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New Health Delivery Networks: Merging Public Health and Health Care Systems


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University of Kentucky


Health Management and Policy Presentations Health Management and Policy


New Health Delivery Networks: Merging Public

Health and Health Care Systems

Glen P. Mays

University of Kentucky, glen.mays@cuanschutz.edu

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Repository Citation

Mays, Glen P., "New Health Delivery Networks: Merging Public Health and Health Care Systems" (2013).Health Management and Policy Presentations. 12.


New Health Delivery Networks: Merging

Public Health and Health Care Systems

Glen Mays, PhD, MPH University of Kentucky


11th Annual Mid-South Cancer Symposium • Memphis, TN • 8 Nov 2013


Failing to connect

Why do

medical care


public health

delivery systems often fail to connect?

What are the

causes and consequences

of this failure?

Where are the

opportunities for connection



Failing to connect

Medical Care Delivery

Public Health Delivery

• Fragmentation • Duplication

• Variability in practice • Limited accessibility

• Episodic and reactive care • Insensitivity to consumer

values & preferences

• Limited targeting of resources to community needs • Fragmentation • Variability in practice • Resource constrained • Limited reach • Insufficient scale

• Limited public visibility & understanding

• Limited evidence base • Slow to innovate & adapt

Inefficient delivery Inequitable outcomes


Failing to connect


What Does Public Health Offer?

Organized programs, policies, and laws to prevent disease and injury and promote health on a population-wide basis

– Epidemiologic surveillance & investigation

– Community health assessment & planning

– Communicable disease control

– Chronic disease and injury prevention

– Health education and communication

– Environmental health monitoring and assessment

– Enforcement of health laws and regulations

– Inspection and licensing

– Inform, advise, and assist school-based,

worksite-based, and community-based health programming


Challenges in public health delivery

Lack of clear, coherent mission and expectations

Complex, fragmented, variable delivery systems

Resources ǂ preventable disease burden

Large inequities in resources & capacity

Variable productivity and efficiency

Gaps in evidence base for public health delivery

Inability to demonstrate value/return on investment


How Does the Public Health System Perform? Delivery of recommended activities

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 1998 2006 2012

Assurance Policy Assessment

% o f a c ti v it ie s ↑ 10% ↓ 5%


Variation in Public Health Delivery

Delivery of recommended public health activities, 2012

National Longitudinal Survey of Public Health Systems, 2012 % of activities 0 5 % 1 0& Pe rc e n t o f U .S. c o m m u n it ie s 20% 40% 60% 80% 100%


Organizations engaged in public health delivery

Delivery of recommended public health activities, 2012

-50% -30% -10% 10% 30% 50%

Local health agency Other local government State health agency Other state government Hospitals Physician practices Community health centers Health insurers Employers/business Schools CBOs

% Change 2006-2012 Scope of Activity 2012


Imbalance of resources & needs


of national health spending is attributable

to conditions that are largely preventable

– Cardiovascular disease

– Diabetes

– Lung diseases


– Injuries

– Vaccine-preventable diseases and sexually

transmitted infections


of national health spending is allocated to

public health and prevention


Variation in Local Public Health Spending

0 .05 .1 .15 P e rc e nt of c ommuni ti e s $0 $50 $100 $150 $200 $250

Expenditures per capita, 2010


Changes in Local Public Health Spending


0 .05 .1 .15 .2 .25 P e rc e nt of c ommuni ti e s -100 -50 0 50 100

Change in per-capita expenditures ($)

62% growth 38%


Mortality reductions attributable to local

public health spending, 1993-2008

-9 -8 -7 -6 -5 -4 -3 -2 -1 0 1 2 Infant mortality Heart

disease Diabetes Cancer Influenza All-cause Alzheimers Injury

P er cen t ch a n g e

Hierarchical regression estimates with instrumental variables to correct for selection and unmeasured confounding


5800 6000 6200 6400 6600 6800 7000 7200 0 20 40 60 80 100 120

Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5

M ed ic al sp en di ng /p er so n ($ ) . Pu bl ic h ea lth sp en di ng /c ap ita ($ ) .

Quintiles of public health spending/capita

Public health spending/capita Medicare spending per recipient

Mays et al. 2009, 2013

Medical cost offsets attributable to local

public health spending, 1993-2008

For every $10 of public health spending, ≈$9 are recovered in lower medical care spending over 15 years


Bridging the Gap: Why Now?

Integrated Medical

Care & Public Health


Some Leading Examples

Hennepin Health ACO

Partnership of county health department, community hospital, and FQHC

Accepts full risk payment for all medical care, public health, and social service needs for Medicaid enrollees

Fully integrated electronic health information exchange Heavy investment in care coordinators

and community health workers

Savings from avoided medical care reinvested in public health initiatives

Nutrition/food environment Physical activity


Some Leading Examples

Akron Accountable Care Community

Partnership of multiple hospital systems, county health department, FQHCs, schools, libraries and CBOs

Targets community-wide population at risk for diabetes

Invests in primary prevention, screening, and active disease management

Savings from avoided medical care reinvested in prevention initiatives

Nutrition/food environment Physical activity


Some Leading Examples

Massachusetts Prevention & Wellness Trust Fund

$60 million invested from nonprofit insurers and hospital systems

Funds community coalitions of health systems, municipalities, businesses and schools

Invests in community-wide, evidence-based prevention strategies with a focus on reducing health disparities Savings from avoided medical care

are expected to be reinvested in the Trust Fund activities


Toward next generation public health

Public health as a chief health strategist for the community

Articulate population health needs & priorities Engage community stakeholders

Plan with clear roles & responsibilities Recruit & leverage resources

Develop and implement policies Ensure coordination

Promote evidence-based practices Monitor and feed back results

Mobilize performance improvement


Evidence gaps: toward a “rapid-learning system”


Public Health Practice-Based Research

Networks (PBRNs)

First cohort (December 2008 start-up) Second cohort (January 2010 start-up) Affiliate/Emerging PBRNs (2011-13)


Conclusions: finding the connection

Act on aligned incentives

Exploit the disruptive policy environment

Innovate, prototype, study – then scale

Pay careful attention to shared governance,

decision-making, and financing structures

Demonstrate value and accountability

to the public


For More Information

Glen P. Mays, Ph.D., M.P.H. glen.mays@uky.edu

University of Kentucky College of Public Health Lexington, KY

Supported by The Robert Wood Johnson Foundation

Email: publichealthPBRN@uky.edu Web: www.publichealthsystems.org Journal: www.FrontiersinPHSSR.org Archive: works.bepress.com/glen_mays Blog: publichealtheconomics.org

Health Management and Policy Presentations Health Management and Policy Health Economics Commons Health Services Research Commons https://uknowledge.uky.edu/hsm_present/12


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