Cross-Jurisdictional Sharing
Room: Triple Crown I, II, & III
Wednesday, April 22, 2015, 10:45 AM to 12:15 PM
Moderator: Kusuma Madamala, PhD, MPH
Gianfranco Pezzino, MD, MPH
Cross-jurisdictional Sharing in Public Health: What We Do (and Do Not) Know
Co-Investigator(s): Patrick Libbey; Grace Gorenflo; Barbara Starrett; & Catherine McNorton
Background: The Center for Sharing Public Health Services is a national resource on cross-jurisdictional sharing (CJS) in public health. CJS occurs when public jurisdictions share services and capacities in order to improve their capacity and build economies of scale that allow more effective and efficient operations. The Center builds evidence and produces and disseminates tools, methods and models to assist public health agencies and policymakers as they consider and adopt CJS approaches. The Center, which was founded in 2012, has supported multiple demonstration projects, provided technical assistance, and conducted case studies throughout the country. Research Objectives: To describe the current status of knowledge about CJS, including successful models and outcomes. Data sets and sources and study design: Mixed methods. Qualitative information from 20 demonstration projects that include 75 health departments in 125 political jurisdictions and five case studies. Quantitative information from 1,119 local governments who responded to a survey on public health shared administrative services. Analysis: Using the qualitative and quantitative information collected, we have identified success factors for CJS initiatives, steps for the implementation of projects, and preliminary outcomes. Principal Findings: We have identified three groups of factors that can help maximize the probability of success of CJS initiatives: prerequisites, facilitating factors, and project characteristics. Prerequisites that should be in place in every project include clarity of objectives, a balanced approach that attempts to improve both effectiveness and efficiency, and mutual trust. Facilitating factors that should be leveraged if present include success in prior collaborations, a sense of regional identity, and positive interpersonal relationships. Project-specific characteristics that can foster success include senior-level support, strong project management skills, robust change management plans, and effective communication. Preliminary findings suggest that CJS projects can achieve outcomes such as reduced costs, greater productivity, enhanced eligibility for grants, increased range of public health services available, and improved quality of services. The vast majority of policymakers that share back-office public health functions would recommend it to others, and many report improved efficiency of operations and cost savings as a result of CJS activities. Conclusions: There is growing qualitative and quantitative evidence that CJS models can be successful in improving effectiveness and efficiency in the delivery of public health services. Implications for Public Health Practice and Policy: CJS models can be successful in improving effectiveness and efficiency in delivering public health services. Policymakers indicate a high level of satisfaction with sharing arrangements. Health officials and policymakers planning or implementing CJS initiatives should carefully consider what success factors they can identify for their projects and should leverage those that are present, while being aware of the potential impact of those that are lacking. Knowledge gaps remain in some areas, such as how to measure changes in effectiveness and efficiency generated by CJS initiatives and how to reproduce sharing models involving local jurisdictions in initiatives that include state or tribal entities.
Justin Marlowe, PhD
Calculating and Apportioning Financial Costs of Cross-jurisdictional Sharing Activities
Co-Investigator(s): Gianfranco Pezzino, MD, MPH
Background: Cross-jurisdictional sharing (CJS) in public health occurs when public jurisdictions share services and capacities. CJS arrangements can produce economies of scale that improve the effectiveness and efficiency of the public health system. Policymakers and public health officials are often interested in the financial impact of CJS arrangements. They are also interested in equitably distributing costs in order to assure tax dollars collected in one jurisdiction don’t subsidize services in another. Research Objectives: To provide a standardized approach to calculate the cost of shared public health services and capacities, to show how policymakers and public health officials can compare that cost to the cost of providing the same service independently, and to advise on how costs of shared services can be distributed equitably. Data sets and sources and study design: An estimate of the costs of providing CJS services was obtained from two demonstration projects: a two-county CJS collaboration in New York and a city-county CJS collaboration augmented by data from a previously conducted quick strike study of 20 cases in Ohio. Expert opinion was utilized to develop a common approach to measuring and distributing costs. Analysis: Expert opinion was used to produce a “primer” describing how to measure and apportion the cost of shared services. Using qualitative and quantitative information from the New York and Ohio demonstration sites, the fiscal impact of the shared service arrangements was calculated. Principal Findings: Significant cost savings have been realized in both projects. The savings result from achieving economies of scale and sharing key management personnel across multiple jurisdictions. Three fundamental steps were identified that allow a standardized method for calculating the fiscal impact of CJS projects and distributing costs across jurisdictions. The first step is determining the direct and indirect costs of the service to be shared if provided independently by each jurisdiction. Basic accounting concepts such as cost objective, allocation basis, fixed costs, and variable costs have to be kept in mind while performing the cost analysis. The second step involves estimating those same costs if the service is provided under a CJS agreement. The third and final step is deciding how to apportion the cost of the shared service or capacity to each involved jurisdiction. Possible strategies (to be used independently or in combination with each other) include equal share, per capita sharing, cost plus fixed fee, ability to pay, prevalence, weighted formula, and fee for service. Conclusions: Preliminary evidence suggests that in some circumstances CJS arrangements can lead to significant cost savings. The use of the proposed systematic approach can provide a standardized way to determine the fiscal impact of CJS arrangements and distribute costs associated with them. Implications for Public Health Practice and Policy: CJS models can be successful in improving the effectiveness and efficiency of public health service delivery. It is important that policymakers and public health officials know the fiscal impact of CJS when making decisions involving its use. It is also important they know how to equitably distribute costs associated with CJS models.
Susan Zahner, DrPH, MPH, RN
Characteristics of Cross-jurisdiction Shared Services Agreements Between Local Health Departments in Wisconsin
Co-Investigator(s): Kusuma Madamala, PhD, MPH; Adam Karlen, BS, RN; & Tracy Mrochek, MPA, BS, RN
Research Objective: To describe characteristics, expected outcomes, extent of implementation, and perceived performance in achieving expected outcomes of a sample of formal cross-jurisdiction shared services agreements obtained from local and tribal health departments in Wisconsin. Data Sets and Sources: Primary data sources include data extracted from an archival sample of 85 written cross-jurisdiction shared service agreements (CJSSA) collected from local and tribal health departments and from interviews with department leaders (n=43). The CJSSA dataset includes primary purpose, number of partners, timeframe, legal form, program focus, and fiscal arrangements. Local health department characteristics were obtained from the State of Wisconsin Local Public Health Survey (2012). Study Design: Cross-sectional mixed methods Analysis: Characteristics of the CJSSA were extracted and described. Organizational characteristics of the health departments engaged in the CJSSA are described. Perceptions on extent of implementation, perceived outcomes, and extent to which expected outcomes are achieved obtained by interview are summarized and described. Benefits, challenges, and recommendations for entering into CJSSA were content coded, summarized, and described. Principal Findings: Preliminary analyses revealed substantial variation in CJSSA characteristics. Commonly reported incentives to collaborate included obtaining funding, mandates to provide a service, and strengthening public health. Positive results of collaborating included expanding capacity and improving services. Challenges included dealing with complexity and financial constraints. Findings from the full analysis will be presented. Conclusions: Cross-jurisdiction shared service arrangements are common among local public health departments. Characteristics, motivations, and expected outcomes for the agreements are varied. Implications for PHSSR: Further analysis is planned to determine what specific CJSSA characteristics are associated with better performance in meeting expected outcomes of the agreements.