Assessing entrepreneurship in governmental public health.

OBJECTIVES: We assessed the feasibility and desirability of public health entrepreneurship (PHE) in governmental public health. METHODS: Using a qualitative case study approach with semistructured interview protocols, we conducted interviews between April 2010 and January 2011 at 32 local health departments (LHDs) in 18 states. Respondents included chief health officers and senior LHD staff, representatives from national public health organizations, health authorities, and public health institutes. RESULTS: Respondents identified PHE through 3 overlapping practices: strategic planning, operational efficiency, and revenue generation. Clinical services offer the strongest revenue-generating potential, and traditional public health services offer only limited entrepreneurial opportunities. Barriers include civil service rules, a risk-averse culture, and concerns that PHE would compromise core public health values. CONCLUSIONS: Ongoing PHE activity has the potential to reduce LHDs' reliance on unstable general public revenues. Yet under the best of circumstances, it is difficult to generate revenue from public health services. Although governmental public health contains pockets of entrepreneurial activity, its culture does not sustain significant entrepreneurial activity. The question remains as to whether LHDs' current public revenue sources are sustainable and, if not, whether PHE is a feasible or desirable alternative.

Impact of health care price transparency on price variation: the New Hampshire experience.

Price variation for medical procedures performed in both hospital outpatient departments and freestanding facilities has not decreased in New Hampshire since the state launched the HealthCost price transparency program in early 2007, according to new research jointly conducted by the New Hampshire Insurance Department and the Center for Studying Health System Change (HSC). New Hampshire stakeholders cited weak provider competition as the key reason for lack of impact. The state's hospital market is geographically segmented in rural areas and has few competitors even in urban areas. In addition, few consumers have strong incentives to shop based on price: Only 5 percent of the state's privately insured residents were enrolled in high-deductible plans in 2007. However, some observers suggested that HealthCost--along with other state price transparency initiatives--has helped to focus employer and policy maker attention on provider price differences and has caused some hospitals to moderate their demands for rate increases.

Suburban poverty and the health care safety net.

Although suburban poverty has increased in the past decade, the availability of health care services for low-income and uninsured people in the suburbs has not kept pace. According to a new study by the Center for Studying Health System Change (HSC) of five communities--Boston, Cleveland, Indianapolis, Miami and Seattle--low-income people living in suburban areas face significant challenges accessing care because of inadequate transportation, language barriers and lack of awareness of health care options. Low-income people often rely on suburban hospital emergency departments (EDs) and urban safety net hospitals and health centers. Some urban providers are feeling the strain of caring for increasing numbers of patients from both the city and the suburbs. Both urban and suburban providers are attempting to redirect patients to more appropriate care near where they live by expanding primary care capacity, improving access to specialists, reducing transportation challenges, and generating revenues to support safety net services. Efforts to improve safety net services in suburban areas are hampered by greater geographic dispersion of the suburban poor and jurisdictional issues in funding safety net services. To improve the suburban safety net, policy makers may want to consider flexible and targeted approaches to providing care, regional collaboration to share resources, and geographic pockets of need when allocating resources for community health centers and other safety net services and facilities.

Designing effective health care quality transparency initiatives.

Among the many health care quality transparency initiatives introduced in recent years, two state-based programs stand out for thoughtful design, implementation and usable, useful data: CalHospitalCompare, a report card for California hospitals, and Massachusetts Health Quality Partners, a report card for Massachusetts primary care physician groups. According to a new Center for Studying Health System Change (HSC) analysis, both programs share key elements that contribute to their effectiveness: engaging and collaborating with the provider community from the outset; paying particular attention to the caliber of the quality data reported; presenting the quality data to consumers in formats that are easy to understand and remember; and providing hospitals and physicians with detailed information on their own performance. Quality transparency initiatives that do not focus sufficiently on these key design and implementation elements are unlikely to influence quality improvement in a meaningful way.

Word of mouth and physician referrals still drive health care provider choice.

Sponsors of health care price and quality transparency initiatives often identify all consumers as their target audiences, but the true audiences for these programs are much more limited. In 2007, only 11 percent of American adults looked for a new primary care physician, 28 percent needed a new specialist physician and 16 percent underwent a medical procedure at a new facility, according to a new national study by the Center for Studying Health System Change (HSC). Among consumers who found a new provider, few engaged in active shopping or considered price or quality information--especially when choosing specialists or facilities for medical procedures. When selecting new primary care physicians, half of all consumers relied on word-of-mouth recommendations from friends and relatives, but many also used doctor recommendations (38%) and health plan information (35%), and nearly two in five used multiple information sources when choosing a primary care physician. However, when choosing specialists and facilities for medical procedures, most consumers relied exclusively on physician referrals. Use of online provider information was low, ranging from 3 percent for consumers undergoing procedures to 7 percent for consumers choosing new specialists to 11 percent for consumers choosing new primary care physicians

Massachusetts health reform: high costs and expanding expectations may weaken employer support.

Passage of health reform legislation in Massachusetts required significant bipartisan compromise and buy in among key stakeholders, including employers. However, findings from a recent follow-up study by the Center for Studying Health System Change (HSC) suggest two important developments may threaten employer support as the reform plays out. First, improved access to the non-group--or individual--insurance market, the availability of state-subsidized coverage, and the costs of increased employee take up of employer-sponsored coverage and rising premiums potentially weaken employers' motivation and ability to provide coverage. Second, employer frustration appears to be growing as the state increases employer responsibilities. While the number of uninsured people has declined significantly, the high cost of the reform has prompted the state to seek additional financial support from stakeholders, including employers. Improving access to health care coverage has been a clear emphasis of the reform, but little has been done to address escalating health care costs. Yet, both must be addressed, otherwise long-term viability of Massachusetts' coverage initiative is questionable.

Community efforts to expand dental services for low-income people.

Poor oral health among low-income people is gaining attention as a significant health care problem. Key barriers to dental services include low rates of dental insurance coverage, limited dental benefits available through public insurance programs, and a lack of dentists willing to serve low-income patients, according to findings from the Center for Studying Health System Change's (HSC) 2007 site visits to 12 nationally representative metropolitan communities. Communities are attempting to provide more dental services to low-income residents. Along with state efforts to increase dentists' participation in Medicaid and the State Children's Health Insurance Program (SCHIP), hospitals, community health centers, health departments, dental schools and others are working to expand dental services, with some focusing on basic preventive services and others pursuing more comprehensive dental care. Many community efforts rely on increasing the number of dental professionals available to treat low-income people. Without additional involvement from the dental community and state and federal policy makers, however, many low-income people likely will continue to lack access to dental care and suffer the consequences.

Public health workforce shortages imperil nation's health.

After the 9/11 terrorist attacks, interest in the state of America's public health system spiked, especially related to emergency preparedness. Significant new federal funding flowed to state and local agencies to bolster public health activities. But the spotlight on shoring up the nation's public health system has faded, and the public appears unaware of escalating threats to such basic services as disease surveillance. Local health departments face a mounting workforce crisis as they struggle to recruit, train and retain qualified workers to meet their communities' needs, according to a new study by the Center for Studying Health System Change (HSC). Factors influencing the workforce shortage include inadequate funding, uncompetitive salaries and benefits, an exodus of retiring workers, insufficient supply of trained workers, and lack of enthusiasm for public health as a career choice. Local public health agencies have pursued strategies to improve workforce monitoring and planning, recruitment, retention, development and training, and academic linkages. However, little progress has been made to alleviate the shortages. Without additional support to address workforce issues, including the recruitment of the next generation of public health leaders, it is unlikely that local public health agencies will succeed in meeting growing community need, a situation potentially imperiling the public's health.