This session reviews progress in the field of public health services & systems research (PHSSR), with a specific focus on findings that can inform the implementation and impact of health reform strategies on the U.S. public health system

Mays, Glen P.

English

University of Kentucky

University of KentuckyUKnowledgeHealth Management and Policy Presentations Health Management and Policy5-19-2014Public Health Services & Systems Research and theReforming U.S. Health SystemGlen P. MaysUniversity of Kentucky, glen.mays@cuanschutz.eduRight click to open a feedback form in a new tab to let us know how this document benefits you.Follow this and additional works at: https://uknowledge.uky.edu/hsm_presentPart of the Health and Medical Administration Commons, Health Economics Commons, andthe Health Services Research CommonsThis Presentation is brought to you for free and open access by the Health Management and Policy at UKnowledge. It has been accepted for inclusionin Health Management and Policy Presentations by an authorized administrator of UKnowledge. For more information, please contactUKnowledge@lsv.uky.edu.Repository CitationMays, Glen P., "Public Health Services & Systems Research and the Reforming U.S. Health System" (2014). Health Management andPolicy Presentations. 68.https://uknowledge.uky.edu/hsm_present/68Public Health Services & Systems Research and the Reforming U.S. Health System Glen Mays, PhD, MPH  University of Kentucky  glen.mays@uky.edu Nat iona l  Coordinat ing  Center  CDC Forum on Public Health Services & Systems Research    •    Atlanta GA   •   19 May 2014 Overview How can PHSSR inform transformation?  Examples of recession-relevant research − Delivery system organization & structure  − Finance and economics Resources for advancing the field Opportunities and challenges for the future WHO 2010 Failures in population health   Failures in population health Commonwealth Fund 2012 Premature Deaths per 100,000 Residents Drivers of population health failures Schroeder SA. N Engl J Med 2007;357:1221-1228 Strategies to promote health and prevent  disease & injury on a population-wide basis: programs, policies, administrative practices Public health services  & systems research A field of inquiry examining the organization, financing, and delivery of public health services at local, state and national levels, and the impact of these activities on population health Mays, Halverson, and Scutchfield. 2003 A Key PHSSR Goal: Optimization  How to optimally deploy a diverse collection of responsibilities, resources, actors & expectations?    – Epidemiologic surveillance & investigation – Community health assessment & planning – Communicable disease control – Chronic disease and injury prevention – Health education and communication – Environmental health monitoring and assessment – Enforcement of health laws and regulations – Inspection and licensing – Inform, advise, and assist school-based, worksite-based, and community-based health programming …and roles in assuring access to medical care PHSSR’s place in the continuum Intervention Research What works – proof  of efficacy Controlled trials Guide to Community Preventive Services   Services/Systems Research How to organize, implement and sustain in the real-world  – Reach – Enforcement/Compliance – Quality/Effectiveness – Cost/Efficiency – Equity/Disparities Impact on population health Comparative effectiveness  & efficiency  Health & Social Systems Public Health Agencies Legal authority Participation incentives Intergovernmental relationships Strategic Interactions Breadth of organizations Leadership Needs Perceptions Preferences Risks Population & Environment Distribution  of effort Scope of services Staffing levels & mix Governing structure Funding levels & mix Division of responsibility Nature & intensity of relationships Scope of activity Compatibility of missions Resources & expertise Resources Threats Outputs and Outcomes Scale of operations Decision Support •Accreditation •Performance measures •Practice guidelines •Quality improvement Reach Effectiveness Timeliness Efficiency Equity Adherence to EBPs Complexity in public health delivery systems Mays et al 2009 Standardization vs. Customization  in public health delivery systems Standardization ▼Harmful variation ▼Wasteful variation ▼Inequitable variation ▼Race to the bottom ▲Network externalities: interoperability/coordination Customization ▲Target resources to greatest needs/risks ▲ Tailor approaches to values & preferences of stakeholders ▲ Deploy unique resources & skills to their best purposes  Effectiveness Efficiency Equity Current delivery system shocks Next Generation Population Health Improvement PHSSR and policy relevance Patient Protection and Affordable Care Act of 2010 Learning how to succeed with population health strategies Designed to achieve large-scale health improvement: neighborhood, city/county, region Target fundamental and often multiple  determinants of health Mobilize the collective actions of multiple stakeholders in government & private sector   - Usual and unusual suspects  - Infrastructure requirements  Mays GP.  Governmental public health and the economics of adaptation to population health strategies.  IOM Population Health Roundtable Discussion Paper.  February 2014.   Incentive compatibility → public goods Concentrated costs & diffuse benefits Time lags: costs vs. improvements Uncertainties about what works Asymmetry in information Difficulties measuring progress Weak and variable institutions & infrastructure Imbalance: resources vs. needs Stability & sustainability of funding Overcoming collective action problems Ostrom E.  1994 Reform-relevant research: organization and structure Who contributes to public health delivery? How are roles and responsibilities divided? How and why do delivery systems vary and change over time? How do system structures affect public health delivery and outcomes? Data: public health production National Longitudinal Survey of Public Health Systems Cohort of 360 communities with at least 100,000 residents Followed over time: 1998, 2006, 2012, 2014* Measured from local public health official’s perspective: – Scope: availability of 20 recommended  public health activities – Network: types of organizations  contributing to each activity – Effort: contributed by designated  local public health agency – Quality: perceived effectiveness  of each activity Constructs reflected in the measures Changes in scope and scale of activities performed Intensive margin: effort exerted by governmental public health Extensive margin: other organizations contributing to public health Quality/effectiveness: degree to which services meet community needs Links to other data sources Area Resource File: community and market characteristics, health resources NACCHO Profile data: local public health agency characteristics ASTHO Profile data: state public health agency characteristics U.S. Census of Governments: other state & local spending Consolidated Federal Funds Report: Other federal spending Medicare Cost Report data files: hospital ownership, market share, uncompensated care  Delivery of recommended public health activities 0%10%20%30%40%50%60%70%80%90%100%1998 2006 2012Assurance Policy Assessment% of activities ↑ 10% ↓ 5% National Longitudinal Survey of Public Health Systems, 2012 Delivery of recommended public health activities % of activities National Longitudinal Survey of Public Health Systems, 2012 Variation in Scope of Public Health Delivery Delivery of recommended public health activities, 2012 National Longitudinal Survey of Public Health Systems, 2012 % of activities 0 5% 10& Percent of U.S. communities 20% 40% 60% 80% 100%   Percent of activities performed Organizations contributing  to local public health production -50% -30% -10% 10% 30% 50%Local health agency  Other local government  State health agency  Other state government  Hospitals  Physician practices  Community health centers  Health insurers  Employers/business  Schools   CBOs% Change 2006-2012 Scope of Production 2012 National Longitudinal Survey of Public Health Systems, 2012 National Longitudinal Survey of Public Health Systems, 2012 Inter-organizational relationships in public health delivery systems Bridging capital in public health delivery systems Trends in betweenness centrality   * * * * * * * * * Change from prior years is statistically significant at p<0.05 Do other organizations complement or substitute  for local public health agency effort?  Results from Multivariate GLLAMM Models -0.3 -0.2 -0.1 0 0.1 0.2 0.3 0.4 0.5HospitalsInsurersEmployersPhysiciansCHCsNote: GLLAMM estimates, holding all other variables constant in the model How do other organizations affect the total supply  of public health activities? Results from Multivariate GLLAMM Models -0.3 -0.2 -0.1 0 0.1 0.2 0.3 0.4 0.5 0.6HospitalsInsurersEmployersPhysiciansCHCsNote: GLLAMM estimates, holding all other variables constant in the model Estimated crowd-out in hospital contributions  to public health activities 0%10%20%30%40%50%60%0 5 10 15 20 25Hospital charity care $/1000 population Scope of hospital contributions Note: GLLAMM estimates, holding all other variables constant in the model A typology of public health delivery systems Scope                High       High         High          Mod           Mod         Low          Low        Centralization   Mod        Low         High          High           Low         High         Low Integration        High       High         Low           Mod           Mod         Low          Mod Source: Mays et al. 2010; 2012 0%5%10%15%20%25%30%35%40%45%50%1 2 3 4 5 6 7Comprehensive Conventional Limited 1998 2006 2012 % of communities Population health and delivery system change Fixed-effects models control for population size, density, age composition, poverty status, racial composition, and physician supply Infant Deaths/1000 Live Births -6.0-4.0-2.00.02.04.06.08.0Cluster 3 Clusters 4-5 Cluster 6 Cluster 70.02.04.06.08.010.0Cluster 3 Clusters 4-5 Cluster 6 Cluster 7-2.0-1.00.01.02.0Cluster 3 Clusters 4-5 Cluster 6 Cluster 70.01.02.03.04.0Cluster 3 Clusters 4-5 Cluster 6 Cluster 7-0.10.00.10.20.30.4Cluster 3 Clusters 4-5 Cluster 6 Cluster 7Cancer deaths/100,000 population Heart Disease Deaths/100,000 Influenza Deaths/100,000 Infectious Disease Deaths/100,000 Infant Deaths/1000 Births Cluster  1-  Clusters 1-3 Clusters 1-  Comprehens | Conventional |   Limited    |  Very Limited Percent Changes in Preventable Mortality Rates Attributable to Delivery System Type Comprehens | Conv ntional |   Limited    |  Very Limited omprehens | Conventional |   Limited    |  Very Limited Compreh ns | Conventional |   Limited    |  Very Limited omprehens | Conv ntional |   Limited    |  Very Limited Reform-relevant research: finance and economics How does public health spending vary across communities and change over time? What are the health effects attributable to changes in public health spending? What are the medical cost effects attributable to changes in public health spending? What are the opportunities for improving efficiency in public health delivery? What we know, sort of… Governmental Expenditures for Public Health Activity, USDHHS National Health Expenditure Accounts 0123456196019631966196919721975197819811984198719901993199619992002200520082011Percent of NHE (x100)Percent of GDP (x1000)Per capita ($100s nominal)Per capita ($100s constant)U.S. Centers for Medicare and Medicaid Services, Office of the Chief Actuary Variation in Local Public Health Spending 0 .05 .1 .15 Percent of communities $0 $50 $100 $150 $200 $250 Expenditures per capita, 2010 Gini = 0.485 Changes in Local Public Health Spending 1993-2010 0 .05 .1 .15 .2 .25 Percent of communities -100 -50 0 50 100 Change in per-capita expenditures ($) 62% growth 38% decline Determinants of Local Public Health Spending Levels – Delivery system size & structure – Service mix – Population needs and risks – Efficiency & uncertainty   Service mix16%Demographic, health & economic33%Governance& decision-making17%Unexplained34%Mays et al. 2009 Mortality reductions attributable to local public health spending, 1993-2008 -9-8-7-6-5-4-3-2-1012InfantmortalityHeartdisease Diabetes Cancer Influenza All-cause Alzheimers InjuryPercent change Hierarchical regression estimates with instrumental variables to correct for selection and unmeasured confounding Mays et al. 2011 58006000620064006600680070007200020406080100120Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5Medical spending/person ($)    .      Public health spending/capita ($)    .Quintiles of public health spending/capitaPublic health spending/capitaMedicare spending per recipientMays et al. 2009, 2013 Medical cost offsets attributable to investments in public health delivery, 1993-2008 For every $10 of public health spending, ≈$9 are recovered  in lower medical care spending over 15 years Community-specific estimates of public health spending on heart disease mortality Log IV regression estimates controlling for community-level and state-level characteristics Mays et al. forthcoming 2014 Impact of 10% Increase in Public Health Spending/Capita Based on Income Per Capita in Communities Mortality Medical costs 95% CI Community-specific estimates of public health spending on heart disease mortality Log IV regression estimates controlling for community-level and state-level characteristics Mays et al. forthcoming 2014 Impact of 10% Increase in Public Health Spending/Capita Based on Scope of Public Health Services Delivered Mortality Medical costs 95% CI How long does it take: Cumulative effects of public health  spending  Changes in Mortality and Medical Care Spending Attributable to 10% Increase in Public Health Spending /Capita Mays et al. forthcoming 2014 Mortality Medical costs 95% CI Log IV regression estimates controlling for community-level and state-level characteristics Effects of economic conditions on public health spending Elasticity estimates GEE regression estimates with logarithmic link function, controlling for population size, age composition, racial composition, physician and hospital supply, and governance structure  Employment GEE regression estimates with logarithmic link function, controlling for population size, age composition, racial composition, physician and hospital supply, and governance structure  Effects of economic conditions on public health delivery Economies of scale and scope  in public health delivery systems Source: 2010 NACCHO National Profile of Local Health Departments Survey 0%10%20%30%40%50%60%70%80%90%100%% of Agencies % of Population Served<50k 50k – 499k 500k+ Jurisdiction Size $0$500$1,000$1,500$2,0000 200 400 600 800 1000$0$1,000$2,000$3,000$4,000$5,0000% 20% 40% 60% 80% 100%Scale (Population in 1000s) Scope (% of Activities) Quality (Perceived Effectiveness) Cost  ($1000s) Cost  ($1000s) $0$500$1,000$1,500$2,0000% 20% 40% 60% 80% 100%Empirical estimates of scale and scope economies Simulated Effects of Regionalization -20%-15%-10%-5%0%5%10%15%<25,000 <50,000 <100,000 <150,000Per Capita CostScopeQualityRegionalization Thresholds Percent Change On the Horizon:   Advancing Reform-relevant Research Diffusion of Public Health PBRNs First cohort (December 2008 start-up)Second cohort (January 2010 start-up)Affiliate/Emerging PBRNs (2011-14)(    New in 2013) PBRN Agencies National Sample Activity Percent/Mean Percent/Mean Identifying research topics 94.1% 27.5% *** Planning/designing studies 81.6% 15.8% *** Recruitment, data collection & analysis 79.6% 50.3% ** Disseminating study results 84.5% 36.6% ** Applying findings in own organization 87.4% 32.1% ** Helping others apply findings 76.5% 18.0% *** Research implementation composite 84.04 (27.38) 30.20 (31.38) ** N 209 505 Local Health Departments Engaged in Research Implementation & Translation Activities During Past 12 months  PBRNs and Research Translation Mays et al.  American Journal of Preventive Medicine 2013.   Studying Production Processes Multi-Network Practice and Outcome Variation (MPROVE) Study, 2013-14 Measures of Interest Availability/Scope: specific activities produced Volume/Intensity: Frequency of producing activity over period of time Capacity: Labor and capital inputs assigned to an activity Reach: Proportion of target population reached by activity Quality: effectiveness, timeliness, equity of activity Efficiency: resources required to produce given volume of activity MPROVE Example: Implementation of community-wide health education campaigns to promote physical activity MPROVE Example: Implementation of educational interventions to reduce tobacco use and/or exposure Ongoing Cost and Value Research Foundational Public Health Capabilities 3 state-specific studies to estimate current spending on FCs 1 national study to estimate FC resource requirements and cost function parameters  Public Health Delivery and Cost Studies 11 state-specific studies on cost variation 3 multi-state studies examining connections between spending, service delivery, and outcomes Toward a “rapid-learning system” in public health Green SM et al. Ann Intern Med. 2012;157(3):207-210 Always Open Glen P. Mays, Ph.D., M.P.H. glen.mays@uky.edu Supported by The Robert Wood Johnson Foundation Email:    publichealthPBRN@uky.edu Web:       www.publichealthsystems.org Journal:  www.FrontiersinPHSSR.org Archive:  works.bepress.com/glen_mays Blog:       publichealtheconomics.org   Nat iona l  Coordinat ing  Center  

Public Health Services & Systems Research and the Reforming U.S. Health System

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Public Health Services & Systems Research and the Reforming U.S. Health System

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