Receding gains: Will the economy erode public health partnerships with physician offices?
■ Progress made in emergency preparedness and health infrastructure is starting to falter as funds diminish and need increases.
By Susan J. Landers — Posted March 16, 2009
It has been said that the nation's public health rides on a funding roller coaster. Sometimes the money flows in its direction, as it did after fears of a bioterrorism attack struck home in 2001. With these resources came improvements in the interworkings of the public health system and its connections and communications with practicing physicians. Now, with the nation's ever-worsening economic crisis, funding cuts threaten to undermine these inroads.
To grasp what is at stake, it is important to look at recent history.
The events of 2001 triggered a seismic shift in the way the nation's health care is delivered. Closer bonds were formed between local public health departments and the multitude of physicians who treat patients in offices, clinics and hospitals. Both groups now sit around the same tables. In some localities, that circumstance has resulted in cost-saving and effective partnerships.
When thousands of communities received emergency preparedness funds, there was a "spirit of collaboration between traditional public health and medical providers: physicians, clinics and hospitals," said Karen Smith, MD, health officer and public health director of California's Napa County Health and Human Services Agency. "That's been one of the unintended benefits, although if anyone had thought about it, it would have been an intended benefit."
Enhancing such partnerships has long been a goal of the American Medical Association. Educating the partners about each other's job and joining in projects that enhance the health of communities in which both serve is a long-standing AMA policy.
The partnerships that began in 2001 and 2002 benefited substantially from post-9/11 attention. Funds for communications infrastructure, for example, have proven their worth, said Georges Benjamin, MD, executive director of the American Public Health Assn.
"There have been several outbreaks of disease for which that infrastructure has been helpful," he said. From foodborne illnesses, to monkey pox and the measles, the infrastructure allowed earlier detection.
Two groups recently tracked those public health funds for a December 2008 report, "Ready or Not? Protecting the Public's Health from Diseases, Disasters and Bioterrorism." The nonprofit, Washington, D.C.-based Trust for America's Health and the Robert Wood Johnson Foundation, a health philanthropy, found that some states were more ready than others after a $6.3 billion infusion of federal money.
They also found that recent budget cuts threaten the progress made in the nation's ability to handle disease outbreaks, natural disasters and bioterrorism.
The report contains state-by-state health preparedness scores based on 10 key indicators to assess emergency capabilities. More than half of the states and the District of Columbia achieved scores of seven or less. Only Louisiana, New Hampshire, North Carolina, Virginia and Wisconsin scored 10 out of 10.
The latest report is the sixth by the groups to measure progress toward improved public health preparedness. Earlier reports documented steady gains, but the current report found that 2005 cuts in federal funding for states and localities, coupled with the more recent budget cuts states are making in response to the recession, put that progress at risk.
The importance of partnerships
Some localities are relying on ties between public health and the private medical sector for help in resolving a range of health problems. For example, partners may find emergency preparedness or chronic disease prevention and care on the agenda of their regularly scheduled meetings, Dr. Smith said.
Determining effective solutions for curbing growth of such chronic diseases as diabetes and heart disease has proven difficult everywhere in the nation, California included, Dr. Smith said. And in California, there is no money in the budget to deal with them. "There is an epidemic of chronic diseases, and we don't have much in the way of resources to approach these issues."
Severe budget shortfalls in California have made the jobs of Dr. Smith and other physicians much more difficult. State programs all were cut. But a big hit also was felt on the local level. "Most of our discretionary money comes from a tax on cars, but people aren't buying cars."
Meanwhile, in Fairfax County, Va., Gloria Addo-Ayensu, MD, MPH, director of the health department, also is continuing to strengthen the ties between public health, physicians and others in the community to fortify the department's ability to continue its work in the face of budget challenges. "Everything we are working on is potentially at risk, since real estate is a big source of revenue, and housing values have dropped and sales are down." Her budget, though, has not seen the severe damage experienced by some of her counterparts.
"We've become a little creative," she said. "We try to engage our partners rather than doing it all ourselves, thinking maybe the schools or churches can assist us."
The Fairfax County Health Dept., for instance, has built a cadre of 3,800 physicians, nurses and other health care professionals to serve as its volunteer Medical Reserve Corps, trained to respond to health emergencies. The Fairfax corps is among the largest in the nation, Dr. Addo-Ayensu said.
The county also educates community physicians and their staffs on proper use of N95 respirators when treating patients who may have dangerous communicable diseases. "Many people talk about surge capacity, and private physicians are the backbone of that capacity," Dr. Addo-Ayensu said. "It's very important that private physicians be able to maintain their practices as long as possible during an event like a pandemic."
The county buys the $250 respirators using Centers for Disease Control and Prevention funds and gives them to the physicians' offices at the end of the training session. So far, about 400 practices have participated.
Dr. Addo-Ayensu notes that emergency response is only one aspect of public health. But "emergency preparedness has made for a better public health system, period."
The teaming up of public health and community physicians has become something of a standard in Baltimore, with Joshua Sharfstein, MD, commissioner of health, a driving force.
Dr. Sharfstein attends meetings of the Baltimore Medical Society's public health committee and has enlisted the help of community physicians for a range of public health programs, from children's literacy to drug addiction.
The City Health Dept. pays the program fee for office-based physicians who sign up to treat opioid-addicted patients with buprenorphine. "We start patients in the drug-treatment systems, and when they are stable, they are moved to private physicians' offices," Dr. Sharfstein said.
When he sought volunteers for the Reach out and Read Program, a literacy program run out of the offices of pediatricians and family physicians, Dr. Sharfstein achieved a high participation rate. "The end result is better literacy for kids and happy clinicians."
Such partnerships are providing mutual help in many parts of the nation, but that may not be enough in Michigan, which encountered the economic downturn earlier than did other states.
A system in trouble
"We are pretty much hanging on by the tip of one finger," said Rebecca Head, PhD, director and health officer for the Monroe County Public Health Dept.
The county did receive some federal emergency preparedness funds after 2001, but now "our emergency preparedness money has gone down and down and down and yet what is expected of us has gone up," Head said.
Michigan's local health departments are required by state code to provide a wide array of services -- such as childhood hearing tests, restaurant inspections and diabetes education -- yet state funding has not increased since 2001, she said. "This year is really a drastic year, and I think it's going to get more drastic throughout."
Her staff of about 60 full- and part-time employees runs programs for approximately 180,000 county residents.
The aging public health work force also is affecting the department. Workers are retiring, but the positions aren't being filled. Despite all the economic woes, "I think we do a tremendous job here," Head said.
Now, health departments throughout Michigan are building their cases to request a boost in state funding. "We need people to understand the importance of public health. There is a saying that the best public health is when nothing happens," she added.
Bright spots on the horizon for Michigan and other states are the new federal stimulus funds that should soon flow their way. The American Recovery and Reinvestment Act includes $1 billion for a Prevention and Wellness Fund that could sustain many programs.
The measure provides $300 million for immunizations, $650 million for community prevention programs and $50 million for reducing health care associated infections. In addition, $500 million is to be spent on the health and public health work force.
This infusion of dollars could save or create 20,000 public health jobs and help restore the jobs of some of the 11,000 workers who have been laid off, according to a Trust for America's Health analysis.
The American Public Health Assn. cheered the stimulus bill's inclusion of public health funding, saying it is an "important first step in ensuring we have the healthy, productive work force that will be required as we move forward from these difficult times."