The Costs of Health Protection: Economic Pearls from the APHA Meetings

What’s the price of protection from disease transmission? Public health’s long-standing responsibilities in disease investigation and control have taken center stage in recent weeks in response to concerns about Ebola transmission risks in the U.S. These responsibilities remain bread-and-butter work of America’s local and state public health agencies more than 150 years after John Snow famously used them to locate and contain the source of that London cholera outbreak. Although CDC stands front and center in coordinating the U.S. Ebola response, local and state agencies shoulder most of the actual effort in investigating suspected cases, tracing and monitoring contacts, maintaining records on investigation and control activities, and disseminating guidelines to physicians and other health professionals regarding response and mitigation protocols. These agencies also play critical roles in advising state and local policymakers regarding legal interventions for disease control (no small task in the case of Ebola), and in keeping the general public up to date and informed. Ebola is a very, VERY special case, but routine disease investigation work happens every day in every community across the U.S. as agencies investigate routine but costly risks such as suspected food-borne and water-borne illnesses, vaccine-preventable diseases, and sexually-transmitted infections.

Amazingly, we know very little about the resources required to perform this work effectively in a given community or state, and about the factors that influence these resource requirements. Without evidence about what it costs to do this work, and about the community characteristics that make this work more or less resource-intensive, there is no way of knowing whether society spends too much or too little on disease investigation activities, and whether we distribute these resources optimally and equitably across the U.S. based on disease risks and prevention opportunities.

This week’s APHA meetings in New Orleans finally gave us some answers about the prices we should be willing to pay for disease investigation and control. Early results from a series of studies funded through our Public Health Delivery and Cost Studies (DACS) were featured at this year’s meetings. One of these studies, led by Adam Atherly and colleagues in the Colorado Public Health PBRN and the University of Colorado, conducted detailed time studies of disease monitoring activities carried out in that state during 2014. Results show that the cost of disease monitoring starts at about $13,000 per year in the average community, and increases by about $400 per case detected but at a decreasing rate of growth – demonstrating large economies of scale. These findings tell us quite a bit about how we might design better funding models to ensure equitable disease investigation capabilities across the U.S., and how we might pool resources and expertise across sparsely populated and low-resource communities to achieve more cost-effective protections.

Another DACS study led by Lori Bilello and colleagues from the Florida PBRN and the University of Florida-Jacksonville, focused on the cost of disease control activities for sexually-transmitted infections. The most striking finding from this study is the sheer magnitude of cost variation across Florida’s local communities. My take on this study is that much of the cost variation reflects differences in the intensity of disease control activities implemented by Florida’s county health departments and their partner organizations, begging the question of whether more intensive activities provide health returns that justify their higher levels of investment. The Florida study also identifies differences in the efficiency of STI control activities, with some agencies lagging behind in the adoption of modern screening and diagnostic technologies that do not require costly and intrusive physical examinations. Donobedian’s law of “no measurement, no improvement” is clearly on display in Florida’s study, as well as in Kim Gearin’s study of community-level variation early childhood vaccination performance in Minnesota.

APHA showcased many other interesting studies on the economics of public health delivery (see our full list of RWJF-supported PHSSR studies presented at APHA this week). This work includes:

§ Our study to estimate the effects of Medicaid expansions on public health spending and service delivery (teaser figure below);

§ Our ongoing work to estimate the costs of supporting Foundational Public Health Capabilities as recommended recently by the Institute of Medicine;

§ Our analysis of geographic variation in implementing high-value public health services for chronic disease prevention, communicable disease control, and environmental health protection using data from the MPROVE study;

§ Our analysis of the early public health implications of Kentucky’s experience in implementing key provisions of the Affordable Care Act.

§ More work from the University of Washington ‘s Betty Bekemeier and colleagues in the Public Health Activities and Services Tracking Study (PHAST), showing links between local health department spending and rates of communicable disease.

Clearly, beignets and the Big Muddy were not the only attractions on the New Orleans riverfront this week (but the beignets were very good indeed).

Stay tuned to this blog and contact the National Coordinating Center for Public Health Services & Systems Research for more information on these or other studies about the economics of public health delivery. I invite you to comment on this blog, tweet at me, nudge me on linkedin, and follow my research archive.

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