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![Page 1: Nathan Hale, PhD Assistant Professor (Research) Deputy Director, South Carolina Rural Health Research Center.](https://reader036.fdocuments.us/reader036/viewer/2022062516/56649d6f5503460f94a5088a/html5/thumbnails/1.jpg)
Local Health Departments and Clinical Services:
Lessons from South Carolina
Nathan Hale, PhDAssistant Professor (Research)
Deputy Director, South Carolina Rural Health Research Center
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Public Health Dilemma
Population based public health =
Current landscape – many remain DSP• 50% Family Planning• 46% Immunizations• 33% EPSDT• 20% Managed Care (Medical Home)
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Dilemma (2) Economic Recession
• Driven further into clinical services?
Healthcare Reform• Catalyst for re-examining priorities –
discontinue?
Transitions occurring more frequently
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Critical Questions
Two critical questions:
• What happens when the transition is made?oReceipt of services?oPopulation based health outcomes?oDifferent for rural communities?
• How do you mitigate the potential impact?
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Rural Populations and EPSDT Services: Challenges and
Opportunities for Local Public Health Departments
Hale, N. Smith, M, Hardin, J. Martin, A. American Journal of Public Health. 2015 Apr;105 Suppl 2:S330-6
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Background SCDHEC – State public health
agency
• 1995 -> SCDHEC 40% of EPSDT Market
• Mid 1990’s -> Transitioned EPSDT services
• Some targeted transitioning -> mostly attrition
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Background Background
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Methods - Data Data
• Retrospective cohort of infants enrolled in Medicaid
• 1995-2010• Eligibility / billing data• Continuous Medicaid enrollment for 12 months
Data Structure• Repeated Cross-sectional• Rolling Panel
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Methods - Variables Dependent
• Any EPSDT visit (dichotomous)• Ratio of Observed to Expected EPSDT visits
Independent• Time (0-15)• SCDHEC Market ShareoHigh (>60%) | Average (20-59%) | Low (<20%)
• Rural Residence (Urban Influence Codes) oUrbanoRural
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Methods - Additional Variables
Time Invariant
Maternal race/ethnicity Maternal age Maternal education Special health care
needs
Time Variant
FQHC/RHC penetration Private sector capacity Managed Care
penetration Medicaid enrollment Reimbursement
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Methods - Analysis Growth Curve Models
• FixedoTime | SCDHEC Market Share | RuraloOther Time-variant | Time-invariant
• RandomoCounty | Time
• 3-way interaction (Time | SCDHEC | Rural)
Stata – xtmelogit | xtmixed • Predicted probabilities | Marginal means
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Methods - Analysis
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1995 2000 2005 20100%
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Low Share Average Share High Share
1995 2000 2005 20100%
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Low Share Average Share
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Low Share Average Share
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Low Share Average Share High Share
Urban Rural
Any EPSDT
# of EPSDT Visits
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Policy Implications Urban -> stabilized -> ultimately improved
• Primary Care Infrastructure
Rural -> steady deterioration -> yet to recover
• Historically underserved | limited primary care
Note: Rural = 10% of the study population
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Challenges & Opportunities
Rural LHDs & ACA (tough position)• Increased demand + constrained supply =
deeper into safetynet & direct service provision
Transition may be very difficult• Potential to exacerbate existing resource
voids
FQHC | Medical home initiatives
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Policy Implications – Big Picture 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 (ie Family Planning Study)
PPACA + Recession -> Increasing opportunity• FQHC | Medical Home | Population health funding
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Thank You!Nathan Hale, PhD.
Research Assistant Professor, Dept of Health Services Policy & Mgmt
Deputy Director, South Carolina Rural Health Research Center
[email protected] (803) 576-7384