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Understanding Changes in Local Public Health Spending Glen Mays, PhD, MPH Department of Health Policy and Management University of Arkansas for Medical.

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Presentation on theme: "Understanding Changes in Local Public Health Spending Glen Mays, PhD, MPH Department of Health Policy and Management University of Arkansas for Medical."— Presentation transcript:

1 Understanding Changes in Local Public Health Spending Glen Mays, PhD, MPH Department of Health Policy and Management University of Arkansas for Medical Sciences

2 Longitudinal change in spending and mortality Half of all gains attributable to medical spending $36,300 per year of life gained What can we say about public health spending? Cutler et al. NEJM 2006

3 Geographic variation in spending and mortality u Medical spending varies by a factor of more than 2 across local areas u Medicare enrollees in high- spending regions receive more care but do not experience lower mortality u What can we say about public health spending? Fisher et al. Annals 2003

4 Some research questions of interest… u How does public health spending vary across communities and change over time? u Are changes in spending associated with changes in population health outcomes? u What is the value of public health spending?

5 Variation in Local Public Health Spending 0 5% 10% 15% Fraction of Agencies $0$50$100$150$200 Expenditures per capita, 2005 Gini = 0.472

6 Change in Local Public Health Spending, % 10% 15% Fraction of Agencies –$50 $0$50 Change in Per Capita Spending (Current Dollars) –$10 –$20 –$30 –$40$40 $30 $20 $10 35% 65%

7 The problem with public health spending u Federal & state funding sources often targeted to communities based in part on disease burden, risk, need u Local funding sources often dependent on local economic conditions that may also influence health u Public health spending may be correlated with other resources that influence health Sources of Local Public Health Agency Revenue, 2005 NACCHO 2005

8 Example: cross-sectional association between PH spending and mortality Quintile of public health spending/capita Public health spending/capita Public health spending/capita Heart disease mortality Deaths per 100,000

9 Example: cross-sectional association between PH spending and Medicare spending

10 Addressing the problem with spending 1.Cross-sectional regression: control for observable confounders 2.Fixed effects: also control for time-invariant, unmeasured differences between communities 3.IV: use exogenous sources of variation in spending 4.Discriminate between causes of death amenable vs. non- amendable to PH intervention PH spending Mortality Unmeasured disease burden, risk Unmeasured economic distress _ Approaches

11 Data used in empirical work u Financial and institutional data collected on the national population of local public health agencies (N3000) in 1993, 1997, and 2005 u Residual state spending estimates from US Census of Governments u Residual federal spending estimates from Consolidated Federal Funding Report u Community characteristics obtained from Census and Area Resource File (ARF)

12 Analytical approach u Dependent variables –Age-adjusted mortality rates, conditions sensitive to public health interventions (infant mortality, heart disease, cancer, diabetes, influenza) –Counterfactual mortality rates (alzheimers, unintentional injuries) u Independent variables of interest –Local spending per capita, all sources –Residual state spending per capita (funds not passed thru to local agencies) –Direct federal spending per capita

13 Analytical approach: IV estimation u Identify exogenous sources of variation in spending, unrelated to outcomes –Governance structures: local boards of health –Centralized state-local PH administration u Controls for unmeasured factors that jointly influence spending and outcomes PH spending Mortality Unmeasured disease burden, risk Unmeasured economic distress Governance

14 Analytical approach u Agency characteristics: type of government jurisdiction, scope of services offered, governance, state-local administration u Community characteristics: population size, rural-urban, poverty, education, age distributions, physicians per capita, CHC funding per low income u State characteristics: Private insurance coverage, Medicaid coverage, state fixed effects Other Variables Used in the Models

15 Factors associated with local public health spending Variable Coefficient 95% CI Local board of health (1=Yes)0.145**(0.099, 0.196) Centralized structure (1=Yes) **(-0.364, ) Population size(log) ***(-0.168, ) Income per capita (log)0.196**(0.001, 0.392) Local tax burden (% of income)0.234**(0.032, 0.436) **p<0.05 ***p<0.01 Hierarchical logistic regression estimates controlling for community-level and state-level characteristics

16 Multivariate estimates of association between spending and mortality *p<0.10 **p<0.05 ***p<0.01 Cross-sectional model Fixed-effects model IV model

17 Conclusions u Local public health spending varies widely across communities u Governance and administrative structures appear influential in spending decisions –Local governing boards –Decentralized administrative structures u Growth in spending is associated with reductions in mortality from leading preventable causes of death

18 Limitations u Aggregate spending measures –Average effects –Role of allocation decisions? u Mortality – distal measures with long incubation periods u Confoundingunmeasured factors tightly correlated with public health spending?


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