SESSION 2A: System Structure & Performance-Public Health Practice
Room: Thoroughbred 1
Wednesday, April 9, 2014, 9-10:15 am
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KC14 Session 2A on System Structure & Performance: Public Health Practice by NCC for PHSSR
MODERATOR
Paul K. Halverson, Dr.P.H., FACHE
PRESENTERS
Alana Knudson, Ph.D.
Promising Rural Public Health Practices for the Post ACA Implementation Era
Co-Investigator: Michael Meit, M.P.H, M.A. (Presenting)
Background: In 2001, the Centers for Disease Control and Prevention (CDC) published Health, United States, 2001 With Urban and Rural Health Chartbook. The CDC Chartbook was widely used in directing rural health policy and programming and has not been updated since 2001. The Rural Health Reform Policy Research Center, a partnership of the University of North Dakota Center for Rural Health and the NORC Walsh Center for Rural Health Analysis (NORC) sought to update the 2001 report to examine the current trends and disparities in urban and rural health.
Data Sets & Sources: For the Chartbook, researchers replicated the analyses conducted in 2001 using the most recent data available (2006-2011) from the Compressed Mortality File (National Vital Statistics System), Area Resource File (HRSA), and U.S. Census Bureau using SAS, STATA and SUDAAN, depending on the dataset. Output included aggregate data stratified by geographic region and level of rurality.
Findings and Conclusion: Findings suggest that rural residents fare worse than their urban counterparts on a number of measures, including rates for smoking, death from chronic obstructive pulmonary disease (COPD), and suicide. Overall, residents of rural areas have less access to physicians and dentists. While the nation’s health has generally improved over the past decade, urban/rural disparities in health status and access to care persist across a variety of measures, and have grown for some measures (e.g., COPD). Concurrent with our efforts to demonstrate ongoing rural health disparities through the development of the updated Chartbook, NORC, in collaboration with the University of Minnesota Rural Health Research Center, sought to identify rural evidence practices for inclusion in toolkits designed to assist communities in the implementation of rural health initiatives. Researchers reviewed HRSA Office of Rural Health Policy-funded programs to identify promising approaches in the areas of obesity prevention, mental health, oral health, community health worker programs, health promotion, and care coordination. Each toolkit is composed of several modules that provide guidance to organizations on how to identify risk factors, convene partners, and apply successful strategies to impact the health of their communities. These toolkits are available through the Rural Community Health Gateway on the Rural Assistance Center (RAC) website at www.raconline.org.
JP Leider, Ph.D.
ACA and uncertainty in big city health departments
Co-Investigators: Shelley Hearne, Dr.P.H., Brian Castrucci, M.P.H, Pamela Russo, M.D., M.P.H
Background: In 2014, all eyes in public health are on the Affordable Care Act (ACA’s). Despite its potential boon to population health through insurance expansion, significant uncertainty has accompanied ACA’s passing and implementation.
Research Objective and Study Design: In order to better understand ACA’s potential impact on urban public health, we conducted a mixed-methods study where we interviewed and surveyed multiple leaders from members of the Big Cities Health Coalition (BCHC) around ACA implementation and impact.
Analysis: Over the course of the interview and survey, each respondent was asked to describe the current impact of ACA on their health department, as well as potential burdens created by ACA, and potential opportunities created by ACA. Qualitative data were coded thematically by two researchers, and managed in NVivo. Survey data were managed and analyzed in Stata. Data from NACCHO’s 2013 Profile were also incorporated.
Principal Findings: 45 respondents participated from 17/18 BCHC LHDs. These LHDs are responsible for the health of 40 million people in the United States. Respondents from 13 cities said they expected to provide more population-based prevention and epidemiology/surveillance due to the ACA by the end of 2014, respectively. Respondents from 12 cities said they expected to do more with chronic disease, and several said they expected to provide more immunization services (7 cities). However, many respondents said they expected to cut back on services due to ACA, as well, including fewer personal health services (8 cities), immunization (6), family planning (5), laboratory services (4), and comprehensive primary care (4). Significant uncertainty around the impact on clinical services was noted by respondents across jurisdictions.
Implications and Conclusions: Public health practitioners at some of the nation’s largest LHDs expect significant impact from ACA in their communities. However, there is not agreement within or across the LHDs on exactly what that impact will be, except for likely funding cuts and challenges associated with the delivery of clinical services. Policymakers should be vigilant that budget cuts do not occur without expected concomitant added capacity by private industry or billing by LHDs, or new challenges may present in the US’ already-patchwork safety net.
Nathan Hale, Ph.D., M.P.H.
Rural Health Departments: Challenges and Opportunities
Co-Investigators: None Listed
Background: The South Carolina Department of Health and Environmental Control (SCDHEC), the state’s public health agency, has transitioned from being a direct provider of EPSDT services to assuring their delivery in the larger healthcare system. These historical changes have created a natural experiment to examine differences in the impact of this transition among rural and urban communities.
Research Objective: To examine rural/urban differences in the level of EPSDT services provided to infants in South Carolina as local health departments (SCDHEC) transitioned from providing these services directly.
Data Sets and Sources: Data for the proposed research were derived from linked South Carolina Medicaid eligibility files, Medicaid billing claims, and birth certificate data.
Study Design: A longitudinal birth cohort of infants (0-12 months of age) continuously enrolled in Medicaid from 1995-2010 with normal birth weights (>2500 grams) was created for analysis. Receipt of any EPSDT visit and the ratio of observed to expected EPSDT visits were used as outcome measures. Change in the level of SCDHEC penetration over time by rural residence was the primary variable of interest.
Analysis: Growth curve models including both fixed and random effects were used for the multivariable analysis. Models included a three-way interaction between time, SCDHEC penetration, and rural residence to ident+6-ify systematic variation in the level of change by residence as time and the level of SCDHC penetration change.
Principal Findings: Fewer infants continuously enrolled in Medicaid received an EPSDT visit on average over time. In urban areas the system appears to have stabilized and improved in some communities. In rural counties dependent on SCDHEC at baseline, the level of EPSDT services has deteriorated over time and has yet to demonstrate clear improvement.
Conclusions: The impact of SCDHEC transitioning from being a direct services provider was markedly different in rural communities than in urban.
Implications: As healthcare reforms are implemented, local health departments operating in rural areas may face increased demand for direct services. At the same time, healthcare reform implementation may also provide a unique opportunity to transition away from providing these services by working collaboratively with Federally Qualified Health Centers.