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Title: 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. (Websters Dictionary)

3
Examples 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 Promotion
  • Health Awareness Tobacco
  • Epidemiology
  • Immunization
  • HIV/AIDS
  • Sexually Transmitted Diseases
  • Tuberculosis Control
  • Refugee Health
  • Minority Health
  • Childrens Medical Services

4
Examples of Public Health Services
  • 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

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 STDs 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
Year 1 2000/2001 Year 2 2001/2002 Year 3 2002/2003 Year 4 2003/2004
Privatized Broward, Dade, Orange, Pinellas, Palm Beach
Non-Privatized Brevard, Duval, Hillsborough, Polk
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 Pgtl 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 lt.0001
  • services 23.48.23 1.9294 174 12.17 lt.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
    gt 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 gt 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

Percent Over 65 yrs of Age -0.007263
Percent Under 15 yrs of Age -0.009275
Percent of Blacks in the Population -0.012931
Percent of Females in the Population -0.007218
27
Methodology
  • Socioeconomic
  • Model Weights

Percent Unemployment -0.065251
Percent of Population Below Poverty Level -0.061036
28
Methodology
  • Primary Care Resources
  • Model Weights

Family practice physician/pop 0.042514
General practice physician/pop 0.019917
Obstetrics-gynecology physician/pop 0.032610
Internal medicine physician/pop 0.014757
Pediatric physician/pop 0.023333
29
Methodology
  • Primary Care Resources
  • Model Weights

Number of hospitals 0.009106
Number of community care centers 0.040816
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 gt 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
Outcome Measure Random Effects Fixed Effect DF Pr gt ltl Sig
Infant Mortality Rate Black, Hispanic, Below Poverty, Under 18, Year Privatized 19 0.53 0.47 N. S.
Non white Infant Mortality Rate Black, Hispanic, Below Poverty, Under 18, Year Privatized 19 0.08 0.08 N. S.
Neonatal Mortality Rate Black, Hispanic, Below Poverty, Under 18, Year Privatized 19 0.95 0.87 N. S.
Post-neonatal Mortality Rate Black, Hispanic, Below Poverty, Under 18, Year Privatized 19 0.14 0.08 N. S.
37
ResultsMixed Procedure
Outcome Measure Random Effects Fixed Effect DF Pr gt ltl Sig
Births to Mothers 15-19 yrs Black, Hispanic, Below Poverty, Under 18, Year Privatized 19 0.67 0.50 N. S.
Low Birth Weight Black, Hispanic, Below Poverty, Under 18, Year Privatized 19 0.14 0.08 N. S.
No Prenatal Care Black, Hispanic, Below Poverty, Under 18, Year Privatized 19 0.11 0.07 N. S.
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 departments 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.
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