What the Recession and Recovery Teach Us about Public Health Delivery Systems

Parts of the U.S. economy are finally showing some signs of real rebound, but what about the nation’s public health enterprise? A new paper in the American Journal of Public Health offers a broad view of changes in public health delivery before and after the Great Recession of 2008. The results show that in communities hardest hit by the recession, public health protections remain far below their pre-recession levels. Consequently, disparities between the strongest and weakest public health delivery systems have widened considerably since the recession.

The National Longitudinal Survey of Public Health Systems (NLSPHS) tracks changes in the organization and delivery of core public health activities in a nationally representative cohort of metropolitan communities across the U.S. Our research center has conducted this survey periodically since 1998, and two recent waves of the survey – in 2006 and 2012 – span the most recent period of economic recession and the initial phases of recovery.

We reported previously that between 2006 and 2012, the average U.S. community experienced a 5% reduction in the proportion of recommended public health activities that were actually implemented in the community. However, this average decrement in public health protections masks considerable heterogeneity across the U.S. The bottom 20% of communities experienced a whopping 25% reduction in the delivery of core public health activities over this timeframe, while the top 20% of communities gained additional activities despite the economic contraction (see figure). The net result was a widening of the gap between the “haves” and the “have nots” in terms of community-wide public health protections.

Multivariate estimates confirmed what any informed model of public health production predicts: local public health delivery fell most sharply among communities that experienced the largest reductions in public health agency spending and household income and the largest increases in unemployment. Perhaps most surprising, however, were the magnitudes:

“a 10% reduction in public health agency spending per capita was associated…with a 31 percentage-point reduction in the availability of public health activities, a 36 percentage-point reduction in the intensive margin of activities contributed by local public health agencies, a 6 percentage-point reduction in the extensive margin of activities contributed by other organizations, and a 29 percentage-point reduction in the perceived effectiveness of public health activities.”

The recession also triggered some key changes in the production of public health activities, as both government and private-sector organizations adjusted their contributions to these activities. Overall, hospitals, health insurers, and community health centers showed more modest reductions in their contributions to public health activities than did government agencies – likely reflecting differences in the resiliency of the revenue sources that these different organizations tap. The net result is that many local public health delivery systems today are much more reliant on contributions from the medical care sector than they were before the recession. This growing co-dependency between public health and medical care delivery may prove to be beneficial over time as initiatives like the CMS State Innovation Models attempt to better align the prevention and treatment ends of health care delivery and financing systems in order to realize population-wide improvements in health status.

The recommended public health activities measured in the NLSPHS reflect a set of 20 programs, policies and administrative practices that national expert panels have consistently recommended to be performed in every U.S. community in order to prevent disease and injury and promote health. This recommended set includes activities to monitor community health status, investigate and control disease outbreaks, educate the public about health risks and prevention strategies, prepare for and respond to natural disasters and other large-scale health emergencies, and enforce health-related laws and regulations such as those concerning tobacco exposure, food and water safety, and air quality. These 20 activities are based on the Institute of Medicine’s Core Public Health Functions definitions and reflect high-value practices recommended by a series of expert panels convened by the U.S. Centers for Disease Control and Prevention. These activities are also closely aligned with the federal government’s Essential Public Health Services Framework and a more recently developed set of Foundational Public Health Capabilities called for by the Institute of Medicine in its 2012 consensus report on public health financing.

These results beg important questions about how public health delivery systems are evolving now as the recovery lurches forward and as key ACA coverage expansion provisions take hold. Fortunately, we are wrapping up a 5th wave of NLSPHS data collection this month, which for the first time will include a large expanded sample of small and rural communities across the U.S. Stay tuned for preliminary findings to be released at next month’s Keeneland Conference on Public Health Services & Systems Research.

The paper described in today’s post is part of an entire supplement issue of the American Journal of Public Health devoted to advances in public health services & systems research, slated for official release in April (thanks to support from the Robert Wood Johnson Foundation and CDC). As the guest editor of this issue, I will be posting highlights from some of my favorite articles on this blog over the next few weeks leading up to the official release. All of these papers are available early online so I encourage readers of this blog to take a peak and post comments here about your observations.

I invite you to comment on this blog, tweet at me, nudge me on linkedin, and follow my research archive.


National Public Health Spending: Still Waiting for Recovery

Among the many joys of a new year are the refreshed and updated full-year estimates of national health spending from the federal government’s National Health Expenditure Accounts (NHEA). We now have the federal government’s official estimates of spending from calendar 2013, including the estimates of governmental public health spending that are of particular interest for readers of this blog. Unfortunately these data show a public health sector that has yet to recover from the recessionary contractions and austerity-minded fiscal responses of recent years (see figure).

Total governmental public health spending stood at $75.4 billion in 2013, nominally up from $74.8 billion the year before but still below the high water mark of $75.5 billion in 2010. Factoring in population growth, per-capita public health spending was $239 in 2013, several dollars short of the $241 per capita expended back in 2009. Overall U.S. health spending grew at a historically low rate of 3.9% in 2013, but despite this the share of spending devoted to public health declined to 2.6% from its recent peak of 3.0% in 2009.

When these data are adjusted for inflation, public health spending trends look even more grim. Using the NHEA’s new chain-weighted price deflator (check it out), we see that total inflation-adjusted public health spending actually declined by 1.1% in 2013, continuing the negative annual rate of growth observed since 2009. Per-capita public health spending stood at $218 in inflation-adjusted dollars – a full 10% below the level observed in 2009 and a 1.6% decline from 2012.

As I posted last year, we know there are many limitations inherent in the data sources and methods used to measure public health spending in the NHEA, and there are ongoing efforts to develop enhanced estimates (including our own). But an important strength of the NHEA data are their longitudinal consistency, allowing us to track year-to-year changes in public health spending with reasonable accuracy.

These trends reveal that public health resources have yet to recover from the Great Recession of 2008, and in fact these resources are still not even keeping pace with population growth and overall levels of price inflation. Although the economy is growing again, government revenues are recovering and medical care spending remains nicely in check, public health spending has not experienced a bounce-back. The health and economic consequences of this erosion of public health resources may not be immediate, but numerous studies tell us that these trends – if left unaddressed – will yield considerable human and monetary losses over time.

The Economics of Implementing Population Health Strategies

Can economic theory and methods help us learn which mechanisms work best in scaling up and spreading evidence-based health protections and prevention strategies to the population level? Economic analysis has become an essential part of the scientific process of identifying which prevention strategies are effective and cost-effective. Two decades of research from CDC’s Prevention Effectiveness program clearly demonstrate this fact. But what does economics offer to the rapidly developing field of implementation science, particularly when applied to the task of preventing disease and injury on a population-wide basis?

I had the chance to examine this issue with some brilliant colleagues this week as more than 700 scholars convened outside Washington DC for the 7th Annual Conference on the Science of Dissemination and Implementation hosted by AcademyHealth and NIH. The field of implementation science attracts a lot of attention these days, bolstered by NIH’s focus on translational research and more recently by PCORI’s game-changing research approach and its heavy emphasis on patient-centered mechanisms for disseminating and implementing effective health interventions. Although a relatively young field of inquiry, D&I research has made impressive strides in less than a decade. A consolidated conceptual framework of D&I processes and mechanisms now exists that integrates constructs from multiple theoretical traditions. Valid and reliable measures of D&I processes are now in use. And researchers are deploying a broad array of experimental, quasi-experimental, and descriptive research designs to study D&I mechanisms in health and medicine, many of which utilize mixed-method approaches.

Even so, economic theory and economic methods are surprisingly hard to find within the current D&I research landscape. This is surprising because, after all, many of the barriers encountered in disseminating and implementing evidence-based health interventions necessarily involve resource constraints, misaligned or under-powered incentives, and asymmetric information. Economics has a lot to say about these problems and their possible solutions. As just one example, we can look to the work of Nobel prize-winning economist Eric Maskin and his game-theoretic approach to implementation theory for solutions to implementation problems that involve social decision-making in the presence of decentralized and asymmetric information – situations that characterize many complex community-level health interventions.

Economic issues are lurking in the shadows of many of the D&I studies presented at this week’s conference, and two particularly prevalent issues are worth calling out. Some D&I studies involve interventions for which no explicit financing mechanism or payment model exists, so the implementation challenge implicitly involves convincing implementation settings to reallocate resources from existing activities in order to support new interventions. For example, RAND’s randomized trials of strategies to help Boys and Girls Clubs implement evidence-based programs for pregnancy and STI prevention fall into this bucket. From an economic implementation perspective, it would seem important to study the population health trade-offs entailed in scaling back staffing for, say, physical activity programs in order to accommodate the new prevention programs.

Other D&I studies focus on interventions that do have explicit financing mechanisms – such as colorectal cancer screenings that are covered by most health insurance plans – but the implementation challenge implicitly involves uncertainties about whether available funding streams are sufficient to fully meet the resource requirements of the intervention and its associated D&I mechanisms. The Emory University/Cancer Prevention and Control Research Network study of community health centers’ use of evidence-based practices for increasing colorectal cancer screenings falls into this bucket. While centers receive insurance payments for eligible insured patients who are screened, the resources expended to implement evidence-based supports like patient outreach and education, reminders, media communication, and provider assessments and feedback may not be commensurate with screening revenue, thereby necessitating some form of cross-subsidization. The extent to which these resource flows and uncertainties influence the spread and sustainability of the intervention appear to be worthy topics for investigation as part of implementation science.

So how can we address these compelling economic research opportunities? I had the good fortune of leading a roundtable session during the second day of the conference devoted to the economics of implementing population health strategies. The goal was to raise awareness among D&I researchers about the potential utility of incorporating economic theory and methods into their implementation science studies, particularly those studies focusing on prevention and population health strategies. Our premise was fairly straightforward:

“Successful strategies to scale up and spread complex community-level interventions require an understanding of the resources required for implementation, how best to distribute them among supporting institutions, and how resource consumption and distribution varies across settings.”

To make the case, I highlighted some of the studies we now have underway through our PHSSR Center and Public Health PBRN program that explicitly examine the economics of implementation, including work involving our National Longitudinal Survey of Public Health Systems (teaser slide below), the Multi-Network Practice and Outcome Variation (MPROVE) study, the Public Health Delivery and Cost Studies (DACS), and our Costing Study of Foundational Public Health Capabilities.

The rich discussion stimulated by this roundtable session has convinced me that there is much to be gained from incorporating economic theory and methods into D&I research studies – particularly those that use a population health lens and public health orientation. The dismal science is poised to play a more active role in this solution-focused scientific endeavor to scale and spread population health.

I invite you to comment on this blog, tweet at me, nudge me on linkedin, and follow my research archive.

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.

Learning from Variation in ACA Implementation

Political scientists, economists, and other social scientists frequently exploit variation in the implementation and timing of policy initiatives in order to estimate impact and effectiveness. The Affordable Care Act (ACA) creates abundant opportunities for these types of variation studies and natural experiments that can help us learn which implementation strategies work best, for which population groups, and under what conditions.

Numerous ACA provisions give states, local governments, health care systems, and even individual providers broad discretion in deciding what to do under ACA and when to do it. Beyond the high-visibility state decisions concerning Medicaid expansions and health insurance exchange operations, states are making hundreds of other implementation decisions about strategies like insurance outreach and enrollment, provider network adequacy, multi-payer payment models, and initiatives to expand and integrate medical, public health, and social services delivery systems to improve population-wide health status. Hospitals and physicians get to decide when and how to try their luck at ACA-supported accountable care organizations (ACOs), patient-centered medical homes (PCMHs), and various forms of bundled-payment and shared-savings models. Insurers and employers are choosing whether and how to incorporate incentives for quality improvement and wellness into their health benefits designs. Public health and community-based organizations get to decide whether and how to compete for funding to implement policy, environmental, and system (PES) changes that promote health and prevent disease and injury with support from the ACA’s Prevention and Public Health Fund. Variation due to public-private discretion, competition and entrepreneurship abound within the ACA.

How do we harvest the potential knowledge and learning from this large-scale implementation variation? A meeting this week at the Brookings Institution in Washington DC focused on developing some key research strategies. One conclusion reached early on in the meeting: it is possible to capitalize on the fact that many, many research institutions have studies underway regarding ACA implementation and impact. RAND’s Health Reform Opinion Survey and COMPARE microsimulation model, the Urban Institute’s Health Reform Monitoring Survey, the University of Chicago’s ACA Scholar Practitioner Research Network, the Princeton University/RWJF State Health Reform Assistance Network, Georgetown’s Center on Health Insurance Reforms, Kaiser Family Foundation’s Health Reform Initiative, and many other fellow travelers have big studies underway regarding key elements of ACA. (This includes our PHSSR Center’s own studies of ACA’s effects on the U.S. public health system). These many individual studies create opportunities for harmonization, triangulation, data linkage and pooled analyses, meta-analyses and research synthesis.

What’s missing from the many “big data” ACA studies are clear pictures of what’s happening on the ground in individual states and communities – an ability to characterize the patterns of variation in implementation at more granular scales, and to determine how these patterns influence health care delivery and outcomes. The research community has yet to provide a clear understanding of how and why ACA implementation strategies vary across the U.S., and how these various strategies play out in different political, institutional, socioeconomic and cultural contexts.

To fully exploit the research opportunities presented by ACA implementation variation, researchers require the ability to be many places at the same time and observe what is happening on the ground in a variety of communities and practice settings. Researchers need the stamina and staying power to observe implementation processes continuously over time. And researchers need the versatility to employ mixed-method research approaches that productively combine (1) large amounts of qualitative data on implementation strategies collected from multiple perspectives and settings with (2) the array of large quantitative data sources that offer measures of provider and consumer behaviors, service delivery patterns, and related health and economic outcomes.

This is where the Brookings Institution’s Engelberg Center for Health Care Reform and their partners at the Rockefeller Institute of Government at SUNY and the Fels Institute of Government at the University of Pennsylvania come into play. Over the past year, scholars at these institutions have convened a multidisciplinary network of researchers across the U.S. who are well-positioned geographically and institutionally to observe ACA implementation strategies at granular levels in some 36 states. The researchers that comprise the ACA Implementation Research Network have access to multiple ACA decision-makers and key informants, multiple sources of secondary data, and a variety of supporting documents and records relevant to ACA implementation at state and local levels. Already, this network has completed a series of baseline studies of ACA implementation in a broad cross-section of states (for example see our report on ACA in Kentucky and similar reports for other states).

After demonstrating proof of concept through these baseline studies in individual states, the ACA Implementation Research Network is now embarking on a series of larger-scale, cross-cutting topics that involve collection and analysis of standardized data on ACA implementation across a large number of states. This first wave of cross-cutting studies target topics such as: (1) state information technology strategies and capacities to support ACA implementation; (2) consumer support and outreach strategies for insurance enrollment; (3) provider network composition among insurers participating in the state exchanges; (4) implementation strategies used in “oppositional states” where policy leaders oppose the ACA; and (5) state strategies for reforming health care and public health delivery systems. I hope to play a leading role in this last cross-cutting study, together with other colleagues in the PHSSR enterprise. Specifically, we hope to leverage studies that we already have underway concerning public health delivery system reform, and to leverage the strength of our public health practice-based research networks (PBRNs) across the U.S.

The ACA Implementation Research Network is strongly committed to engaging knowledge users in the design and implementation of its ACA research, and to disseminating findings rapidly and continuously to decision-makers in policy and practice settings. We are excited to be a part of this collaborative experiment in large-scale policy implementation field research, and we believe it will become a valuable source of knowledge and learning over time. Fellow travelers in public health economics and delivery system research will want to keep close tabs the progress of this new effort.

Northern Lights: Canadian Insight on Bridging Public Health and Health Care Delivery to Improve Population Health

The United States and Canada have long compared the relative performance of their medical care systems in order to identify pathways for improvement, but the public health systems of these two countries receive much less attention by scholars and pundits. Having spent the past few days meeting with some of the best public health minds and hands in Canada, I conclude that there is much to be learned about ways of improving the organization, financing and delivery of public health strategies in the U.S. through comparative research with Canadian models.

Canada’s system of universal health care financing and delivery formed incrementally during the 1940s through the 1980s, but its public health institutions developed quite independently following a much longer time path. The result – at least until relatively recently – was public health institutions that operated relatively autonomously from health care delivery institutions with separate funding streams, much like the U.S. experience. Over time, Canada’s provinces and territories have implemented various forms of regionalized health care delivery in an effort to pool resources and expertise for the purposes of improving quality, constraining costs, and reducing inequities in delivery. Over the past decade or so, many (but not all) provinces have transferred public health responsibilities and funding from municipal and provincial agencies to these regional health care delivery institutions, called regional health authorities. Provincial Ministries of Health have retained overall responsibilities for stewardship of their integrated regional health systems using the levers of funding, policy, monitoring and accountability. The provinces also administer some core public health functions centrally such as selected surveillance, epidemiology, and laboratory capabilities – much like many state public health agencies in the U.S.

Structurally, Canada’s integrated regional health authorities look and feel like advanced versions of the accountable care organization (ACO) models that are now taking shape in the U.S., at least in the more comprehensive and ambitious ACO models that endeavor to incorporate public health responsibilities into “totally accountable care” strategies. As such, Canada seems to offer Americans a unique opportunity to gaze into the future and anticipate some of the benefits and challenges associated with bridging public health and medical care delivery systems to improve population health.

Why am I so enthusiastic about the knowledge to be gained from US-Canadian comparative research on public health systems and services? In full disclosure, most of my knowledge derives from several days of intensive exchange with colleagues in the west coast province of British Columbia. BC has a diverse population of about 4.3 million, spread across a geographic area larger than Texas. Five regional health authorities operate in the province of BC, two of which serve the heavily urbanized population of greater Vancouver, with other authorities serving vast areas of sparsely populated rural and remote communities. In my couple of days in this province, I was able to gather intelligence on Canadian public health systems research and share insight from our U.S. based studies through a number of different venues, including:

§ Giving seminars for the BC Centre for Disease Control and the multi-institutional BC Population Health Network based in urban Vancouver, where some of the province’s best public health scientists and practitioners convene (slides here and here);

§ Speaking at the 141st meeting of the Health Officer’s Council of British Columbia held in suburban New Westminster and meeting with this fiercely independent group of public health physician leaders, many of whom function within the regional health authorities (slides here);

§ Jumping a seaplane over to the island city of Victoria to meet and lecture with the awe-inspiring intellectual leaders of public health systems research at the University of Victoria and their colleagues at collaborating institutions like the University of British Columbia, University of Toronto, and University of Saskatchewan (slides here);

§ Boarding the mothership at the Province of British Columbia Ministry of Health to meet with their Population and Public Health Division and speak as part of the Ministry’s research and policy rounds (slides here and here).

My conclusion from this whirlwind: the evidence, experiences, and ideas of this diverse Canadian providence are extremely relevant to our American experimentation with public health system transformation. Moreover, the other Canadian provinces beyond BC offer yet additional models of public health organization, financing, and delivery that are ripe for comparative analysis. Health systems researchers would be foolish not to harvest the rich opportunities for comparative public health delivery research spanning the American-Canadian border.

Fortunately, Canada already has a strong foundation of applied public health services and systems research (PHSSR) led by ongoing studies of researchers based at the University of Victoria. This group embarked on a large program of research known as the Core Public Health Functions Research Initiative in 2006, with the goal of elucidating the implementation and impact of BC’s multi-pronged strategies to improve the effectiveness of core public health functions across the province. This effort led to an even larger and geographically more expansive research program funded by the Canadian Institutes of Health Research (CIHR) beginning in 2009 and known as the Renewal of Public Health Services in BC and Ontario, which supports comparative research on the implementation and impact of core public health strategies across these two diverse provinces. The academic ringleaders of Canada’s PHSSR enterprise include Professor Marjorie McDonald, RN, PhD, who holds a chair in public health education and population intervention research at the School of Nursing, and Dr. Trevor Hancock, MB, MHSc, who is a professor and senior scholar in the School of Public Health and Social Policy and one of the founders of the international Healthy Cities/Healthy Communities movement.

These Canadian PHSSR researchers approach their work with the versatility and realism that only mixed-method investigations can achieve. And much like our U.S. based public health PBRNs, these scholars are firmly entrenched in the principles and practices of collaborative, practice-based research. Every study is led by a team of “knowledge users” firmly embedded in the real world of public health practice and policy, along with relevant academic researchers. Not coincidentally, this research group has produced some of its best work to date on studies of “Knowledge to Action” strategies that support the use of evidence in public health program development and implementation processes. Another defining feature of this team’s research it its strategic selection of specific public health practice domains to study as “exemplars” for how public health delivery systems function as a whole – a concept that is analogous to the long-standing use of tracer conditions in health services research. To date UVic’s exemplars have included healthy living strategies, food safety, unintentional injury prevention, and emergency preparedness.

To be sure, BC’s rich public health research environment is only partially attributable to its research universities like UVic and UBC. A large, diverse, and talented pool of scholars exists within the BC Ministry of Health and within regional health authorities like Frasier Health, many of whom have formal linkages and appointments with the surrounding universities. Epidemiologists, economists, sociologists, engineers, policy and legal scholars, biomedical scientists, and many other disciplines are represented among these “pracademics” who produce and publish top-shelf research alongside their operational and managerial responsibilities within the health system. Conducting applied research studies within the Ministry of Health and its regional health authorities appears to be far from a novel concept within the province of BC. A new Guiding Framework for Public Health in BC was released by the Ministry last year, which has begun to provide new focus for applied research and evaluation within the province.

My few days of immersion in BC public health research and reality left me with a few intriguing impressions that seem worthy of further exploration through comparative PHSSR and public health economics research, including the following:

§ Bringing public health and medical care delivery under a common organizational structure and global budget may not automatically and instantaneously result in integrated health systems that adopt a population health perspective and prioritize upstream, long-term strategies for disease prevention and health promotion. Challenges persist in balancing the resource needs and performance expectations of medical care and public health even in integrated regional structures. Our American ACOs need to learn from relevant Canadian models and experiences.

§ Governance and decision-making structures for public health vary in their composition and functioning across Canada as they do in the U.S. These structures appear highly influential in shaping public health strategy and implementation, and as such represent worthy mechanisms to study and understand.

§ Canada’s health system leaders and public health researchers are making enviable progress in integrating a health equity lens into their science, policy and practice. BC’s new First Nation’s Health Authority is one manifestation of this perspective that is worthy of special attention from researchers and policy analysts, particularly given its explicit emphasis on wellness and culture and its unique governance and decision-making structures. The U.S. PHSSR enterprise has not been particularly deliberate nor successful in incorporating the perspectives and experiences of Native American populations into its research, so this is an area that could benefit from Canadian leadership and expertise.

§ Canadian policy leaders and researchers continue to struggle with the underlying theory, methods and mechanics of defining and measuring core public health functions, their costs, and their health and economic value. These are challenges that American scholars and practitioners clearly share. For forward momentum, there appears to be some enthusiasm behind the idea of adapting some of our U.S. PHSSR methods and measures for deployment in the Canadian context, including our National Longitudinal Survey of Public Health Systems, our MPROVE measures of public health implementation, and our DACS cost estimation methods. Doing so would open up some extremely powerful opportunities for international comparative research.

I encourage fellow travelers in PHSSR and public health economics to look northward for inspiration and insight that can advance your own programs of research. Watch this blog for future posts on our progress in mobilizing Canadian-American comparative research on public health delivery systems.

Expanding Experiments in Public Health Delivery Systems

One of the most promising developments in health and social policy research these days is the renewed push for using experimental designs to determine the effectiveness and efficiency of programs, policies, and implementation strategies in real-world settings. Random-assignment studies have been the gold standard in medical research for more than a half-century now because of the strong internal validity they provide, but these types of study designs are much less frequently used to study non-clinical interventions. The time and monetary costs of trials, logistical barriers, legal and ethical concerns, and the problem of weak external validity have led many health services researchers and policy implementers to shy away from randomized designs in favor of purely observational and quasi-experimental studies. Those large and massively expensive social experiments conducted in the 1970s and 1980s – like the RAND Health Insurance Experiment, the Negative Income Tax Experiment, and the COMMIT Smoking Cessation Trial – are probably partly to blame for our more recent trial-reluctance, despite the extremely valuable evidence generated by some (but not all) of these costly studies.

What’s driving enthusiasm for experimentation now are the concepts of the pragmatic trial and the large simple trial in the context of promoting comparative effectiveness research (CER) and a learning health system. By relaxing some of the requirements of a traditional randomized double-blind placebo-controlled clinical trial, it becomes possible to implement trials in real-world settings reflecting realistic policy and program choices and alternatives, thereby dramatically improving external validity without sacrificing much internal validity. Pragmatic trial designs can also reduce the monetary and time costs required to produce new evidence, such as by using existing data sources and reporting systems to monitor health and economic outcomes both before and after research subjects and/or settings are randomized to alternatives. And of course, it’s not just individual “patients” who can be randomly assigned to “treatment” alternatives – with a low-cost pragmatic trial, it becomes possible to randomly assign work teams, organizations, multi-organizational collaboratives, and even entire communities to different ways of doing things and different levels of exposure.

Research funders like the Patient Centered Outcomes Research Institute (PCORI) are now actively encouraging the use of pragmatic trials, mostly in the context of studying specific therapeutic interventions and their clinical delivery systems. And groups like MIT’s Jameel Poverty Action Lab (JPAL) are actively organizing low-cost pragmatic trials on a variety of health and social program interventions centered on poverty reduction, mostly in developing countries but now more recently in the U.S. The Coalition for Evidence Based Policy and the White House itself are also major proponents of this approach in U.S. health and social policy research.

These developments suggest that the time is right for American public health agencies and their partners who implement public health programs and policies across the U.S. to expand their use of pragmatic experimental trials. Many of the programs, policies, and delivery system strategies used in public health to prevent disease and injury and promote health on a population-wide basis have inadequate evidence concerning their health and economic impact. This fact is partly responsible for ongoing political and policy controversies concerning the ACA’s Prevention and Public Health Fund. Moreover, public health delivery systems in the U.S. are undergoing significant changes in their organization, financing, and operations due to economic and policy imperatives triggered by health care reform and public finance constraints. In the face of these policy uncertainties and pressures for change, why not incorporate pragmatic trials into our public health decision-making and implementation processes?

State and local public health agencies often have considerable (though perhaps under-appreciated) discretion over key details concerning how programs and policies are implemented. What types and levels of staffing to use, where and how to locate programs, how to recruit and engage target populations, how to tailor approaches for specific subgroups of interest, what mechanisms to use for disseminating and communicating information, what duration, sequencing and timing of activities to implement, how to divide roles and responsibilities among collaborating organizations, what financing and payment mechanisms to use – to the extent that these ingredients plausibly influence the effectiveness and efficiency of public health strategies, they represent promising targets for experimentation. Moreover, public health agencies are awash in existing data sources from both active and passive surveillance systems and program reporting requirements that can be used to structure pragmatic trials.

Powerful examples of pragmatic trials organized in public health settings are becoming more numerous, providing proof-of-concept that it is possible and worthwhile to organize such experiments. For example, a group of after-school programs for children in the Chicago area organized a field experiment to test different informational and material incentives designed to improve children’s food choices in a USDA-supported free meal program, showing that the introduction of small material incentives increased the take-up of healthy snacks by more than 400%. Similarly, a trial that I posted about earlier this summer from the ARM meeting tested the cost-effectiveness of a novel strategy for boosting child vaccination rates using a reminder and recall (R&R) intervention delivered centrally by local health departments in collaboration with community-based primary care practices. That study found that the collaborative, health department-delivered R&R model outperformed a standard physician practice-based R&R model both in terms of vaccination rates and in terms of costs, clearly showing the value of collective action involving public health agencies and primary care practices. Most recently the Coalition for Evidence Based Policy announced 3 new studies that will receive funding through its competition for low-cost randomized controlled trials, and 2 of these studies involve public health programs and delivery systems. One study in Durham NC costing just $183,000 will examine the health and economic impact of a postnatal nurse home visiting program, and another study conducted by the federal OSHA agency costing just $153,000 will test the effectiveness of a novel randomized workplace safety inspection policy that randomly selects worksites to receive onsite federal worker safety inspections.

Our National Coordinating Center for PHSSR is working to help create the conditions and infrastructure necessary to support pragmatic trials and other strong research designs in U.S. public health delivery system settings. For example, we have launched Practice-Based Research Networks (PBRNs) in more than 30 states that bring together state and local public health agencies and university-based researchers into ongoing research collaborations for the purposes of studying variation, change, and innovation in public health delivery. With several years of history in collaborative research now under their belts, many of our PBRNs are now well-positioned to progress to pragmatic trial designs wherein a network’s participating local public health settings can be randomly assigned to pursue different implementation approaches. One such trial is already underway in our Kentucky PBRN to test the effects of cultural competency training for local public health workers. A growing base of experience now exists with implementing studies that involve multiple PBRNs in the U.S., bringing in a larger number and diversity of communities and public health settings into the study design. Moreover, we recently launched a series of natural experiment studies in public health settings that, while not randomized, are helping both public health researchers and practitioners use more advanced research design and analytic methodologies like propensity-score matching and instrumental-variables estimation to support causal inferences and address threats to internal validity.

On the data and measurement front, our Center is working with colleagues at the University of Washington and other partners to standardize the measurement approaches and data sources used in state and local public health settings, in order to make large-scale pragmatic trials even more possible. For example, our recent Multi-Network Practice and Outcome Variation Examination (MPROVE) study has been working with PBRNs in six states to develop and implement a standard set of measures of public health delivery involving chronic disease prevention, communicable disease control, and environmental health protection –many of which are constructed using existing, routine data systems at state and local levels. These MPROVE measures, maintained over time, can provide a powerful data platform for supporting pragmatic trials in many different programmatic areas ranging from obesity prevention to food-borne illness control. Our Center also works to construct and analyze longitudinally linked analytic data files from a variety of other sources, including NACCHO’s periodic National Profile census survey of local health departments, the Census Bureau’s Annual Surveys of State & Local Government Finance, and our own National Longitudinal Survey of Public Health Systems which has followed a national cohort of communities since 1998.

To be sure, experimental designs are neither appropriate nor feasible for answering all of the questions of interest in empirical public health economics and PHSSR. But there are certainly many opportunities for using trials in public health settings to produce valuable evidence that are currently unrealized. Using resources like PBRNs and our expanding set of PHSSR measures and data sources, it is possible to employ pragmatic randomized trial designs more frequently to generate strong evidence about what works best for whom in public health delivery. Rigor and relevance need not be mutually exclusive.