the impact of privatization of primary care programs in large county health departments in florida...

The Impact of Privatization of The Impact of Privatization of Primary Care Programs in Large Primary Care Programs in Large County Health Departments in County Health Departments in

FloridaFlorida

Arlesia Brock, Ph.D.

College of Public Health

University of South Florida

This research is sponsored by the National Institute of Child Health and Human Development Center for Demographic and Behavioral Sciences.

Key TermsKey Terms

Public Health - an aspect of health services Public Health - an aspect of health services concerned with threats to the overall health of concerned with threats to the overall health of the population of a community based on the population of a community based on population health analysis that generally includes population health analysis that generally includes infectious disease surveillance, infectious disease infectious disease surveillance, infectious disease control, and promotion of healthy behaviors control, and promotion of healthy behaviors (health promotion) among members of the (health promotion) among members of the community. Public health is defined in community. Public health is defined in medical/clinical terms as the approach to medical/clinical terms as the approach to medicine that is concerned with the health of the medicine that is concerned with the health of the community as a whole. (Webster’s Dictionary)community as a whole. (Webster’s Dictionary)

Examples of Public Health ServicesExamples of Public Health Services

Public Health Preparedness Vital Statistics Pharmacy Services Public Health Nursing Emergency Operations Laboratory Services Rural Health Health Professional

Recruitment Emergency Medical

Services Brain & Spinal Cord Injury

Communications & Health Communications & Health PromotionPromotion

Health Awareness & Health Awareness & TobaccoTobacco

Epidemiology Epidemiology ImmunizationImmunization HIV/AIDSHIV/AIDS Sexually Transmitted Sexually Transmitted

DiseasesDiseases Tuberculosis ControlTuberculosis Control Refugee HealthRefugee Health Minority HealthMinority Health Children’s Medical ServicesChildren’s Medical Services

Examples of Public Health ServicesExamples of Public Health Services

Environmental Environmental EpidemiologyEpidemiology

Water ProgramsWater Programs Facility ProgramsFacility Programs Radiation ControlRadiation Control Onsite Sewage ProgramsOnsite Sewage Programs Local Health CouncilsLocal Health Councils Medical Disability Medical Disability

ProgramsPrograms

Dental HealthDental Health Family & Community Family & Community

HealthHealth Chronic Disease PreventionChronic Disease Prevention WIC & Nutrition WIC & Nutrition Child Nutrition Child Nutrition Medical Quality AssuranceMedical Quality Assurance Health Care Practitioner Health Care Practitioner

RegulationRegulation

Key TermsKey Terms

Privatization - The transfer of responsibility for Privatization - The transfer of responsibility for services or activities from government agencies services or activities from government agencies to private providers.to private providers.

Key TermsKey Terms

Primary Care - That level of the health care system Primary Care - That level of the health care system that provides entry into the system for all new that provides entry into the system for all new needs and problems, provides person focused needs and problems, provides person focused (not disease oriented) care over time, provides (not disease oriented) care over time, provides care for all but very uncommon or unusual care for all but very uncommon or unusual conditions, and coordinates or integrates care conditions, and coordinates or integrates care provided elsewhere or by others (Starfield, 1998).provided elsewhere or by others (Starfield, 1998).

Research QuestionsResearch Questions

Question 1 – Cost of ServicesQuestion 1 – Cost of Services

What are the costs of primary care What are the costs of primary care services provided by contracted services provided by contracted service providers relative to services service providers relative to services provided by the public health provided by the public health departments?departments?


Question 2 – Access to ServicesQuestion 2 – Access to Services

Where primary care services have Where primary care services have been privatized, what is the effect on been privatized, what is the effect on access to care for Medicaid and access to care for Medicaid and uninsured patients?uninsured patients?


Question 3 – Health OutcomesQuestion 3 – Health Outcomes

What is the effect of privatization on What is the effect of privatization on health outcomes in privatized and health outcomes in privatized and non-privatized counties?non-privatized counties?

Limitations and DelimitationsLimitations and Delimitations The study used different units of analysis (program level, zip code The study used different units of analysis (program level, zip code

level, county level) for measuring the three dimensions (cost, level, county level) for measuring the three dimensions (cost, access, and health outcomes) because of the limited availability of access, and health outcomes) because of the limited availability of some data.some data.

Health outcomes could not be directly measured for Department Health outcomes could not be directly measured for Department of Health clients. Performance indicators used by the Department of Health clients. Performance indicators used by the Department of Health were used as proxy measures.of Health were used as proxy measures.

Performance indicators for all primary care programs used in the Performance indicators for all primary care programs used in the cost analysis were not available. cost analysis were not available.

Some health status indicators used for evaluating primary care at Some health status indicators used for evaluating primary care at population levels were assigned to other funding sources and population levels were assigned to other funding sources and therefore not selected for analysis. For example STD’s are funded therefore not selected for analysis. For example STD’s are funded through communicable disease programs. through communicable disease programs.

HypothesesHypotheses

Hypothesis 1Hypothesis 1

Contracting primary care to private Contracting primary care to private providers reduces the cost of providers reduces the cost of providing services when compared to providing services when compared to providing these services within the providing these services within the county health department.county health department.

MethodologyMethodology

Data Sources for Hypothesis 1Data Sources for Hypothesis 1• Contract Management System Variance Contract Management System Variance

Report Report • CountiesCounties

Brevard, Broward, Dade, Duval, Brevard, Broward, Dade, Duval, Hillsborough, Orange, Palm Beach, Pinellas, Hillsborough, Orange, Palm Beach, Pinellas, and Polkand Polk

• Fiscal YearsFiscal Years 10/1/2000 – 9/30/2001 through 10/1/2000 – 9/30/2001 through 10/1/2003 – 9/30/200410/1/2003 – 9/30/2004


Year 1Year 12000/20012000/2001

Year 2Year 22001/20022001/2002

Year 3Year 32002/20032002/2003

Year 4Year 42003/2004 2003/2004

PrivatizedPrivatizedBroward, Dade, Broward, Dade, Orange, Pinellas, Orange, Pinellas, Palm BeachPalm Beach

““ “ “ “ “

Non-PrivatizedNon-PrivatizedBrevard, Duval, Brevard, Duval, Hillsborough, PolkHillsborough, Polk ““

“ “ “ “


Data Sources for Hypothesis 1Data Sources for Hypothesis 1• Primary Care ProgramsPrimary Care Programs

Chronic Disease PreventionChronic Disease Prevention Family PlanningFamily Planning Maternal Health/IPOMaternal Health/IPO Healthy Start PrenatalHealthy Start Prenatal Healthy Start InfantsHealthy Start Infants Comprehensive Child HealthComprehensive Child Health Comprehensive Adult HealthComprehensive Adult Health

Variables Used in the StudyVariables Used in the Study

Dependent VariableDependent Variable• Cost Cost

Independent VariablesIndependent Variables• Unduplicated number of clientsUnduplicated number of clients• Number of services performedNumber of services performed• Program Program • Fiscal year (2001 - 2004)Fiscal year (2001 - 2004)


Mixed Model with Repeated Mixed Model with Repeated MeasuresMeasures

y = Xy = X + Z + Z + +

GEE Estimation with Repeated GEE Estimation with Repeated SubjectSubject

ResultsResultsMixed ProcedureMixed Procedure

Fit StatisticsFit Statistics

-2 Res Log Likelihood-2 Res Log Likelihood 6786.26786.2

AIC (smaller is better)AIC (smaller is better) 6790.26790.2

AICC (smaller is better)AICC (smaller is better) 6790.26790.2

BIC (smaller is better)BIC (smaller is better) 6794.36794.3

Solution for Fixed EffectsSolution for Fixed Effects

EffectEffect EstimateEstimate SESE DF DF t valuet value P>l t l P>l t l

privatized 0privatized 0 -5.58E7 62858977-5.58E7 62858977 57 57 - 0.89- 0.89 0.3778 0.3778

privatized 1privatized 1 -5.59E7 62858668-5.59E7 62858668 57 57 - 0.89- 0.89 0.3771 0.3771

clientsclients 42.896942.8969 9.0349 1749.0349 174 4.75 4.75 <.0001 <.0001

servicesservices 23.48.2323.48.23 1.9294 174 12.171.9294 174 12.17 <.0001 <.0001

ResultsResultsGENMOD ProcedureGENMOD Procedure

Goodness of FitGoodness of FitCriterionCriterion DFDF ValueValue Value/DFValue/DFDevianceDeviance 229229 318.4377318.4377 1.39061.3906Scaled DevianceScaled Deviance 229229 318.4377318.4377 1.39061.3906Pearson Chi-SquarePearson Chi-Square 229229 236.0080236.0080 1.03061.0306Scaled PearsonScaled Pearson 229229 236.0080236.0080 1.03061.0306Log LikelihoodLog Likelihood -159.2188 -159.2188

Analysis of Initial Parameter EstimatesAnalysis of Initial Parameter EstimatesParameterParameter EstimateEstimate SE SE 95% CL95% CL Chisq > l Chisq > l2l2lInterceptIntercept 0.4149 0.4149 0.3209 -0.2300 1.0598 0.3209 -0.2300 1.0598 1.59 0.20731.59 0.2073Clients Clients 0.0000 0.0000 -0.0000 0.0001 0.0000 0.0000 -0.0000 0.0001 0.01 0.90570.01 0.9057ServicesServices 0.0000 0.0000 0.0000 0.0000 0.0000 0.42 0.5191 0.0000 0.0000 0.0000 0.42 0.5191Expenditures Expenditures -0.0000-0.0000 -0.0000 0.0000 -0.0000 0.23 0.6322 -0.0000 0.0000 -0.0000 0.23 0.6322Yr 2001Yr 2001 -0.0221-0.0221 0.3855 -0.7777 0.7335 0.3855 -0.7777 0.7335 0.00 0.95430.00 0.9543Yr 2002Yr 2002 -0.0155-0.0155 0.3871 -0.7741 0.7431 0.3871 -0.7741 0.7431 0.00 0.96810.00 0.9681Yr 2003Yr 2003 -0.0078 0.0000 -0.7486 0.7331-0.0078 0.0000 -0.7486 0.7331 0.00 0.98360.00 0.9836Yr 2004Yr 2004 -0.0000-0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 0.0000 . . . .

ResultsResultsGENMOD ProcedureGENMOD Procedure

Analysis of GEE Parameter EstimatesAnalysis of GEE Parameter Estimates

ParameterParameter Z Z Pr > l Z lPr > l Z l

InterceptIntercept 0.33 0.33 0.73920.7392Clients Clients 1.76 1.76 0.07830.0783ServicesServices 0.15 0.15 0.88320.8832Expenditures -1.18 Expenditures -1.18 0.23880.2388Yr 2001Yr 2001 0.60 0.60 0.54850.5485Yr 2002Yr 2002 0.99 0.99 0.32200.3220Yr 2003Yr 2003 1.06 1.06 0.28920.2892

Yr 2004 . .Yr 2004 . .



In counties where primary care In counties where primary care programs have been privatized, programs have been privatized, potential access to primary care potential access to primary care services will be greater than in non-services will be greater than in non-privatized areas. privatized areas.


Data Sources for Hypothesis 2Data Sources for Hypothesis 2

U.S. Census Bureau at U.S. Census Bureau at www.census.govwww.census.gov Census 2000 Summary Files 1 and 3Census 2000 Summary Files 1 and 3

American Fact Finder Quick ReportsAmerican Fact Finder Quick Reports1999 Zip Code File1999 Zip Code File

MedlinePlus at MedlinePlus at www.nlm.nih.govwww.nlm.nih.gov AMA Physician Select: Online Doctor AMA Physician Select: Online Doctor Finder Finder

(American Medical Association)(American Medical Association)Find a Hospital (American Hospital Find a Hospital (American Hospital

AssociationAssociation


Data Sources for Hypothesis 2Data Sources for Hypothesis 2

Bureau of Primary Health Care (HRSA)Bureau of Primary Health Care (HRSA)

Primary Care Programs Directory 1998Primary Care Programs Directory 1998

Florida Association of Community Health Care Florida Association of Community Health Care Centers at Centers at www.fachc.orgwww.fachc.org

Florida Department of Health at Florida Department of Health at www.doh.state.fl.uswww.doh.state.fl.us


Demographic and Population Demographic and Population CharacteristicsCharacteristics• Percent of Population over 65 yrs of agePercent of Population over 65 yrs of age• Percent of Population under 15 yrs of agePercent of Population under 15 yrs of age• Percent of Blacks in the PopulationPercent of Blacks in the Population• Percent of Females in the PopulationPercent of Females in the Population

SocioeconomicsSocioeconomics• Percent unemploymentPercent unemployment• Percent below poverty levelPercent below poverty level


Primary Care Resources Primary Care Resources • Family practice physician/populationFamily practice physician/population• General practice physician/populationGeneral practice physician/population• Obstetric-gynecology physician/populationObstetric-gynecology physician/population• Internal medicine physician/populationInternal medicine physician/population• Pediatric physician/populationPediatric physician/population• Number of hospitals (w/Emergency Dept)Number of hospitals (w/Emergency Dept)• Number of community care centersNumber of community care centers


Calculating a Variable Specific Score Calculating a Variable Specific Score

Variable-specific = Variable-specific = Zip Code PercentZip Code Percent x 10 x 10

ScoreScore Tot Zip Code Avg. Tot Zip Code Avg.

Unemployment = Unemployment = 2.82.8 x 10 x 10

Score 5.0Score 5.0

Unemployment = 5.6Unemployment = 5.6

ScoreScore


Demographics and Demographics and Population Population CharacteristicsCharacteristics

Model WeightsModel Weights

Percent Over 65 Percent Over 65 yrs of Ageyrs of Age -0.007263-0.007263

Percent Under 15 Percent Under 15 yrs of Ageyrs of Age

-0.009275-0.009275

Percent of Blacks Percent of Blacks in the Populationin the Population

-0.012931-0.012931

Percent of Percent of Females in the Females in the PopulationPopulation -0.007218-0.007218


SocioeconomicSocioeconomic


Percent Percent UnemploymentUnemployment

-0.065251-0.065251

Percent of Percent of Population Below Population Below Poverty LevelPoverty Level -0.061036-0.061036


Primary Care Primary Care ResourcesResources


Family practice Family practice physician/popphysician/pop 0.0425140.042514

General practice General practice physician/popphysician/pop 0.0199170.019917

Obstetrics-Obstetrics-gynecology gynecology physician/popphysician/pop 0.0326100.032610

Internal medicine Internal medicine physician/popphysician/pop 0.0147570.014757

Pediatric Pediatric physician/popphysician/pop 0.0233330.023333


Primary Care Primary Care ResourcesResources


Number of Number of hospitalshospitals

0.0091060.009106

Number of Number of community care community care centerscenters 0.0408160.040816


Primary Care Access Score Primary Care Access Score

PCA = wPCA = w11vv11 + w + w22vv22 + . . . w + . . . w1313vv1313

ScoreScore

GEE ModelGEE Model

y = y = xxii

where y = primary care access score where y = primary care access score

x = privatization status (0,1)x = privatization status (0,1)

ResultsResults

Goodness of FitGoodness of FitCriterionCriterion DFDF ValueValue Value/DFValue/DFDevianceDeviance 418418 933.2442933.2442 2.23262.2326Scaled DevianceScaled Deviance 418418 420.0000420.0000 1.00481.0048Pearson Chi-SquarePearson Chi-Square 418418 933.2443933.2443 2.23262.2326Scaled PearsonScaled Pearson 418418 420.0000420.0000 1.00481.0048Log LikelihoodLog Likelihood -763.6208 -763.6208

Analysis of GEE Parameter EstimatesAnalysis of GEE Parameter EstimatesEmpirical Standard Error EstimatesEmpirical Standard Error Estimates

ParameterParameter EstimateEstimate SESE 95% CL 95% CL ZPr > lZlZPr > lZlInterceptIntercept -0.8401 0.1340 -1.1028 -0.5774 -6.27 0.0001-0.8401 0.1340 -1.1028 -0.5774 -6.27 0.0001PrivatizationPrivatization StatusStatus 0.3363 0.3363 0.1983 -0.0524 0.7250 1.70 0.1983 -0.0524 0.7250 1.70

0.08990.0899



In counties where primary care In counties where primary care programs have been privatized, programs have been privatized, health outcomes on primary care health outcomes on primary care sensitive indicators (i.e. post-sensitive indicators (i.e. post-neonatal mortality) will be better neonatal mortality) will be better than in non-privatized areas. than in non-privatized areas.


Data Sources for Hypothesis 3Data Sources for Hypothesis 3 U.S. Census Bureau at U.S. Census Bureau at www.census.govwww.census.gov

American Community Survey 2000 - 2003American Community Survey 2000 - 2003

American Fact Finder Quick ReportsAmerican Fact Finder Quick Reports

Florida Department of Health at Florida Department of Health at www.doh.state.fl.uswww.doh.state.fl.us

Florida CHARTS at www.floridacharts.comFlorida CHARTS at www.floridacharts.com


Dependent VariablesDependent Variables• Infant Mortality RateInfant Mortality Rate• Non-white Infant Mortality RateNon-white Infant Mortality Rate• Percentage of low birth weight birthsPercentage of low birth weight births• Live births to mothers age 15-19Live births to mothers age 15-19• Neonatal mortalityNeonatal mortality• Post-neonatal mortalityPost-neonatal mortality• No prenatal care No prenatal care


Independent VariablesIndependent Variables• Privatization status (coded as 0 and 1)Privatization status (coded as 0 and 1)• Percent of Blacks in the PopulationPercent of Blacks in the Population• Percent of Hispanics in the PopulationPercent of Hispanics in the Population• Percent of Population under 18Percent of Population under 18• Percent of Population below poverty levelPercent of Population below poverty level• Year (2001 – 2003)Year (2001 – 2003)


Outcome MeasureOutcome Measure Random EffectsRandom Effects Fixed Fixed EffectEffect

DFDF Pr > ltlPr > ltl SigSig

Infant Mortality Infant Mortality Rate Rate

%Black, %Hispanic, %Black, %Hispanic, %Below Poverty, Under %Below Poverty, Under 18, Year18, Year

PrivatizedPrivatized 1919 0.530.53

0.470.47N. S.N. S.

Non white Infant Non white Infant Mortality Rate Mortality Rate



0.080.08N. S.N. S.

Neonatal Mortality Neonatal Mortality RateRate



0.870.87N. S.N. S.

Post-neonatal Post-neonatal Mortality RateMortality Rate



0.080.08N. S.N. S.


Outcome MeasureOutcome Measure Random EffectsRandom Effects Fixed Fixed EffectEffect

DFDF Pr > ltlPr > ltl SigSig

Births to Mothers Births to Mothers 15-19 yrs15-19 yrs



0.500.50N. S.N. S.

Low Birth WeightLow Birth Weight %Black, %Hispanic, %Black, %Hispanic, %Below Poverty, Under %Below Poverty, Under 18, Year18, Year


0.080.08N. S.N. S.

No Prenatal CareNo Prenatal Care %Black, %Hispanic, %Black, %Hispanic, %Below Poverty, Under %Below Poverty, Under 18, Year18, Year


0.070.07N. S.N. S.

ConclusionConclusion

The results of this study provides empirical The results of this study provides empirical evidence that privatization of primary care evidence that privatization of primary care programs does not result in cost savings or offer programs does not result in cost savings or offer significant differences in health outcomes when significant differences in health outcomes when compared to non-privatized programs. The study compared to non-privatized programs. The study also reveals that access does not differ also reveals that access does not differ significantly in privatized and non-privatized significantly in privatized and non-privatized counties. counties.

RecommendationsRecommendations

Public Health systems are undergoing a major Public Health systems are undergoing a major transition as the health department’s role in the transition as the health department’s role in the provision of primary care services declines; provision of primary care services declines; however, preserving, protecting and promoting however, preserving, protecting and promoting the health of communities should remain an the health of communities should remain an important consideration. important consideration.

Evaluation of all dimensions of privatization are Evaluation of all dimensions of privatization are necessary if there is to be movement toward necessary if there is to be movement toward equitable allocation of finite resources. equitable allocation of finite resources.

SummarySummary Privatization of government services is likely to Privatization of government services is likely to

continue throughout the next decade. However continue throughout the next decade. However more research is needed on this trend. more research is needed on this trend.

In the case of primary care services, this analysis In the case of primary care services, this analysis revealed that privatization did not result in a cost revealed that privatization did not result in a cost savings. As a result, we should evaluate what savings. As a result, we should evaluate what effects privatization has on the health of effects privatization has on the health of Floridians. By making the correct choices, we Floridians. By making the correct choices, we can efficiently and effectively improve the health can efficiently and effectively improve the health of all Floridians.of all Floridians.

the impact of privatization of primary care programs in large county health departments in florida...

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overall health

aspect of health services

health care system

population health analysis

key terms public health

primary care programs

infectious disease control

disease oriented care