutritional counseling, evaluation of medications, and family history evaluation and genetic counseling, this paper focuses on principles and methods. Three published studies have analyzed the expected financial benefits from counseling women with diabetes prior to pregnancy. These studies are compared and lessons drawn, with discussion of implications of preconception care for women with other conditions. In order to argue that preconception care is a “good buy,” its costs and benefits must be assessed from the perspectives of a variety of stakeholders involved in health care services. This paper will first define a “business case” analysis and outline the methods for determining the “return on investment” from the perspective of various health care organizations. Similarities and differences between such an analysis and a standard cost-effectiveness analyses that calculate returns to the health care system as a whole or to society will be explained. Second, the paper reviews the literature on business case analyses from areas other than preconception care. Third, the paper discusses what data sources are available and needed to apply business case methods in preconception care with particular focus on women with diabetes. Finally, the paper draws conclusions about future steps needed to assess the business case for preconception care. What is a business case analysis? Concepts and definitions business case 3 budget impact analysis 4 3 business case payers purchasers providers 3 Although business case analyses by definition focus on businesses, they are relevant to other stakeholders as well. In particular, the consumer perspective is also important to keep in mind. If consumers do not consider a service such as preconception care to provide good value for their investment of time and money, low demand and utilization could render the business case unfavorable. Further, government agencies must meet budgets, and the short term financial impact of policy changes may influence funding decisions. In the long run, though, public health programs are expected to optimize population health subject to resource availability, which requires analysis of both short-term and long-term health outcomes and economic consequences. Analytical techniques and outcome measures cost-effectiveness cost-benefit 5 6 7 A financial analysis of a business case can be viewed as a CBA conducted from the perspective of an individual firm or organization. One important distinction between financial analyses and standard economic evaluations is that the latter are supposed to reflect the opportunity cost or value of resources from a societal perspective whereas a financial analysis considers the direct monetary or budgetary impact to a specific organization. 8 9 Time horizon and discount rate 3 10 11 9 5 Prospective and retrospective evaluations prospective 12 13 14 16 17 18 19 20 retrospective ex post 21 Lessons from business case literature 8 22 23 24 22 10 3 3 25 3 3 25 26 29 28 27 Economic analyses of preconception care Preventive services and screenings offered to women who expect to become pregnant in the near future; Interconception care for women who have given birth and intend to bear another child at some point in the future; Counseling about the impact of pre-existing health risks or conditions for affected women of childbearing age and their impact on pregnancy outcomes. 30 31 32 31 33 34 35 37 35 36 37 Discussion 35 37 38 39 all 40 41 32 42 Better data are needed to establish the business case for preconception care. Although benefits of preconception care can be projected, data derived from the evaluation of actual preconception care initiatives are needed to make a compelling business case. Further, observational data comparing pregnancy outcomes among women who choose to use preconception care and those who do not are subject to biases due to non-randomized study design. A business case analysis of interventions with both demonstrated efficacy (works if followed) and effectiveness (behaviors are actually changed and lead to improved outcomes) is likely to be more persuasive. In order to develop a compelling business case for preconception care, studies of preconception care interventions accompanied by rigorous evaluations with randomized or matched groups of controls are required. 24 Conclusion and the way forward Research demonstrating the effectiveness and financial returns to investments in preconception care is necessary to make a financial business case for preconception care. In particular, the only economic evaluations that have been published to date have been of specific components of preconception care, such as counseling women with diabetes or promoting preconception use of folic acid supplements. Evaluations of the costs and benefits of different “bundles” of preconception care services or comprehensive preconception care are needed. Further, such evaluations must include payer-specific cost data to be relevant to framing the business case for preconception care. 41 3 24