Bridging Health and Health Care
Transcript of Bridging Health and Health Care
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Bridging Health and Health CareWednesday, January 14, 2015 12-1pm ET
Local Public Health Clinic Retraction and Reproductive Health Service Utilization & Outcomes
Conference Phone: 877-394-0659Conference Code: 775 483 8037#Please remember to mute your phone and computer speakers during the presentation.
PHSSR NATIONAL COORDINATING CENTER AT THE UNIVERSITY OF KENTUCKY COLLEGE OF PUBLIC HEALTH
PHSSR Research-In-Progress Series:
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Agenda
Welcome: Rick Ingram, DrPH, National Coordinating Center
Presenter: “Local Public Health Clinic Retraction and Reproductive Health Service Utilization & Outcomes”
Nathan Hale, PhD, Research Assistant Professor, Dep’t of Health Services Policy and Management, Arnold School of Public Health, U. of South Carolina
Commentary:Alana Knudson, PhD, Principal Research Scientist, Public Health, NORC at University of Chicago
Michael Smith, MSPH, Epidemiologist & Director, Maternal and Child Health Research & Planning, S. Carolina Dep’t. of Health & Environmental Control
Questions and Discussion
Future Webinars
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Presenter
Nathan Hale, PhD
Research Assistant Professor
Department of Health Services Policy and Management
Arnold School of Public Health
University of South Carolina
Deputy Director
South Carolina Rural Health Research Center
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Nathan Hale, PhD1
Assistant Professor (Research)
Mike Smith, MSPH2
Maternal and Child Health Epidemiologist
1 2
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• Disease/Injury Prevention
• Environment
• Sanitation
Population Based
• Uninsured
• Access to Care
• Services gaps for Women/Children
Clinical Services • IOM
Reports/Recommendations
• Accreditation
• Healthcare Reform
Population Based
?
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Population based public health =
Current landscape – many remain DSP• 50% Family Planning
• 46% Immunizations
• 43% EPSDT
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Economic Recession• Driven further into clinical services?
Healthcare Reform• Catalyst for re-examining priorities – discontinue?
Transitions occurring more frequently
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Two critical questions:
• What happens when the transition is made?
• How do you mitigate the potential impact?
Opportunity to examine in South Carolina
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SCDHEC – State public health agency
• Title X – Clinical services for Family Planning
• Medicaid – Significant provider of clinical serviceso~50% of caseload
• Fiscal ConstraintsoState and local revenue
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0
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Total Revenue for Family Planning Services (2002-
2011)
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0
20,000
40,000
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2003 2004 2005 2006 2007 2008 2009 2010 2011
SCDHEC Family Planning Caseload
(2003-2011)
-28,000
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Retraction of Clinical Services oReduced staffing / clinic hourso Select clinic closings
• Geographic variation Reduced capacity geographically distributed Clinic closings geographically distributed
• Time variation Reduced capacity occurred in waves
Clinic closing every year from 2003 - 2010
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Aim 1 – Impact of clinical service retraction on receipt of annual family planning visits
Aim 2 – Impact of clinical service retraction on population-based health outcomes
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Data• Cohort of women enrolled in Medicaid
• 2001-2012
• Eligibility / billing data
Data Structure• Rolling Panel
• Entry 1st year of Eligibility on Record
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Dependent• Receipt of Annual Visit
• Sexually Transmitted Infections (STI)
• Short Pregnancy Spacing <18 months from previous live birth
• All variables dichotomous (yes/no) in each year of study
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Independent• Time (0-12)• SCDHEC County Typology (4-level categorical)
No Reduced Capacity / No Clinic Closing (NRC/NCC) Reduced Capacity / Clinic Closing (RC/CC) Reduced Capacity / No Clinic Closing (RC/NCC)
No Reduced Capacity / Clinic Closing (NRC/CC)
• Reduced Capacity = >30% reduction in SCDHEC caseload Mirror change in state-level caseload
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Generalized estimating equations (GEE)• Used to analyze correlated data (panel)
• Population-averaged probabilities (marginal means)
• Interaction (Time | County Typology)
Stata – xtgee• Binary data | link logit | auto-regressive correlation
matrix with a single lag
• Marginal effects (Stata margins command)
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19%18%
36%
27%
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
Typology 1 Typology 2 Typology 3 Typology 4
Distribution of Study Population by
County Typology
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0
1,000
2,000
3,000
4,000
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7,000
8,000
9,000
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Nu
mb
er
of
Wo
me
n
Number of Newly Medicaid Eligible Women by
County Typology and Year (2001-2012)
No Reduced Capacity Reduced Capacity/Clinic Closing
Reduced Capacity/No Clinic Closing No Reduced Capacity/Clinic Closing
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*Study population - reflects the collective values for all women eligible for Medicaid
Over the duration of the study period (2001 -2012)
^Chi square p<0.05
Selected Outcomes
Total Typology 1 Typology 2 Typology 3 Typology 4
N=2,234,439 n=444,617 n=399,138 n=776,163 n=614,521
Annual Visits^562,588 (25.18%)
109,118 (24.54%)
91,450 (22.91%)
214,145 (27.59%)
147,875 (24.06%)
STI^87,644 (3.92%)
18,301 (4.12%)
12,503 (3.13%)
33,222 (4.28%)
23,618 (3.84%)
Repeat Pregnancy^ 80,303 (3.59%)
15,528 (3.49%)
17,716 (4.44%)
25,563 (3.29%)
21,496 (3.50%)
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All models adjusted for race/ethnicity, age, marital status, Medicaid enrollment and changes in Medicaid enrollment over time,
annual visits provided by provided by private providers and changes visits by private providers, annual visits provided by
FQHCs and changes in visits over time.
Model 1: Annual Visits
Coefficient P-value95% Confidence Interval
(LBL - UBL)
Variables of Interest
Year 0.003 0.037 -0.004 0.010
Year^2 0.003 <0.001 0.003 0.004
County Typology
No Reduced Capacity/No Closing Reference
Reduced Capacity/Closing -0.021 0.032 -0.063 0.020
Reduced Capacity / No Closing 0.321 <0.001 0.291 0.351
No Reduced Capacity/Closing -0.079 <0.001 -0.112 -0.045
County Typology*Year
No Reduced Capacity/No Closing Reference
Reduced Capacity/Closing -0.022 <0.001 -0.028 -0.017
Reduced Capacity / No Closing -0.032 <0.001 -0.037 -0.028
No Reduced Capacity/Closing 0.005 0.025 0.001 0.010
Intercept -1.203 -1.236 -1.170
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0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Av
era
ge
d P
rob
ab
ilit
y
Average Adjusted Probability of Having an Annual Visit by
County Typology and Year
No Reduced Capacity Reduced Capacity/Closing
Reduced Capacity/No Closing No Reduced Capacity/Closing
NRC/NCC Δ μp = 28% RC/CC Δ μp = 9%
RC/NCC Δ μp = 0.5% NRC/CC Δ μp = 34%
Respond to Demand?
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-0.06
-0.04
-0.02
0
0.02
0.04
0.06
Av
era
ge
d P
rog
ab
lity
Marginal Effect of County Typology on Annual Visits
Reduced Capacity/Closing Reduced Capacity/No Closing
No Reduced Capacity/Closing
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All models adjusted for race/ethnicity, age, marital status, Medicaid enrollment and changes in Medicaid enrollment over time,
annual visits provided by provided by private providers and changes visits by private providers, annual visits provided by
FQHCs and changes in visits over time.
Model 2: STI
Coefficient P-value95% Confidence Interval
(LBL - UBL)
Variables of Interest
Year 0.058 <0.001 0.051 0.065
Year^2
County Status
No Reduced Capacity/No Closing Reference
Reduced Capacity/Closing -0.159 0.001 -0.255 -0.063
Reduced Capacity / No Closing -0.099 0.002 -0.164 -0.035
No Reduced Capacity/Closing -0.197 <0.001 -0.270 -0.124
County Status*Year
No Reduced Capacity/No Closing Reference
Reduced Capacity/Closing 0.029 <0.001 0.017 0.042
Reduced Capacity / No Closing 0.012 0.008 0.003 0.020
No Reduced Capacity/Closing 0.017 <0.001 0.008 0.027
Intercept -4.077 -4.148 -4.005
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0.00
0.01
0.02
0.03
0.04
0.05
0.06
0.07
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Av
era
ge
d P
rob
ab
ilit
y
Average Adjusted Probability of Having an STI by
County Typology and Year
No Reduced Capacity Reduced Capacity/Closing
Reduced Capacity/No Closing No Reduced Capacity/Closing
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-0.006
-0.004
-0.002
0
0.002
0.004
0.006
0.008
0.01
0.012
Av
era
ge
d P
rog
ab
lity
Marginal Effect of County Typology on STI
Reduced Capacity/Closing Reduced Capacity/No Closing
No Reduced Capacity/Closing
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All models adjusted for race/ethnicity, age, marital status, Medicaid enrollment and changes in Medicaid enrollment over time,
annual visits provided by provided by private providers and changes visits by private providers, annual visits provided by
FQHCs and changes in visits over time.
Model 3: Repeat Pregnancy
Coefficient P-value95% Confidence Interval
(LBL - UBL)
Variables of Interest
Year 0.4140 <0.001 0.3932 0.4348
Year^2 -0.0211 <0.001 -0.0224 -0.0198
County Status
No Reduced Capacity/No Closing
Reduced Capacity/Closing 0.6859 <0.001 0.5627 0.8092
Reduced Capacity / No Closing -0.0957 0.062 -0.1963 0.0048
No Reduced Capacity/Closing 0.1510 0.006 0.0434 0.2585
County Status*Year
No Reduced Capacity/No Closing
Reduced Capacity/Closing -0.0478 <0.001 -0.0629 -0.0327
Reduced Capacity / No Closing 0.0096 0.133 -0.0029 0.0220
No Reduced Capacity/Closing -0.0149 0.028 -0.0282 -0.0016
Intercept -5.1910 -5.2986 -5.0835
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0.00
0.01
0.02
0.03
0.04
0.05
0.06
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Av
era
ge
d P
rob
ab
ilit
y
Average Adjusted Probability of Having a Repeat Pregnancy by
County Typology and Year
No Reduced Capacity Reduced Capacity/Closing
Reduced Capacity/No Closing No Reduced Capacity/Closing
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-0.004
-0.002
0
0.002
0.004
0.006
0.008
0.01
0.012
0.014
0.016
0.018
Av
era
ge
d P
rog
ab
lity
Marginal Effect of County Typology on Repeat Pregnancies
Reduced Capacity/Closing Reduced Capacity/No Closing
No Reduced Capacity/Closing
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Service Receipt – annual visits • Reduced Capacity -> some disruption
• Disruption in the sense of responding to demand
• ~6% max difference μp between county typologies
Outcomes • Marginal effects stronger in reduced capacity counties
• Magnitude of the effects -> relatively small
• Trajectories over time similar across typology
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Increased burden in finding provider• Already a burdensome task
More difficult in underserved communities with limited provider capacity
Same quality of services?
Reality for individual women shouldn’t be dismissed
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State• Funding decreases -> trade-offs
• Transition efforts by LHD critical for mitigating the potential impact – must play active assurance role
Transition efforts• Reduced capacity (no closing) -> equally disruptive
• Risk complacency in reducing rather than closing
• Equally rigorous efforts when reducing capacity are needed
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Retraction of clinical services = Impact
Real Question – What is tolerable impact?
PPACA + Recession -> Increasing demand• How can LHDs really make this transition?• Targeted retraction of clinical services probably the more
likely scenario
PPACA + Recession -> Increasing opportunity• FQHC | Medical Home | Population health funding
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Commentary
Alana Knudson, PhDPrincipal Research Scientist, Public HealthNORC at University of Chicago
Michael Smith, MSPHEpidemiologist and Director, Maternal and Child Health
Research & Planning South Carolina Dep’t. of Health & Environmental Control
Questions and Discussion
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Upcoming PHSSR Research in Progress Webinars
Thursday, January 22 (1-2pm ET)Using an Evidence-Based Framework to Identify Improvement Measures for the
New York Prevention Agenda’s “Promote Mental Health and Prevent Substance Abuse” Priority
Chris Maylahn, MPH, and Priti Irani, MSOffice of Public Health Practice, New York State Department of Health
Wednesday, February 4 (12-1pm ET) TBD
Wednesday, February 11 (12-1pm ET) Cross-Jurisdictional Shared Service Arrangements in Local Public Health Susan Zahner, MPH, DrPH, University of Wisconsin-Madison
Thursday, February 19 (1-2pm ET)Local public health structures and improved maternal and child health outcomesTamar A. Klaiman, PhD, MPH, University of the Sciences
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For more information contact:Ann V. Kelly, Project Manager
111 Washington Avenue #212Lexington, KY 40536
859.218.2317
www.publichealthsystems.org