Local Health Departments and Clinical Services:

Lessons from South Carolina

Nathan Hale, PhDAssistant Professor (Research)

Deputy Director, South Carolina Rural Health Research Center

Public Health Dilemma

Population based public health =

Current landscape – many remain DSP• 50% Family Planning• 46% Immunizations• 33% EPSDT• 20% Managed Care (Medical Home)

Dilemma (2) Economic Recession

• Driven further into clinical services?

Healthcare Reform• Catalyst for re-examining priorities –

discontinue?

Transitions occurring more frequently

Critical Questions

Two critical questions:

• What happens when the transition is made?oReceipt of services?oPopulation based health outcomes?oDifferent for rural communities?

• How do you mitigate the potential impact?

Rural Populations and EPSDT Services: Challenges and

Opportunities for Local Public Health Departments

Hale, N. Smith, M, Hardin, J. Martin, A. American Journal of Public Health. 2015 Apr;105 Suppl 2:S330-6

Background SCDHEC – State public health

agency

• 1995 -> SCDHEC 40% of EPSDT Market

• Mid 1990’s -> Transitioned EPSDT services

• Some targeted transitioning -> mostly attrition

Background Background

Methods - Data Data

• Retrospective cohort of infants enrolled in Medicaid

• 1995-2010• Eligibility / billing data• Continuous Medicaid enrollment for 12 months

Data Structure• Repeated Cross-sectional• Rolling Panel

Methods - Variables Dependent

• Any EPSDT visit (dichotomous)• Ratio of Observed to Expected EPSDT visits

Independent• Time (0-15)• SCDHEC Market ShareoHigh (>60%) | Average (20-59%) | Low (<20%)

• Rural Residence (Urban Influence Codes) oUrbanoRural

Methods - Additional Variables

Time Invariant

Maternal race/ethnicity Maternal age Maternal education Special health care

needs

Time Variant

FQHC/RHC penetration Private sector capacity Managed Care

penetration Medicaid enrollment Reimbursement

Methods - Analysis Growth Curve Models

• FixedoTime | SCDHEC Market Share | RuraloOther Time-variant | Time-invariant

• RandomoCounty | Time

• 3-way interaction (Time | SCDHEC | Rural)

Stata – xtmelogit | xtmixed • Predicted probabilities | Marginal means

Methods - Analysis

1995 2000 2005 20100%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Low Share Average Share High Share

1995 2000 2005 20100%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Low Share Average Share

1995 2000 2005 20100

1

2

3

4

5

6

7

8

Low Share Average Share

1995 2000 2005 20100

1

2

3

4

5

6

7

8

Low Share Average Share High Share

Urban Rural

Any EPSDT

# of EPSDT Visits

Policy Implications Urban -> stabilized -> ultimately improved

• Primary Care Infrastructure

Rural -> steady deterioration -> yet to recover

• Historically underserved | limited primary care

Note: Rural = 10% of the study population

Challenges & Opportunities

Rural LHDs & ACA (tough position)• Increased demand + constrained supply =

deeper into safetynet & direct service provision

Transition may be very difficult• Potential to exacerbate existing resource

voids

FQHC | Medical home initiatives

Policy Implications – Big Picture Retraction of clinical services = Impact

Real Question – What is tolerable impact?

PPACA + Recession -> Increasing demand• How can LHDs really make this transition?• Targeted retraction of clinical services probably the

more likely scenario (ie Family Planning Study)

PPACA + Recession -> Increasing opportunity• FQHC | Medical Home | Population health funding

Thank You!Nathan Hale, PhD.

Research Assistant Professor, Dept of Health Services Policy & Mgmt

Deputy Director, South Carolina Rural Health Research Center

halen@mailbox.sc.edu (803) 576-7384