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

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

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

3. 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 Promotion Health Awareness & Tobacco Epidemiology Immunization HIV/AIDS Sexually Transmitted Diseases Tuberculosis Control Refugee Health Minority Health Children’s Medical Services Examples of Public Health Services

4. Environmental Epidemiology Water Programs Facility Programs Radiation Control Onsite Sewage Programs Local Health Councils Medical Disability Programs Dental Health Family & Community Health Chronic Disease Prevention WIC & Nutrition Child Nutrition Medical Quality Assurance Health Care Practitioner Regulation Examples of Public Health Services

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

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

7. Research Questions • Question 1 – Cost of Services What are the costs of primary care services provided by contracted service providers relative to services provided by the public health departments?

8. Research Questions • Question 2 – Access to Services Where primary care services have been privatized, what is the effect on access to care for Medicaid and uninsured patients?

9. Research Questions • Question 3 – Health Outcomes What is the effect of privatization on health outcomes in privatized and non-privatized counties?

10. Limitations and Delimitations • The study used different units of analysis (program level, zip code level, county level) for measuring the three dimensions (cost, access, and health outcomes) because of the limited availability of some data. • Health outcomes could not be directly measured for Department of Health clients. Performance indicators used by the Department of Health were used as proxy measures. • Performance indicators for all primary care programs used in the cost analysis were not available. • Some health status indicators used for evaluating primary care at population levels were assigned to other funding sources and therefore not selected for analysis. For example STD’s are funded through communicable disease programs.

11. Hypotheses • Hypothesis 1 Contracting primary care to private providers reduces the cost of providing services when compared to providing these services within the county health department.

12. Methodology • Data Sources for Hypothesis 1 • Contract Management System Variance Report • Counties • Brevard, Broward, Dade, Duval, Hillsborough, Orange, Palm Beach, Pinellas, and Polk • Fiscal Years • 10/1/2000 – 9/30/2001 through • 10/1/2003 – 9/30/2004

13. Methodology

14. Methodology • Data Sources for Hypothesis 1 • Primary Care Programs • Chronic Disease Prevention • Family Planning • Maternal Health/IPO • Healthy Start Prenatal • Healthy Start Infants • Comprehensive Child Health • Comprehensive Adult Health

15. Variables Used in the Study • Dependent Variable • Cost • Independent Variables • Unduplicated number of clients • Number of services performed • Program • Fiscal year (2001 - 2004)

16. Methodology • Mixed Model with Repeated Measures y = Xb + Zg + e • GEE Estimation with Repeated Subject

17. ResultsMixed Procedure Fit Statistics -2 Res Log Likelihood 6786.2 AIC (smaller is better) 6790.2 AICC (smaller is better) 6790.2 BIC (smaller is better) 6794.3 Solution for Fixed Effects Effect Estimate SE DF t value P>l t l privatized 0 -5.58E7 62858977 57 - 0.89 0.3778 privatized 1 -5.59E7 62858668 57 - 0.89 0.3771 clients 42.8969 9.0349 174 4.75 <.0001 services 23.48.23 1.9294 174 12.17 <.0001

18. ResultsGENMOD Procedure Goodness of Fit Criterion DF Value Value/DF Deviance 229 318.4377 1.3906 Scaled Deviance 229 318.4377 1.3906 Pearson Chi-Square 229 236.0080 1.0306 Scaled Pearson 229 236.0080 1.0306 Log Likelihood -159.2188 Analysis of Initial Parameter Estimates Parameter Estimate SE 95% CL Chisq > lc2l Intercept 0.4149 0.3209 -0.2300 1.0598 1.59 0.2073 Clients 0.0000 0.0000 -0.0000 0.0001 0.01 0.9057 Services 0.0000 0.0000 0.0000 0.0000 0.42 0.5191 Expenditures -0.0000 -0.0000 0.0000 -0.0000 0.23 0.6322 Yr 2001 -0.0221 0.3855 -0.7777 0.7335 0.00 0.9543 Yr 2002 -0.0155 0.3871 -0.7741 0.7431 0.00 0.9681 Yr 2003 -0.0078 0.0000 -0.7486 0.7331 0.00 0.9836 Yr 2004 -0.0000 0.0000 0.0000 0.0000 . .

19. ResultsGENMOD Procedure Analysis of GEE Parameter Estimates Parameter Z Pr > l Z l Intercept 0.33 0.7392 Clients 1.76 0.0783 Services 0.15 0.8832 Expenditures -1.18 0.2388 Yr 2001 0.60 0.5485 Yr 2002 0.99 0.3220 Yr 2003 1.06 0.2892 Yr 2004 . .

20. Hypotheses • Hypothesis 2 In counties where primary care programs have been privatized, potential access to primary care services will be greater than in non-privatized areas.

21. Methodology • Data Sources for Hypothesis 2 • U.S. Census Bureau at www.census.gov Census 2000 Summary Files 1 and 3 American Fact Finder Quick Reports 1999 Zip Code File • MedlinePlus at www.nlm.nih.gov AMA Physician Select: Online Doctor Finder (American Medical Association) Find a Hospital (American Hospital Association

22. Methodology • Data Sources for Hypothesis 2 • Bureau of Primary Health Care (HRSA) Primary Care Programs Directory 1998 • Florida Association of Community Health Care Centers at www.fachc.org • Florida Department of Health at www.doh.state.fl.us

23. Variables Used in the Study • Demographic and Population Characteristics • Percent of Population over 65 yrs of age • Percent of Population under 15 yrs of age • Percent of Blacks in the Population • Percent of Females in the Population • Socioeconomics • Percent unemployment • Percent below poverty level

24. Variables Used in the Study • Primary Care Resources • Family practice physician/population • General practice physician/population • Obstetric-gynecology physician/population • Internal medicine physician/population • Pediatric physician/population • Number of hospitals (w/Emergency Dept) • Number of community care centers

25. Methodology • Calculating a Variable Specific Score Variable-specific = Zip Code Percent x 10 Score Tot Zip Code Avg. Unemployment = 2.8 x 10 Score 5.0 Unemployment = 5.6 Score

26. Methodology • Demographics and Population Characteristics Model Weights

27. Methodology • Socioeconomic Model Weights

28. Methodology • Primary Care Resources Model Weights

29. Methodology • Primary Care Resources Model Weights

30. Methodology • Primary Care Access Score PCA = w1v1 + w2v2 + . . . w13v13 Score • GEE Model y = bxi where y = primary care access score x = privatization status (0,1)

31. Results Goodness of Fit Criterion DF Value Value/DF Deviance 418 933.2442 2.2326 Scaled Deviance 418 420.0000 1.0048 Pearson Chi-Square 418 933.2443 2.2326 Scaled Pearson 418 420.0000 1.0048 Log Likelihood -763.6208 Analysis of GEE Parameter Estimates Empirical Standard Error Estimates Parameter Estimate SE 95% CL ZPr > lZl Intercept -0.8401 0.1340 -1.1028 -0.5774 -6.27 0.0001 Privatization Status 0.3363 0.1983 -0.0524 0.7250 1.70 0.0899

32. Hypotheses • Hypothesis 3 In counties where primary care programs have been privatized, health outcomes on primary care sensitive indicators (i.e. post-neonatal mortality) will be better than in non-privatized areas.

33. Methodology • Data Sources for Hypothesis 3 • U.S. Census Bureau at www.census.gov American Community Survey 2000 - 2003 American Fact Finder Quick Reports • Florida Department of Health at www.doh.state.fl.us • Florida CHARTS at www.floridacharts.com

34. Variables Used in the Study • Dependent Variables • Infant Mortality Rate • Non-white Infant Mortality Rate • Percentage of low birth weight births • Live births to mothers age 15-19 • Neonatal mortality • Post-neonatal mortality • No prenatal care

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

36. ResultsMixed Procedure

37. ResultsMixed Procedure

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

39. Recommendations • Public Health systems are undergoing a major transition as the health department’s role in the provision of primary care services declines; however, preserving, protecting and promoting the health of communities should remain an important consideration. • Evaluation of all dimensions of privatization are necessary if there is to be movement toward equitable allocation of finite resources.

40. Summary • Privatization of government services is likely to continue throughout the next decade. However more research is needed on this trend. • In the case of primary care services, this analysis revealed that privatization did not result in a cost savings. As a result, we should evaluate what effects privatization has on the health of Floridians. By making the correct choices, we can efficiently and effectively improve the health of all Floridians.