What's New with HCFO - July 14, 2006 (Print All Articles)

Public Health Preparedness: Are Public Health Systems Ready for a Disaster?

Public Health Preparedness: Are Public Health Systems Ready for a Disaster?

A glance at the newspapers reminds us of the many reasons to examine the preparedness of our health care system: the arrival of a new hurricane season, the fear of bioterrorism, and the potential for an avian flu pandemic, just to name a few. In these and other crises, hospital emergency departments (EDs) are on the frontlines of disaster response. As such, the needs of hospital EDs must be integrated into public health planning. But as a battle hospital relies on support and supplies from headquarters, EDs rely on the public health systems and public health departments, which are integral in managing and responding to situations on a community level. Strengthening this essential continuum of care between community systems and frontline treatment centers has been identified as a strategic goal by the Department of Health and Human Services, which included enhancing the ability of the nation’s health care system to effectively respond to bioterrorism and other public health challenges as part of its five year objectives from FY 2004-2009.¹

Recent reports have further demonstrated this pressing need. The Institute of Medicine (IOM) recently released a series of reports on the state of the nation’s emergency rooms that question the ability of our health system to deal with major disasters. The reports found that many emergency departments and trauma centers are overcrowded. Between 1993 and 2003, the number of emergency visits grew by 27 percent, from 90 million to 114 million. Yet, over the same period of time, there has been a decrease of 425 EDs and 198,000 hospital beds. Furthermore, the emergency care system is inadequately prepared to handle a major disaster; the overcrowding of EDs has left little surge capacity for a major event, whether it is a natural disaster, disease outbreak, or terrorist attack. Additionally, many emergency medical services (EMS) personnel lack the necessary equipment, funds, and training to deal with these events.²

Not only did these reports find the emergency care system to be “overburdened and underfunded,” it also found it to be “highly fragmented.” This fragmentation hampers our ability to respond to disasters at the community level. Cities and regions are often served by multiple 911 call centers and EMS services are not effectively coordinated with EDs and trauma centers; as a result, the regional flow of patients is poorly managed. The reports further found that there is ineffective communication between EMS and public health departments with the two often operating on different radio frequencies and with different procedures in emergencies.³

As research and analysis of these shortcomings in our nation’s preparedness systems is presented, recommendations on strengthening our capabilities have begun to emerge. First, the IOM calls for action to relieve overcrowding and other detrimental practices such as boarding of patients and ambulance diversion. The expansion of emergency departments to accommodate these patients and potentially more in case of a disaster is vital. In addition to expansion, innovative programs on a local level that address admissions, discharges, and patient movement within the hospital have shown promise.⁴ Second, the IOM reports recommend the creation of a “coordinated, regionalized, accountable system,” in order to better ensure the best emergency services for the patients. They also call for the creation of national performance standards by the federal government in different areas of emergency response and care.

A successful disaster response will require this system to rely on strengthened relationships between public health departments and the clinician community, in areas of information systems and communication networks, and in infrastructure and personnel.⁵ New technologies will enable these networks to function smoothly, yet the lessons of Hurricane Katrina remind us that disasters can sometime disrupt the electronic systems we rely on daily, so better coordination among professionals in the medical and public health communities is important. Hospital and health department preparedness plans must be better coordinated in all facets.⁶ Finally, health departments must better organize and adapt in order to respond to a new expanded role in emergency preparedness, while not losing sight of more traditional public health functions.⁷

These recommendations lay out general areas where gaps in our nation’s preparedness need solutions. As some of the cited publications suggest, the answers lie both in new ideas, as well as in evaluating previous efforts to determine what solutions work best.

Current HCFO grantee Michael Stoto, Ph.D., of RAND, is conducting a series of comparative studies examining the regionalization of public health systems—the organization and development of such systems, as well as the impact they would have on public health preparedness.

Another HCFO sponsored project conducted by Gloria Bazzoli, Ph.D., examined organization and performance of trauma systems. Among its findings was the identification of common factors that were found to be important in the development of comprehensive trauma systems, such as broad-based participation of key stakeholders, patient and resourceful local trauma leaders, events that catalyzed change, and funding for trauma programs.

The integration and coordination of EDs and public health systems remains important to our future disaster response and preparedness planning. HCFO funded research will continue to inform this policy debate.

HCFO Funded Research

Title: Measuring the Value of Public Health Systems
Institution: The University of Michigan
Grant Period: March 2006–February 2007
Principal Investigator: Peter Jacobson, J.D.
How can the value of governmental public health systems (GPHSs) be defined and measured? The GPHS is a state and local apparatus designed to assess and respond to threats to the public’s health through population-based and individual health services. The researchers will examine how other public or quasi-public entities define and measure value; the methodologies used to measure value; the criteria for determining and measuring value; and how measuring the value of these services will affect other important dimensions of public health systems, such as accountability. The objective of this study is to develop ways for policymakers to incorporate value measures for governmental public health system activities into resource allocation decisions.

Click here for more information.

Title: Structural Capacities, Processes, and Performance of Essential Public Health Services by Small Local Public Health Systems
Institution: University of Wisconsin
Grant Period: February 2006–January 2008
Principal Investigator: Susan Zahner, Ph.D.
What factors influence the performance of small local public health agencies (LPHA) in Wisconsin? The researchers will identify key factors by determining the contributions of specific structural capacities and processes in providing three public health services: 1) monitoring health status, 2) mobilizing community partnerships, and 3) developing policies and plans. The objective of the study is to gain insight into specific factors that can improve the quality of small local public health systems in order to assist policymakers and administrators with targeting resources and technical assistance.

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Title: Causes and Consequences of Change in Local Public Health Spending
Institution: University of Arkansas for Medical Sciences
Grant Period: March 2006–February 2007
Principal Investigator: Glenn Mays, Ph.D., M.P.H.
The researchers will examine the causes and consequences of changes in local public health agency spending. In particular, they will address the following questions: 1) How have local health spending levels and funding sources changed over the past decade; 2) How have disparities in spending levels changed among communities defined by population size, rural/urban location, socioeconomic and racial/ethnic composition, and structural characteristics of the public health system; 3) To what extent have economic, demographic, and policy-related factors precipitated change in local public health spending levels and funding sources over this period; and, 4) To what extent are changes in local public health spending associated with changes in local population health status and disease burden? The objective of the study is to assist policymakers at the federal, state, and local levels in crafting desirable strategies for funding local public health services and to provide insight into the effects of changes in spending on population health, correction of existing gaps, and disparities in the allocation of resources.

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Title: Regionalization in Local Public Health Systems: Variation in Rationale, Implementation, and Impact of Public Health Preparedness
Institution: RAND
Grant Period: February 2006–January 2007
Principal Investigator: Michael Stoto, Ph.D.
What is the effect of regionalization of public health structures? The researchers will use four comparative case studies to 1) document various rationales for creating regional public health structures; 2) understand how these structures have been organized, implemented, and governed; and 3) assess the current and likely impact of regional structures on public health preparedness and public health systems more generally. The case studies will address coordination, standardization, and developing regional capacity. The objective of the study is to provide a better understanding of the regionalization of pubic health systems in order to inform the many state and local health departments currently developing regional structures.

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Title: Trauma System Structure and Performance
Institution: Hospital Research and Educational Trust
Grant Period: September 1991 - August 1994
Principal Investigator: Gloria J. Bazzoli, Ph.D.
How well do regionalized trauma systems work and what affects their performance? This study explored the impact of the structure and organization of regionalized trauma care systems on their effectiveness, measured by patterns of hospital utilization, trauma mortality, financing, and stability. The project surveyed all existing trauma systems in the United States to identify key structural features, conduct case studies in areas with trauma systems and areas without such systems to examine the reasons behind the development of particular structures, and conduct descriptive analyses to assess empirically the relationship between structure and performance. The objective of the study was to provide information to state and local policymakers, hospitals, physicians, and other community leaders to help them develop more effective trauma systems, which will be particularly timely in light of legislation passed in 1990 that provided federal funding for regionalized trauma systems.

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¹ United States Department of Health and Human Services. HHS Strategic Goals and Objectives, FY 2004-2009. http://aspe.hhs.gov/hhsplan/
² Institute of Medicine. The Future of Emergency Care: Key Findings and Recommendations. June 2006. http://www.iom.edu/Object.File/Master/35/040/Emergency%20Care%20Findings%20and%20Recs.pdf
³ Ibid
⁴ Levine, Susan and F. Kunkle. ERs Swamped Despite New Beds and Strategies. The Washington Post. June 18, 2006. http://www.washingtonpost.com/wp-dyn/content/article/2006/06/17/AR2006061700777.html?nav=rss_health
⁵ Lurie, Nicole. Public Health Preparedness in the 21st Century. The Rand Corporation. March 28, 2006. http://www.rand.org/pubs/testimonies/2006/RAND_CT257.pdf
⁶ Davis et al. Public Health Preparedness – Integrating Public Health and Preparedness Progams. The Rand Corporation. 2006. http://www.rand.org/pubs/technical_reports/2006/RAND_TR317.sum.pdf
⁷ Wasserman et al. Organizing State and Local Health Departments for Public Health Preparedness. The Rand Corporation. 2006. http://www.rand.org/pubs/technical_reports/2006/RAND_TR318.sum.pdf

Grantee Spotlight – Anthony Lo Sasso, Ph.D.

Grantee Spotlight – Anthony Lo Sasso, Ph.D.

Anthony Lo Sasso, Ph.D., is associate professor and senior research scientist in the Health Policy and Administration Division of the School of Public Health at The University of Illinois–Chicago. An economist and applied econometrician, Dr. Lo Sasso’s research interests include the health care safety net and other health care policy initiatives; work place health benefits; and economic aspects of mental health and substance abuse. In 2005, Lo Sasso and co-author Tom Buchmueller, Ph.D. received AcademyHealth’s Article-of-the-Year Award for their work on the effect of SCHIP on public and private insurance coverage. He recently completed a five-year Independent Scientist Award from the Agency for Healthcare Research and Quality studying workplace health benefits and their affect on employee health.

Lo Sasso received his B.A. and M.A. in economics from DePaul University and his Ph.D in economics from Indiana University.

In March of 2001, Lo Sasso received a HCFO grant to examine the relationship between the safety net (i.e. hospitals and federally qualified health centers) and employer provided health insurance. Specifically, his research focused on how the structure and characteristics of the safety net affect employees’ decisions to accept coverage for themselves and their families and employers’ decisions to offer it. The researchers compiled data using the March Current Population Survey Annual Demographic File from 1990-2000 and information on uncompensated care reported in the American Hospital Association’s annual survey of hospitals and administrative data on Federally Qualified Health Centers as reported to the Bureau of Primary Health Care. These detailed measures on individual health insurance coverage and health care facilities were used to investigate the link between coverage and safety-net characteristics over an 11-year period.

Findings indicate that safety net services “crowd out” private health insurance for childless adults with access to good safety-net services. The extent of this crowd out appears mixed, however, with hospital uncompensated care largely unrelated to health insurance coverage and health center uncompensated care associated with relatively small “crowd out.” For children under the age of 14, there is only weak evidence that the safety net affects take-up of private insurance. Lo Sasso explains “the research is noteworthy because, in contrary to some previous research, we do not find evidence of large crowd-out associated with safety net health care services. This suggests that government support of the health care safety net may represent a minimally distortive means of improving health for low-income individuals.”

For more information on Anthony Lo Sasso, Ph.D., and a list of selected publications please see:
http://apr.sph.uic.edu/faculty_profile/facultyprofile.asp?i=losasso

New HCFO Findings Brief

It is important that the tools used to rank physicians provide consumers and payers with an accurate representation of physician treatment behavior, allowing consumers to make more informed decisions while helping health plans make better choices about which physicians to include in their networks. A recently completed HCFO study by J. William Thomas, PhD, of the University of Southern Maine and Kyle L. Grazier, DrPH, of the University of Michigan assessed the feasibility of using episode-based physician profiling and identified a number of methodological issues that can influence the validity of cost efficiency rankings for some specialties.

This Month in the News

Mary A. Pittman, Ph.D., president of the Health Research and Educational Trust, was quoted in a June 19, 2006 article published by United Press International that examined new ethics guidelines for doctor-patient communication released by the American Medical Association . The article notes that “communication breakdowns are the most common root cause of health care errors that harm patients” and that focusing on communication, especially with those patients who have limited English proficiency, could help to reverse this trend. Pittman states that “not only do health care workers need training on how to communicate more effectively with patients, but health care organizations also need to provide staff with tools and resources necessary to overcome language and cultural barriers.”

Susan Zahner, Ph.D. , Assistant Professor at the University of Wisconsin, School of Nursing, was recently awarded the Excellence in Public Health Research Award from the Wisconsin Public Health Association . Zahner was honored for her research focusing on the public health system, including studies on collaborative partnerships, public health nurses, and the performance of rural public health systems.

New HCFO Grants Awarded

New HCFO Grants Announced

Three new grants have been awarded by the Robert Wood Johnson Foundation's HCFO initiative, examining the effects of the Washington State Diabetes Collaborative, Medicare beneficiaries’ responses to coverage gaps versus actuarially equivalent coverage, and Maine’s DirigoHealth initiative.

Grant Number: 56739
Title: Medicare Beneficiaries’ Response to Coverage Gaps Versus Actuarially Equivalent Continuous Coverage for Prescription Drugs
Grantee Institution: University of Maryland at Baltimore
Principal Investigator: Bruce Stuart, Ph.D.
Grant Period: July 01, 2006 –June 30, 2007
Grant Summary:
Are Medicare beneficiaries likely to react differently when faced with the donut-hole “gap” in Medicare Part D than they would with actuarially equivalent continuous coverage? The researchers propose to challenge the hypothesis that actuarially equivalent but structurally different cost sharing arrangements have similar impacts on beneficiaries' prescription drug utilization patterns. The researchers would also determine whether the relationship between use and benefit structure is sensitive to the overall generosity of insurance coverage. This project builds on Stuart's previous HCFO grant assessing the effects of gaps in drug coverage for Medicare beneficiaries with common chronic diseases. That study found that gaps in drug coverage lead to reduced utilization rates and that the effects are magnified for those with common chronic diseases such as diabetes, COPD, and mental illness. This project would extend the understanding of how Medicare beneficiaries react to benefit structure, but would also be useful to private payers as they search for a cost sharing formula that contains costs while minimizing disruption in medication regimens. The objective of this project is to provide policymakers with a better understanding of how Medicare beneficiaries behave when faced with alternative cost-sharing structures.

For more information, please visit the grant webpage.

Grant Number: 58064
Title: Impact of the Washington State Diabetes Collaborative on Patient Health and Economic Outcomes
Grantee Institution: Washington State Department of Health
Principal Investigator: Amira El-Bastawissi, Ph.D.
Grant Period: July 01, 2006–February 28, 2008
Grant Summary:
How do the clinics and primary care physicians participating in Collaborative III of the Washington State Diabetes Collaborative affect the health and economic outcomes of diabetic patients? The collaborative combines elements from Collaboratives of the Institute for Healthcare Improvement and the Chronic Care Model developed by Edward Wagner and colleagues. The researchers would capture the later-stage results of the collaborative, “thus offering an impact evaluation of a mature system-change model.” In particular, the researchers would explain how different components of the collaborative approach to diabetes care management directly affect health and economic outcomes (utilization and costs). The objective of the study is to better inform health plans, public payers, health care providers, and employers about the economic impact of the collaborative, to inform their quality improvement, benefit design, and payment decisions for diabetic patients.

For more information, please visit the grant webpage.

Grant No.: 58012
Title: Evaluation of Maine's Dirigo Health Reform
Institution: Mathematica Policy Research, Inc.
Principal Investigator: James M. Verdier, Ph.D.
Grant Duration: July 01, 2006 - October 31, 2007
Paragraph Summary: What are the program accomplishments and vulnerabilities of DirigoChoice, a subsidized health insurance program which is the centerpiece of Maine’s health care reform legislation, Dirigo Health. While it is too early in the program’s implementation to measure Dirigo’s ultimate impact on coverage, cost, and quality, the researchers will evaluate program accomplishments and vulnerabilities. Specifically, the following questions will be addressed: (1) Are low wage workers and their families more likely to take up health insurance coverage, and does this affect their ability to get care when needed? (2) Are small employers more aware of and likely to offer health insurance to their employees? What factors of the program are more successful at enrolling small businesses and how satisfied are employers with the program? (3) How is the DirigoChoice “savings offset payment” calculated, and is this revenue stream sustainable? (4) Is this approach to insurance coverage expansions replicable in other states? The objective of this project is to assess the progress of Maine’s approach to coverage expansion and to determine if DirigoChoice is sustainable and replicable.

For more information, please visit the grant webpage.

Spotlight on Grantee Publication

Gloria Bazzoli, Ph.D., a professor of Health Administration at Virginia Commonwealth University, is the co-author of an article that appeared in the March 2006 issue of HSR, titled “The Influence of Health Policy and Market Factors on the Hospital Safety Net”. The article details HCFO sponsored research examining the effect of the Balance Budget Act of 1997 on the hospital safety net.

Current HCFO grantee publications and recent grant findings will be regularly featured in the results section of our Web site.

New NCHS Data Available for Researchers

The National Center for Health Statistics (NCHS) announces the availability of a new resource, the 2004 National Nursing Home Survey (NNHS), for researchers and policymakers interested in studying the characteristics of nursing homes and residents receiving care, and the clinical management of their care. Results from this survey will be available for release to the public in August.

The 2004 NNHS is a periodic national probability sample survey of nursing homes, their staff, and the residents that they serve. Conducted first in 1973-74, the 2004 survey has undergone a redesign with expanded content and a computerized data collection system. The 2004 NNHS public use micro-data file will be available for downloading at the NNHS website below. Also available are complete file documentation and program code to read and format the data set using SAS, SPSS and Stata.

Detailed web tables with tabulated data will also be available following this upcoming release of the results from the 2004 NNHS. These tables will include data on the characteristics of the facilities, such as information about Medicare and Medicaid certification, bed size, type of ownership, services provided and per diem rates also presented in data files, reports, and web tables from previous surveys. New facility data items also summarized in these tables include: information on special care units and programs; formal contracts with agencies and providers; end-of-life care programs; and electronic information systems.

Data for current residents will be presented by demographics, health and functional status, services provided, primary diagnosis and all-listed diagnoses as presented in previous data files, reports and web tables. Also summarized in these 2004 tables will be new information on residents such as: advance directives, falls, use of restraints, use of special units and programs, hospitalizations, pain management, end of life care, and medications.

The facility and current resident data sets will be available at http://www.cdc.gov/nchs/nnhs.htm. The NNHS is a component of a family of surveys known collectively as the National Health Care Survey (NHCS). For information on other surveys in the long-term care component, ambulatory care, inpatient care and ambulatory surgery components of the NHCS, please visit http://www.cdc.gov/nchs/nhcs.htm.

HCFO Announces Public Health Services Research Special Topic Solicitation

The Robert Wood Johnson Foundation, through its Changes in Health Care Financing and Organization (HCFO), is issuing a special topic solicitation on public health systems research. Potential projects should contribute to an enhanced understanding of public health systems, which comprise the array of public and private entities that engage in activities to promote health and prevent disease and injury at the population level. Pending RWJF Board of Trustees approval, this solicitation will be issued each of the next three years. The 2006 Solicitation is now posted on the HCFO website.

Conflicts of Interest Curriculum Module

Conflicts of interest can easily arise and threaten the integrity and credibility of research, researchers, funders, and the field as a whole. It is important that researchers be able to identify these conflicts of interest and know how to manage them when they arise. AcademyHealth, with support from the Association of American Medical Colleges, developed a Curriculum Module that can be used by individuals and institutions to evaluate their own behavior, update their policies, educate their trainees, and guide the management of difficult ethical situations. The module is designed to engage the user through a participatory group discussion and includes “ready to use” materials that can be modified for different classroom applications and degree program levels.

Details can be found at http://www.academyhealth.org/ethicalcurriculum/

AcademyHealth Health Policy Orientation

Health Policy Orientation October 23-26, 2006
Washington, D.C.

Join us for the AcademyHealth Health Policy Orientation: Behind the Scenes of Decision Making in Washington on October 23-26 in Washington, D.C. With a one-to-one ratio of faculty to participants, the orientation offers an in-depth introduction to the key players, formal and informal policymaking processes, and critical health policy issues.

View the agenda online here.