Public Health Services and Systems Research & Health Reform

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The Patient Protection and Affordable Care Act (PPACA) was signed into law by President Obama in March 23, 2010. The law authorizes many new programs and changes many existing programs, and will undoubtedly transform the field of health services research (HSR). A relevant section of PPACA, perhaps less known to the HSR community, is section 4301, Research on Optimizing the Delivery of Health Services.  It states “the Secretary of Health and Human Services, acting through the Director of the Centers for Disease Control and Prevention, shall provide funding for research in the area of public health services and systems.” This authorization is historic for the emerging field of Public Health Services and Systems Research (PHSSR), a “sister” discipline to HSR, which has only attracted modest Federal investment to date.

PPACA specifically calls for research that 1) examines evidence-based practices relating to prevention, with a particular focus on high priority areas as identified by the Secretary in the National Prevention Strategy or Healthy People 2020, including comparisons of community-based public health interventions in terms of effectiveness and cost; 2) analyzes the translation of interventions from academic settings to real world settings; and 3) identifies effective strategies for organizing, financing, or delivering public health services in real world community settings, including comparing state and local health department structures and systems in terms of effectiveness and cost.¹

PHSSR investigates the public health infrastructure. It seeks to uncover information about how the public health system’s inputs (e.g. organizational structure, financing) and outputs (e.g. programs, services) affect health outcomes. It has emerged as a sister discipline to HSR; both fields share a related set of research questions, have a common base of methods, and often rely on similar types of data sources to develop meaningful research on population health. The two fields are closely linked and often draw upon the same pool of researchers.²  

Central to PPACA is the creation of a Prevention and Public Health Fund (the Fund), which provides $15 billion in mandatory appropriations for public health and prevention programs over the next ten years. Three core categories of expenditures are anticipated under the Fund, including community prevention; core capacity; and research, development, and dissemination of best practices. Many people invested in the field are hopeful that funding for PHSSR will come from the Fund, under this last category.

PPACA marks only the second time that PHSSR has been authorized by Federal legislation. Strategies to leverage this opportunity may be learned from the PHSSR community’s experience with the 2006 Pandemic and All-Hazards Preparedness Act (PAHPA)—the first Federal law to authorize funding for the discipline. PAHPA authorized the Secretary of the U.S. Department of Health and Human Services to identify the existing public health systems research knowledge base and establish a research agenda. Because PHSSR was still being established as a research discipline at the time the legislation was drafted, PAHPA was written to support the growth of the field by generating research and supporting the research infrastructure. As such, it supports the development of junior investigators through post-doctoral programs and mandates the funding of “research centers at accredited schools of public health to conduct public health systems research for preparedness and emergency response.”  To date, the Centers for Disease Control and Prevention (CDC) Coordinating Office for Terrorism and Preparedness Emergency Response (COTPER) has funded nine Preparedness and Emergency Response Research Centers (PERRCs). The PERRCs are required to conduct PHSSR.

Currently, the public health community, under the leadership of the Coalition for Health Services Research (AcademyHealth’s advocacy arm), is mobilizing to secure appropriations for PHSSR in FY 2012. Similar to PAHPA, the community hopes PPACA will result in the generation of new research as well as improvements in the research infrastructure—the human capital, methods, and data necessary to expand PHSSR’s evidence base.  

Exemplary PHSSR, which has the potential to inform evidence-based public health practice, is currently being conducted by several HCFO grantees, including:

Title: Mapping the Gaps: Enhancing Local Health Departments Capacity to Match Services to Health Needs
Grantee Institution: RAND Corporation 
Principal Investigator: Tamara Dubowitz
Grant Period: February 1, 2009–January 31, 2011

The researchers will assess whether and how geographic information systems (GIS) can be employed by local health departments (LHDs) to inform planning efforts so that they more closely align community health needs with public health services and programs. Specifically they will: 1) examine how LHDs in California and Florida collect and use data to quantify community health needs and distribute LHD services and expenditures; and 2) work with LHD partners to create a gap analysis that identifies spatial congruencies and mismatches between community health needs and the distribution of LHD programs and services. The objective of this project is to help shape decision making by policymakers by providing them with clear illustrations of the need for additional resources or redirection of current services and programs.

Title: Public Health Entrepreneurship
Grantee Institution: University of Michigan
Principal Investigator: Peter Jacobson
Grant Period: February 1, 2009–March 31, 2011

This project will explore the feasibility of characterizing, documenting, and disseminating existing public health entrepreneurial activities. Specifically, researchers will address the question: What are the activities public health entrepreneurs currently pursue to generate new sources of revenue and new service delivery innovations and what organizational adaptations encouraged or resulted from those activities? They will: 1) identify existing entrepreneurial public health activities and assess the public health system’s organizational capacity to engage in such initiatives; 2) identify ways that public health practitioners can use entrepreneurship to enhance the capacity to improve population health; 3) share identified practices across public health practitioners; and 4) stimulate a wide-ranging debate among public health advocates, practitioners, and policymakers about the role of entrepreneurship in how the public health system can best be organized to meet population health challenges. The objective of this project is to provide public health policymakers and practitioners with the first systematic description of innovative strategies to generate new revenues or more efficient and effective practices to improve population health.

Title: Informing the Design of Funding Allocation Formulas in Public Health
Grantee Institution: Florida Atlantic University
Principal Investigator: Patrick Bernet
Grant Period: January 1, 2008–June 30, 2011

The researchers will examine formula-based allocation strategies in public health practice. In particular, they will assess the impact on funding allocations of various formula design options, including the use of different indicators of target population need, the cost of providing services, state or local resource availability, and various approaches to combining indicators in formula calculations. The will also study the policy implications associated with using different indicators or strategies, including measures of population health disparities and approaches to assuring equity versus equivalency in funding allocations. The objective of this project is to generate practical guidance for public health program managers seeking to make informed choices when developing allocation formulas to best serve program goals.

Title: Developing and Applying a Descriptive Framework for Analyzing Food Safety Resources
Grantee Institution: University of Florida
Principal Investigator: Michael B. Batz
Grant Period: January 1, 2008–March 31, 2010

The researchers will develop a descriptive framework for public health-oriented analysis of food safety resources. The researchers will use the framework to describe and analyze federal food safety expenditures comprehensively and will apply it on a pilot basis to selected states and localities. Development of the framework will necessitate addressing the following research questions: 1) How should government food safety expenditures be organized into functional categories that enable the evaluation of resource allocation from a public health perspective? 2) Can actual food safety expenditure data be translated into these public health-oriented categories in a way that is feasible and useful for policymakers? 3) How are federal food safety resources allocated across these public health-oriented categories? 4) What are the recent trends in federal food safety expenditures across the system and across these public health-oriented categories, including federal allocations to state and local agencies? 5) How does the current federal resource allocation compare with what data and expert judgment suggest about opportunities to reduce risk across the system? 6) Can the framework be feasibly and usefully applied to state and local expenditures, taking into account budget data availability and the large number of individual agencies? 7) For a pilot set of states and localities, how are current food safety resources allocated across public health-oriented categories? and 8) What budgetary practices of government agencies foster or impede understanding and analysis of food safety expenditures from a public health perspective? The objective of this project is to provide policymakers with a tool for describing and analyzing government food safety expenditures on a system-wide basis and in ways that are relevant to reducing food borne illness.

1. From the Patient Protection and Affordable Care Act, available at http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf.
2. Holve, E. et al.  “A Needs Assessment for Data and Methods in Public Health Systems Research.” AcademyHealth, 2010. Available at http://www.academyhealth.org/files/interestgroups/phsr/FinalPhsrNAjan2010.pdf.