Local Health Department Revenue Diversification and Revenue Volatility: Can One Be Used to Manage the Other?

OBJECTIVE: Revenue volatility-particularly in the form of sudden and significant reductions in funding-has been shown to negatively affect local health departments (LHDs) by impacting the amount and type of services delivered. This study examined the potential effectiveness of revenue diversification as a means of managing LHD financial risk. More specifically, we examine the relationship between revenue diversification and revenue volatility among LHDs in Washington State. DESIGN AND SETTING: We applied fixed-effects linear regression models with robust standard errors to revenue data reported during 1998-2014 by all LHDs operating in Washington State. We also assessed the robusticity of our results to alternative specifications for revenue diversification and volatility. MAIN OUTCOME MEASURES: LHD revenue and revenue volatility. RESULTS: Between 1998 and 2014, LHDs in Washington State were exposed to considerable upside and downside fiscal risks. While average revenue volatility was close to 0 (0.2%), observed values ranged from -35% to 63%. LHD revenues were already highly diversified: as measured using a reversed Herfindahl-Hirschman Index, diversification values ranged between 0.56 and 1.00. There is little evidence to suggest the existence of a statistically significant relationship between revenue diversification and volatility. CONCLUSIONS: Revenue volatility presents LHDs with important short- and long-term operational challenges. Our models suggest that revenue diversification did not reduce revenue volatility among Washington State LHDs in 1998-2014. Further research will need to examine whether revenue diversification reduces LHD financial risk in other settings.

Dance of Dollars: State Funding Effects on Local Health Department Expenditures.

OBJECTIVE: We examined changes in total local health department (LHD) expenditures in the state of Washington following introduction of a new state funding program to support core public health services and infrastructure. METHODS: We used a pre/posttest design regression model to evaluate changes in LHD expenditures 1, 2, and 6 years into the new state program. To address potential endogeneity in the model, we repeated all 3 analyses using 2-stage least squares regression. RESULTS: In the base case, overall spending among LHDs significantly increased with receipt of the new state funds in the first years of the program (2008 and 2009). However, those increases were not sustained over the longer term (2013). In subpopulation analyses, total LHD spending increased more among larger LHDs. CONCLUSIONS: Between 2006 and 2013, new state investments in core public health functions increased Washington State LHD expenditures in the short term, but those increases did not persist over time. For public health financial modernization efforts to translate into public health infrastructure modernization successes, the way new investments are structured may be as important as the amount of funding added.

Significant difference in HEDIS annual chlamydia testing rates between women who had given birth and those who had not among young Medicaid women.

We used the 2013 Medicaid Analytic eXtract (MAX) database to estimate chlamydia testing rates separately for sexually active women aged 15-25 years who had, or had not, given birth in 2013. Approximately 9.2% of sexually active women aged 15-25 years gave birth in 2013. The Healthcare Effectiveness Data Information Set (HEDIS) annual chlamydia testing rate was significantly higher among women who had given birth than women who had not in 2013 (59.7 vs 29.4%, P<0.05). Our findings suggest a need for more research to understand how differences in population mix changes and preventive screening practices for pregnant and non-pregnant women affect publicly reported chlamydia screening rates.

Corrigendum to: Significant difference in HEDIS annual chlamydia testing rates between women who had given birth and those who had not among young Medicaid women.

We used the 2013 Medicaid Analytic eXtract (MAX) database to estimate chlamydia testing rates separately for sexually active women aged 15-25 years who had, or had not, given birth in 2013. Approximately 9.2% of sexually active women aged 15-25 years gave birth in 2013. The Healthcare Effectiveness Data Information Set (HEDIS) annual chlamydia testing rate was significantly higher among women who had given birth than women who had not in 2013 (59.7 vs 29.4%, P<0.05). Our findings suggest a need for more research to understand how differences in population mix changes and preventive screening practices for pregnant and non-pregnant women affect publicly reported chlamydia screening rates.

Current and (Potential) Future Effects of the Affordable Care Act on HIV Prevention.

Recent advances in science, program, and policy could better position the nation to achieve its vision of the USA as a place where new HIV infections are rare. Among these developments, passage of the Patient Protection and Affordable Care Act (ACA) in 2010 may prove particularly important, as the health system transformations it has launched offer a supportive foundation for realizing the potential of other advances, both within and beyond the clinical arena. This article summarizes opportunities to expand access to high-impact HIV prevention interventions under the ACA, examines whether available evidence indicates that these opportunities are being realized, and considers potential challenges to further gains for HIV prevention in an era of health reform. This article also highlights the new roles that HIV prevention programs and providers may assume in a health system no longer defined by fragmentation among public health, medical care, and community service providers.

Ryan White HIV/AIDS Program Assistance and HIV Treatment Outcomes.

BACKGROUND: The Ryan White HIV/AIDS Program (RWHAP) provides persons infected with human immunodeficiency virus (HIV) with services not covered by other healthcare payer types. Limited data exist to inform policy decisions about the most appropriate role for RWHAP under the Patient Protection and Affordable Care Act (ACA). METHODS: We assessed associations between RWHAP assistance and antiretroviral therapy (ART) prescription and viral suppression. We used data from the Medical Monitoring Project, a surveillance system assessing characteristics of HIV-infected adults receiving medical care in the United States. Interview and medical record data were collected in 2009-2013 from 18 095 patients. RESULTS: Nearly 41% of patients had RWHAP assistance; 15% relied solely on RWHAP assistance for HIV care. Overall, 91% were prescribed ART, and 75% were virally suppressed. Uninsured patients receiving RWHAP assistance were significantly more likely to be prescribed ART (52% vs 94%; P < .01) and virally suppressed (39% vs 77%; P < .01) than uninsured patients without RWHAP assistance. Patients with private insurance and Medicaid were 6% and 7% less likely, respectively, to be prescribed ART than those with RWHAP only (P < .01). Those with private insurance and Medicaid were 5% and 12% less likely, respectively, to be virally suppressed (P ≤ .02) than those with RWHAP only. Patients whose private or Medicaid coverage was supplemented by RWHAP were more likely to be prescribed ART and virally suppressed than those without RWHAP supplementation (P ≤ .01). CONCLUSIONS: Uninsured and underinsured HIV-infected persons receiving RWHAP assistance were more likely to be prescribed ART and virally suppressed than those with other types of healthcare coverage.

Nearly Half Of US Adults Living With HIV Received Federal Disability Benefits In 2009.

The effects of HIV infection on national labor-force participation have not been rigorously evaluated. Using data from the Medical Monitoring Project and the National Health Interview Survey, we present nationally representative estimates of the receipt of disability benefits by adults living with HIV receiving care compared with the general US adult population. We found that in 2009, adults living with HIV were nine times more likely than adults in the general population to receive disability benefits. The risk of being on disability is also greater for younger and more educated adults living with HIV compared to the general population, which suggests that productivity losses can result from HIV infection. To prevent disability, early diagnosis and treatment of HIV are essential. This study offers a baseline against which to measure the impacts of recently proposed or enacted changes to Medicaid and private insurance markets, including the Affordable Care Act and proposed revisions to the Social Security Administration's HIV Infection Listings.

Human immunodeficiency virus transmission at each step of the care continuum in the United States.

IMPORTANCE: Human immunodeficiency virus (HIV) transmission risk is primarily dependent on behavior (sexual and injection drug use) and HIV viral load. National goals emphasize maximizing coverage along the HIV care continuum, but the effect on HIV prevention is unknown. OBJECTIVES: To estimate the rate and number of HIV transmissions attributable to persons at each of the following 5 HIV care continuum steps: HIV infected but undiagnosed, HIV diagnosed but not retained in medical care, retained in care but not prescribed antiretroviral therapy, prescribed antiretroviral therapy but not virally suppressed, and virally suppressed. DESIGN, SETTING, AND PARTICIPANTS: A multistep, static, deterministic model that combined population denominator data from the National HIV Surveillance System with detailed clinical and behavioral data from the National HIV Behavioral Surveillance System and the Medical Monitoring Project to estimate the rate and number of transmissions along the care continuum. This analysis was conducted January 2013 to June 2014. The findings reflect the HIV-infected population in the United States in 2009. MAIN OUTCOMES AND MEASURES: Estimated rate and number of HIV transmissions. RESULTS: Of the estimated 1,148,200 persons living with HIV in 2009, there were 207,600 (18.1%) who were undiagnosed, 519,414 (45.2%) were aware of their infection but not retained in care, 47,453 (4.1%) were retained in care but not prescribed ART, 82,809 (7.2%) were prescribed ART but not virally suppressed, and 290,924 (25.3%) were virally suppressed. Persons who are HIV infected but undiagnosed (18.1% of the total HIV-infected population) and persons who are HIV diagnosed but not retained in medical care (45.2% of the population) were responsible for 91.5% (30.2% and 61.3%, respectively) of the estimated 45,000 HIV transmissions in 2009. Compared with persons who are HIV infected but undiagnosed (6.6 transmissions per 100 person-years), persons who were HIV diagnosed and not retained in medical care were 19.0% (5.3 transmissions per 100 person-years) less likely to transmit HIV, and persons who were virally suppressed were 94.0% (0.4 transmissions per 100 person-years) less likely to transmit HIV. Men, those who acquired HIV via male-to-male sexual contact, and persons 35 to 44 years old were responsible for the most HIV transmissions by sex, HIV acquisition risk category, and age group, respectively. CONCLUSIONS AND RELEVANCE: Sequential steps along the HIV care continuum were associated with reduced HIV transmission rates. Improvements in HIV diagnosis and retention in care, as well as reductions in sexual and drug use risk behavior, primarily for persons undiagnosed and not receiving antiretroviral therapy, would have a substantial effect on HIV transmission in the United States.

Role flexing: how community, religion, and family shape the experiences of young black men who have sex with men.

While the disproportionate impact of HIV on young black men who have sex with men (MSM) is well documented, the reasons for this disparity remain less clear. Through in-depth interviews, we explored the role of familial, religious, and community influence on the experiences of young black MSM and identified strategies that these young men use to negotiate and manage their sexual minority status. Between February and April 2008, 16 interviews were conducted among HIV-infected and HIV-uninfected young (19- to 24-year-old) black MSM in the Jackson, Mississippi, area. Results suggest that overall, homosexuality remains highly stigmatized by the men's families, religious community, and the African American community. To manage this stigma, many of the participants engaged in a process of "role flexing," in which individuals modified their behavior in order to adapt to a particular situation. The data also provided evidence of internalized homophobia among a number of the participants. The impact of stigma on risk behavior should be more fully explored, and future intervention efforts need to explicitly address and challenge stigma, both among young men themselves and the communities in which they reside. Attention should also be paid to the role masculinity may play as a driver of the HIV epidemic among young black MSM and how this knowledge can be used to inform prevention efforts.

Operational research to improve HIV prevention in the United States.

The HIV/AIDS epidemic in the United States continues despite several recent noteworthy advances in HIV prevention. Contemporary approaches to HIV prevention involve implementing combinations of biomedical, behavioral, and structural interventions in novel ways to achieve high levels of impact on the epidemic. Methods are needed to develop optimal combinations of approaches for improving efficiency, effectiveness, and scalability. This article argues that operational research offers promise as a valuable tool for addressing these issues. We define operational research relative to domestic HIV prevention, identify and illustrate how operational research can improve HIV prevention, and pose a series of questions to guide future operational research. Operational research can help achieve national HIV prevention goals of reducing new infections, improving access to care and optimization of health outcomes of people living with HIV, and reducing HIV-related health disparities.