The contributions of managed care plans to public health practice: evidence from the nation's largest local health departments

Measuring Local Public Health and Primary Care Collaboration: A Practice-Based Research Approach

OBJECTIVE

To describe the degree of public health and primary care collaboration at the local level and develop a model framework of collaboration, the Community Collaboration Health Model (CCHM).

DESIGN

Mixed-methods, cross-sectional surveys, and semistructured, key informant interviews.

SETTING

All local health jurisdictions in Colorado, Minnesota, Washington, and Wisconsin.

PARTICIPANTS

Leaders from each jurisdiction were identified to describe local collaboration. Eighty percent of local health directors completed our survey (n = 193), representing 80% of jurisdictions. The parallel primary care survey had a 31% response rate (n = 128), representing 50% of jurisdictions. Twenty pairs of local health directors and primary care leaders participated in key informant interviews.

MAIN OUTCOME MEASURE(S)

Thirty-seven percent of jurisdictions were classified as having strong foundational and energizing characteristics in the model. Ten percent displayed high energizing/low foundational characteristics, 11% had high foundational/low energizing characteristics, and 42% of jurisdictions were low on both.

RESULTS

Respondents reported wide variation in relationship factors. They generally agreed that foundational characteristics were present in current working relationships but were less likely to agree that relationships had factors promoting sustainability or innovation.

CONCLUSIONS

Both sectors valued working together in principle, yet few did. Identifying shared priorities and achieving tangible benefits may be critical to realizing sustained relationships resulting in population health improvement. Our study reveals broad variation in experiences among local jurisdictions in our sample. Tools, such as the CCHM, and technical assistance may be helpful to support advancing collaboration. Dedicated funding, reimbursement redesign, improved data systems, and data sharing capability are key components of promoting collaboration. Yet, even in the absence of new reimbursement models or funding mechanisms, there are steps leaders can take to build and sustain their relationships. The self-assessment tool and the CCHM can identify opportunities for improving collaboration and link practitioners to strategies.

Identifying Barriers to Collaboration Between Primary Care and Public Health: Experiences at the Local Level

OBJECTIVES

Interest is increasing in collaborations between public health and primary care to address the health of a community. Although the understanding of how these collaborations work is growing, little is known about the barriers facing these partners at the local level. The objective of this study was to identify barriers to collaboration between primary care and public health at the local level in 4 states.

METHODS

The study team, which comprised 12 representatives of Practice-Based Research Networks (networks of practitioners interested in conducting research in practice-based settings), identified 40 key informants from the public health and primary care fields in Colorado, Minnesota, Washington State, and Wisconsin. The key informants participated in standardized, semistructured telephone interviews with 8 study team members in 2014 and 2015. Interviews were audio recorded and transcribed verbatim. We analyzed key themes and subthemes by drawing on grounded theory.

RESULTS

Primary care and public health participants identified similar barriers to collaboration. Barriers at the institutional level included the challenges of the primary care environment, in which providers feel overwhelmed and resources are tight; the need for systems change; a lack of partnership; and geographic challenges. Barriers to collaboration included mutual awareness, communication, data sharing, capacity, lack of resources, and prioritization of resources.

CONCLUSIONS

Some barriers to collaboration (eg, changes to health care billing, demands on provider time) require systems change to overcome, whereas others (eg, a lack of shared priorities and mutual awareness) could be addressed through educational approaches, without adding resources or making a systemic change. Overcoming these common barriers may lead to more effective collaboration.

Hospital Contributions to the Delivery of Public Health Activities in US Metropolitan Areas: National and Longitudinal Trends

OBJECTIVES

We investigated changes in hospital participation in local public health systems and the delivery of public health activities over time and assessed the relationship between hospital participation and the scope of activities available in local public health systems.

METHODS

We used longitudinal observations from the National Longitudinal Survey of Public Health Systems to examine how hospital contributions to the delivery of core public health activities varied in 1998, 2006, and 2012. We then used multivariate regression to assess the relationship between the level of hospital contributions and the overall availability of public health activities in the system.

RESULTS

Hospital participation in public health activities increased from 37% in 1998 to 41% in 2006 and down to 39% in 2012. Regression results indicated a positive association between hospital participation in public health activities and the total availability of public health services in the systems.

CONCLUSIONS

Hospital collaboration does play an important role in the overall availability of public health services in local public health systems. Efforts to increase hospital participation in public health may have a positive impact on the scope of services provided and population health in US communities.

Economic shocks and public health protections in US metropolitan areas

OBJECTIVES

We examined public health system responses to economic shocks using longitudinal observations of public health activities implemented in US metropolitan areas from 1998 to 2012.

METHODS

The National Longitudinal Survey of Public Health Systems collected data on the implementation of 20 core public health activities in a nationally representative cohort of 280 metropolitan areas in 1998, 2006, and 2012. We used generalized estimating equations to estimate how local economic shocks relate to the scope of activities implemented in communities, the mix of organizations performing them, and perceptions of the effectiveness of activities.

RESULTS

Public health activities fell by nearly 5% in the average community between 2006 and 2012, with the bottom quintile of communities losing nearly 25% of their activities. Local public health delivery fell most sharply among communities experiencing the largest increases in unemployment and the largest reductions in governmental public health spending.

CONCLUSIONS

Federal resources and private sector contributions failed to avert reductions in local public health protections during the recession. New financing mechanisms may be necessary to ensure equitable public health protections during economic downturns.

Local health departments and the 2008 recession: characteristics of resiliency

BACKGROUND

The 2008 recession had a significant impact on local health departments (LHDs), with more than half of such agencies experiencing job losses and program cuts.

PURPOSE

To identify potential modifiable factors that can protect LHDs from job losses and budget cuts during future economic crises.

METHODS

This retrospective cohort study used data from 2005 and 2010 surveys of LHDs. The outcome of interest was financial resiliency for maintaining budgets during the recession and was based on the ratio of observed to predicted expenditures (O/E) per capita for 2010. Logistic regression was used to model the resiliency of the LHD with independent variables grouped around domains of organization, revenues, and services, with stratification by size of the LHD jurisdiction. Data were analyzed in 2013.

RESULTS

Of the 987 LHDs in the final data set, 328 (33.2%) were categorized as resilient and 659 (66.8%) as non-resilient. Overall, resilient LHDs received a higher percentage of revenues from non-local sources compared to non-resilient LHDs (p<0.05) and had a more diversified service mix, with significantly (p<0.05) more treatment, population, and regulatory services. In the final regression models, findings differed substantially across the stratifications of LHD jurisdictional population size, with no single independent or control variable significantly associated with resiliency across all population categories.

CONCLUSIONS

Funding streams and service mix may be modifiable characteristics, suggesting possible means for LHDs to weather future economic stress; however, these characteristics may be unique to the size of the population served.

Local health department activities to ensure access to care

BACKGROUND

Local health departments (LHDs) can play an important role in linking people to personal health services and ensuring the provision of health care when it is otherwise unavailable. However, the extent to which LHDs are involved in ensuring access to health care in its jurisdictions is not well known.

PURPOSE

To provide nationally representative estimates of LHD involvement in specific activities to ensure access to healthcare services and to assess their association with macro-environment/community and LHD capacity and process characteristics.

METHODS

Data used were from the 2010 National Profile of Local Health Departments Study, Area Resource Files, and the Association of State and Territorial Health Officials' 2010 Profile of State Public Health Agencies Survey. Data were analyzed in 2012.

RESULTS

Approximately 66.0% of LHDs conducted activities to ensure access to medical care, 45.9% to dental care, and 32.0% to behavioral health care. About 28% of LHDs had not conducted activities to ensure access to health care in their jurisdictions in 2010. LHDs with higher per capita expenditures and larger jurisdiction population sizes were more likely to provide access to care services (p <0.05).

CONCLUSIONS

There is substantial variation in LHD engagement in activities to ensure access to care. Differences in LHD capacity and the needs of the communities in which they are located may account for this variation. Further research is needed to determine whether this variation is associated with adverse population health outcomes.

The adoption and discontinuation of clinical services by local health departments

OBJECTIVES

We identified factors associated with local health department (LHD) adoption and discontinuation of clinical services.

METHODS

We used multivariate regression with 1997 and 2008 LHD survey and area resource data to examine factors associated with LHDs maintaining or offering more clinical services (adopter) versus offering fewer services (discontinuer) over time and with the number of clinical services discontinued among discontinuers.

RESULTS

Few LHDs (22.2%) were adopters. The LHDs were more likely to be adopters if operating in jurisdictions with local boards of health and not in health professional shortage areas, and if experiencing larger percentage increase in non-White population and Medicaid managed care penetration. Discontinuer LHDs eliminated more clinical services in jurisdictions that decreased core public health activities' scope over time, increased community partners' involvement in these activities, had larger increases in Medicaid managed care penetration, and had lower LHD expenditures per capita over time.

CONCLUSIONS

Most LHDs are discontinuing clinical services over time. Those that cover a wide range of core public health functions are less likely to discontinue services when residents lack care access. Thus, the impact of discontinuation on population health may be mitigated.

Governance typology: a consensus classification of state-local health department relationships

CONTEXT

Public health practitioners and researchers often refer to state public health systems as being centralized, decentralized, shared, or mixed. These categories refer to governance of the local public health units within the state and whether they operate under the authority of the state government, local government, shared state and local governance, or a mix of governance structures within the state.

OBJECTIVE

This article describes the development of an objective method of classifying states as centralized, decentralized, shared, or mixed. We also discuss some initial analyses that have been conducted to identify how public health resources and activities vary across states with different classifications.

DESIGN

Cross-sectional study.

SETTING

State health agencies.

PARTICIPANTS

Survey respondents were organizational leaders from all 50 state health agencies.

MAIN OUTCOME MEASURE(S)

Total full-time equivalent employees, total health agency expenditures, expenditures on clinical services, and provision of clinical services.

RESULTS

Centralized state health agencies employ more full-time equivalent employees, have higher total expenditures, and provide more clinical services than decentralized state health agencies. Although higher expenditures on clinical services were observed, these differences were not statistically significant.

CONCLUSIONS

It is important to take governance classification into account when investigating variation in services, resources, or performance of governmental public health systems. As public health systems and services researchers seek to identify best practices in the organization of public health systems, consistent definition of different types of organization is critical. This system provides an objective and reliable system for classifying governance relationships that allows for comparisons that are meaningful to both practitioners and researchers.

Methods in public health services and systems research: a systematic review

CONTEXT

Public Health Services and Systems Research (PHSSR) is concerned with evaluating the organization, financing, and delivery of public health services and their impact on public health. The strength of the current PHSSR evidence is somewhat dependent on the methods used to examine the field. Methods used in PHSSR articles, reports, and other documents were reviewed to assess their methodologic strengths and challenges in light of PHSSR goals.

EVIDENCE ACQUISITION

A total of 364 documents from the PHSSR library met the inclusion criteria as empirical and based in the U.S. After additional exclusions, 327 of these were analyzed.

EVIDENCE SYNTHESIS

A detailed codebook was used to classify articles in terms of (1) study design; (2) sampling; (3) instrumentation; (4) data collection; (5) data analysis; and (6) study validity. Inter-coder reliability was assessed for the codebook; once it was found reliable, the available empirical documents were coded.

CONCLUSIONS

Although there has been a dramatic increase in the amount of published PHSSR recently, methods used remain primarily cross-sectional and descriptive. Moreover, although appropriate for exploratory and foundational work in a new field, these approaches are limiting progress toward some PHSSR goals. Recommendations are given to advance and strengthen the methods used in PHSSR to better meet the goals and challenges facing the field.

Understanding the organization of public health delivery systems: an empirical typology

CONTEXT

Policy discussions about improving the U.S. health care system increasingly recognize the need to strengthen its capacities for delivering public health services. A better understanding of how public health delivery systems are organized across the United States is critical to improvement. To facilitate the development of such evidence, this article presents an empirical method of classifying and comparing public health delivery systems based on key elements of their organizational structure.

METHODS

This analysis uses data collected through a national longitudinal survey of local public health agencies serving communities with at least 100,000 residents. The survey measured the availability of twenty core public health activities in local communities and the types of organizations contributing to each activity. Cluster analysis differentiated local delivery systems based on the scope of activities delivered, the range of organizations contributing, and the distribution of effort within the system.

FINDINGS

Public health delivery systems varied widely in organizational structure, but the observed patterns of variation suggested that systems adhere to one of seven distinct configurations. Systems frequently migrated from one configuration to another over time, with an overall trend toward offering a broader scope of services and engaging a wider range of organizations.

CONCLUSIONS

Public health delivery systems exhibit important structural differences that may influence their operations and outcomes. The typology developed through this analysis can facilitate comparative studies to identify which delivery system configurations perform best in which contexts.

Geographic variation in public health spending: correlates and consequences

OBJECTIVES

To examine the extent of variation in public health agency spending levels across communities and over time, and to identify institutional and community correlates of this variation.

DATA SOURCES AND SETTING

Three cross-sectional surveys of the nation's 2,900 local public health agencies conducted by the National Association of County and City Health Officials in 1993, 1997, and 2005, linked with contemporaneous information on population demographics, socioeconomic characteristics, and health resources.

STUDY DESIGN

A longitudinal cohort design was used to analyze community-level variation and change in per-capita public health agency spending between 1993 and 2005. Multivariate regression models for panel data were used to estimate associations between spending, institutional characteristics, health resources, and population characteristics.

PRINCIPAL FINDINGS

The top 20 percent of communities had public health agency spending levels >13 times higher than communities in the lowest quintile, and most of this variation persisted after adjusting for differences in demographics and service mix. Local boards of health and decentralized state-local administrative structures were associated with higher spending levels and lower risks of spending reductions. Local public health agency spending was inversely associated with local-area medical spending.

CONCLUSIONS

The mechanisms that determine funding flows to local agencies may place some communities at a disadvantage in securing resources for public health activities.

Public health delivery systems: evidence, uncertainty, and emerging research needs

The authors review empirical studies published between 1990 and 2007 on the topics of public health organization, financing, staffing, and service delivery. A summary is provided of what is currently known about the attributes of public health delivery systems that influence their performance and outcomes. This review also identifies unanswered questions, highlighting areas where new research is needed. Existing studies suggest that economies of scale and scope exist in the delivery of public health services, and that key organizational and governance characteristics of public health agencies may explain differences in service delivery across communities. Financial resources and staffing characteristics vary widely across public health systems and have expected associations with service delivery and outcomes. Numerous gaps and uncertainties are identified regarding the mechanisms through which organizational, financial, and workforce characteristics influence the effectiveness and efficiency of public health service delivery. This review suggests that new research is needed to evaluate the effects of ongoing changes in delivery system structure, financing, and staffing.

Local public health agency funding: money begets money

Local public health agencies are funded federal, state, and local revenue sources. There is a common belief that increases from one source will be offset by decreases in others, as when a local agency might decide it must increase taxes in response to lowered federal or state funding. This study tests this belief through a cross-sectional study using data from Missouri local public health agencies, and finds, instead, that money begets money. Local agencies that receive more from federal and state sources also raise more at the local level. Given the particular effectiveness of local funding in improving agency performance, these findings that nonlocal revenues are amplified at the local level, help make the case for higher public health funding from federal and state levels.

Developing a community health promotion agenda for a managed care organization

Coordination and collaboration between organizations interested in promoting the health of the populations they serve can potentially help to ensure that key services are provided as well as augment the efforts beyond that which could be accomplished by each organization alone. Understanding the perspectives of each organization can facilitate development of health promotion initiatives that will be of mutual benefit. In Maryland, when a Medicaid managed care program was initiated, Memoranda of Understanding were signed between each managed care organization (MCO) and each of the 24 local health departments; many stipulated that the parties will coordinate on community health issues. This report describes a telephone survey of the health departments that was performed by one MCO to better understand the interests and expectations of the health departments and discusses a process for developing a community health promotion agenda for an MCO.

Institutional and economic determinants of public health system performance

OBJECTIVES

Although a growing body of evidence demonstrates that availability and quality of essential public health services vary widely across communities, relatively little is known about the factors that give rise to these variations. We examined the association of institutional, financial, and community characteristics of local public health delivery systems and the performance of essential services.

METHODS

Performance measures were collected from local public health systems in 7 states and combined with secondary data sources. Multivariate, linear, and nonlinear regression models were used to estimate associations between system characteristics and the performance of essential services.

RESULTS

Performance varied significantly with the size, financial resources, and organizational structure of local public health systems, with some public health services appearing more sensitive to these characteristics than others. Staffing levels and community characteristics also appeared to be related to the performance of selected services.

CONCLUSIONS

Reconfiguring the organization and financing of public health systems in some communities-such as through consolidation and enhanced intergovernmental coordination-may hold promise for improving the performance of essential services.

The effects of managerial beliefs on service: privatization and discontinuation in local health departments

This study examines the influence of Local Health Department (LHD) directors' managerial beliefs on the decision to privatize or discontinue personal health services. A stratified representative national sample of LHD directors was interviewed by telephone. Directors who believed temporary workers should be used wherever possible had about three times the odds of privatizing one or more personal health services. Directors who believed their department should focus exclusively on the core functions had more than ten times the odds of discontinuing at least one service. Declining revenue was not predictive of either privatization or discontinuation of personal health services.

Availability and perceived effectiveness of public health activities in the nation's most populous communities

OBJECTIVES

We examined the availability and perceived effectiveness of 20 basic public health activities in the communities where most Americans reside.

METHODS

A self-administered questionnaire was mailed to the 497 directors of US local health departments serving at least 100 000 residents.

RESULTS

On average, two thirds of the 20 public health activities were performed in the local jurisdictions surveyed, and the perceived effectiveness rating averaged 35% of the maximum possible. In multivariate models, availability of public health activities varied significantly according to population size, socioeconomic measures, local health department spending, and presence of local boards of health.

CONCLUSIONS

Local public health capacity varies widely across the nation's most populous communities, highlighting the need for targeted improvement efforts.

The public health workforce

Defining the public health workforce and specifying its performance requirements present equal challenges as the nation anticipates public health needs for the twenty-first century. The core group of professionals employed by government public health agencies works in close partnership with a wide range of public, private, and voluntary organizations. The wider circle includes almost all physicians, dentists, and nurses, plus many other health, environmental, and public safety professionals. The task of ensuring that this workforce is prepared with skills and knowledge to face both identified and emerging public health challenges is immense.