Assessing the impact of Medicaid managed care on TB activities in local health departments.

Three in-depth case studies were conducted to explore the impact of Medicaid managed care on local health department prevention activities. Tuberculosis (TB) was selected as a sentinel issue because TB includes both clinical treatment and population-based public health considerations (such as surveillance and contact tracing). Overall, study results indicated that there has been a minimal impact on TB prevention and control services, primarily because few TB patients are served by managed care. However, the sites offer many suggestions for areas to monitor, possible collaborative opportunities, and mechanisms to assure continued TB prevention and control.

The education of local health department top executives.

An analysis was done on the educational backgrounds of current top agency executives of U.S. local health departments (LHD), using the National Association of City and County Health Officials 1992-1993 national survey of LHDs as the data source. Nurses are often the executive in jurisdictions with less than 50,000, while executives of jurisdictions with more than 250,000 are predominantly physicians. Overall, 78 percent of LHD executives have no formal public health training, and executives of larger jurisdictions are more likely to have a public health degree. Because a majority of executives lack formal training opportunities for them need major expansion. Particular emphasis should be placed on expanding short-term opportunities such as state-based leadership and distance-based learning programs.

Managed care and the public health challenge of TB.

Managed care is fast becoming the dominant form of medical care delivery and financing in the United States, yet its effects on public health practice remain largely unknown. Tuberculosis (TB) is a classic example of a disease with both public health and medical care implications, and as such it provides an opportunity for examining the impact on public health of the shift towards managed care in the medical marketplace. The authors approach the role of managed care in TB control by first considering the need for interorganizational coordination at the community level. The authors identify four basic models of how managed care organizations may fit into TB control efforts in local communities, using observations from 12 local public health jurisdictions to illustrate these models. These TB control models provide insight into the general mechanisms through which managed care organizations may affect other areas of public health practice.

Determinants of US local health department expenditures, 1992 through 1993.

OBJECTIVES: This study examined local health department expenditures and their relationship to several departmental characteristics, including the size of the population in the department's jurisdiction. METHODS: Local health department characteristics were obtained from a 1992/93 nationwide mail survey and modeled by means of multiple linear regression. RESULTS: Great variability existed in the per capita expenditures of local health departments, and approximately 70% of the variability was accounted for by differences in jurisdiction population size. Additional characteristics of the health departments explained another 11%. The average unadjusted per capita expenditure by local health departments nationwide was $26. CONCLUSIONS: Local health department expenditures that support essential public health services average a dime a day per person.

Not-so-strange bedfellows: models of interaction between managed care plans and public health agencies.

Alliances between managed care plans and public health agencies are a growing phenomenon in local health care markets, with profound implications for health care quality, cost, and accessibility. A typology of interorganizational relations between managed care plans and local public health agencies is drawn from observations of over 60 public health jurisdictions. Relations are described along three dimensions corresponding to the strategic intent, functional operation, and structural design of each alliance type. The identified models of interaction reveal the motivations for forming alliances, the mechanics of their operation, and the possible outcomes. These alliances suggest that a wide range of interorganizational strategies is possible in order to pursue the shared interests of local public health agencies and managed care plans. Nonetheless, public health agencies may face challenges in forging managed care alliances that benefit community-wide populations and that are open to participation by the full spectrum of health care providers in the community.

Privatizing health services: alternative models and emerging issues for public health and quality management.

Concerns about the cost, quality, and efficiency of services provided within public sector health care systems are leading policy makers and health care administrators to reinvent government and develop alternative methods for the delivery of services traditionally offered in the public sector. Privatization structures that incorporate strong quality management principles, both through formal accountability systems and through financial risk-sharing arrangements, appear to hold the greatest promise for achieving quality and efficiency goals.

Performing public health functions: the perceived contribution of public health and other community agencies.

As public health struggles to define its role within health care reform, the need to examine carefully the component organizations providing and/or supporting health care for the public appears critical. This article identifies the nature and extent of involvement by agencies other than the official local public health department in performing public health practices and functions within 63 local public health jurisdictions. Adequacy of overall public health performance is significantly related to the extent of participation of outside agencies. Outside agencies contribute over 26 percent to the total public health performance for the jurisdictions surveyed. Other agencies of government, both at the state and local level, are the predominant outside contributors to public health practice. Private and voluntary agencies are perceived as minor contributors. Little variation exists among communities in which outside agencies tend to perform particular public health activities. Findings suggest that local public health departments can maximize their impact by understanding better the nature of working relationships within multi-institutional arrangements, encouraging greater levels of collaboration and integration and acting as catalysts for increased support of public health activities.

Recent changes in local health department spending.

This study determined differences in U.S. local health department (LHD) expenditures between 1989 and 1993 and examined the factors that were associated with those changes. Adjusted to constant 1993 dollars, nearly half (48%) of the studied LHDs experienced budget decreases and 52% experienced budget increases. The median change in LHD budgets was 0.2% growth per year. Significant associations were found between the likelihood of a department experiencing a budget increase and several measures describing the LHD's administrative and economic environment.

Medicaid managed care and public health policy.

This article provides an overview of managed care concepts and highlights several issues for public health practitioners. Taken from a transcription, this summary is based on a Forum on Public Health and Health Reform held in Atlanta, Georgia, on May 12, 1995, sponsored by the Public Health Practice Program Office, Centers for Disease Control and Prevention. Examples of issues related to managed care for public health practitioners discussed here include: (1) building on managed care plan report cards for large employers so they have an expanded community perspective; (2) developing report cards for Medicaid managed care plans; (3) obtaining patient encounter information from managed care plans for purposes of surveillance and epidemiologic studies; (4) adjusting provider utilization profiles to take into account the differences in the population being served; (5) linking managed care plans with specialized public health providers and community institutions; and (6) consumer surveys related to prevention and public health services.

Validation of a screening survey to assess local public health performance.

The study seeks to validate an abbreviated protocol for measuring local public health performance. Primary data were collected during 1993 on a series of indicators keyed to defined public health core functions and their associated practices. The data were obtained from responses provided by local health department directors and were reviewed for accuracy by respective state health department personnel. All local public health jurisdictions (370) in six states were surveyed with a screening protocol. A sample of 36 of these jurisdictions was then resurveyed by means of a full-length protocol using 84 different indicators of public health performance. Correlations between scores obtained from the screening survey and those from the reference survey were high for overall public health performance, for each of the three functions, and for some of the ten practices. A group of only four queries was shown to predict reliably the overall scores. Findings support the conclusion that public health practice can be defined, measured, and monitored. A proposed surveillance system is feasible.

Creating and validating practical measures for assessing public health practices in local communities.

Efforts to develop a surveillance system to measure local public health performance were initiated in 1991. The organizing framework for the proposed system consisted of three core functions formulated by the Institute of Medicine and linked with 10 practices previously defined. A surveillance protocol was developed using local public health jurisdictions rather than specific agencies within the jurisdictions, as the units of study. Selection of 84 indicators was assisted by follow-up study of a group of departments analyzed in 1979 and by review of recent public health literature. Each of the 84 performance indicators was linked to one of the 10 practices. Responses to the survey were obtained from local health department directors. Results yielded scores for the surveyed jurisdiction with regard to adequacy of performance for each practice, the proportional contribution to performance by the local health department, and the identification of other providers contributing to the coverage of each practice within the jurisdiction. A shortened version of the protocol (26 indicators) was tested in all local jurisdictions in six states and shown to correlate reliably with scores obtained from the longer protocol for overall public health performance, as well as for performance of each of the three core functions and for some of the 10 practices. A subset of four indicators was shown to predict reliably the overall score. The findings support the proposition that public health practice can be defined, measured, and monitored and that current widely accepted definitions of core functions and practices have utility. Measurement and surveillance tools for these functions and practices are available and tested.

Public health performance related to selected health status and risk measures.

Many public health interventions are targeted for high-risk locales. For this reason, health status and public health effort may appear inversely related. We designed a study to relate public health performance to health status or risk measures. This study hypothesized that differences in local need might prompt divergent levels of public health response and that the resultant diversity might imply disarray. From a group of 62 local health departments that have been the subject of intensive study, 34 were chosen serving jurisdictions with populations in excess of 100,000. Data were collected on selected health status as well as socioeconomic and budget measures. The data were then examined in a four-cell format, aggregating levels of public health performance with health status or risk levels according to each measure. The analysis of public health performance, when related to selected measures, suggests that public health endeavors may differ appropriately in different jurisdictions.

Assessing public health practice: application of ten core function measures of community health in six states.

Factor analysis, combined with an evaluation of item difficulty and discrimination, can provide useful insights in questionnaire development. In 1993, as part of a study to develop a questionnaire to assess performance of the core functions of public health at a community level, 370 local health departments (LHDs) in six states completed a 26-item questionnaire (94% response). This study describes factor analysis results after controlling for item difficulty and discrimination. Fifteen items had intermediate difficulty and fair-to-good discrimination. Factor analysis of these 15 items identified four factors. Three of these factors included items from more than one of the core functions. These findings pose an interesting question for future research: are the core functions of public health better conceived as three discrete, distinguishable factors or as three interlocking factors that form a single, seamless unit?