nathan hale, phd assistant professor (research) deputy director, south carolina rural health...
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Local Health Departments and Clinical Services:
Lessons from South Carolina
Nathan Hale, PhDAssistant Professor (Research)
Deputy Director, South Carolina Rural Health Research Center
Public Health Dilemma
Population based public health =
Current landscape – many remain DSP• 50% Family Planning• 46% Immunizations• 33% EPSDT• 20% Managed Care (Medical Home)
Dilemma (2) Economic Recession
• Driven further into clinical services?
Healthcare Reform• Catalyst for re-examining priorities –
discontinue?
Transitions occurring more frequently
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?
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
Background SCDHEC – State public health
agency
• 1995 -> SCDHEC 40% of EPSDT Market
• Mid 1990’s -> Transitioned EPSDT services
• Some targeted transitioning -> mostly attrition
Background Background
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
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
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
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
Methods - Analysis
1995 2000 2005 20100%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Low Share Average Share High Share
1995 2000 2005 20100%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Low Share Average Share
1995 2000 2005 20100
1
2
3
4
5
6
7
8
Low Share Average Share
1995 2000 2005 20100
1
2
3
4
5
6
7
8
Low Share Average Share High Share
Urban Rural
Any EPSDT
# of EPSDT Visits
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
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
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
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