Massachusetts Public Health Regionalization Project: A Statewide Conversation Sponsors and supporters: February 29, 2008 Coalition for Local Public Health MA Association of Health Boards MA Environmental Health Association MA Health Officers Association MA Public Health Association MA Association of Public Health Nurses Boston University School of Public Health Cambridge Advanced Practice Center for Emergency Preparedness MA Departments of Environmental Protection and Public Health National Association of County and City Health Officials, with funding from Robert Wood Johnson Foundation Welcome. How far did you have to travel to get here? 1. Less than 10 miles 2. 10-20 miles 3. 20-50 miles 4. 50-100 miles 5. More than 100 miles Less than 10 miles 8% 10-20 miles 16% 20-50 miles 39% 29% 8% 50-100 miles More than 100 miles What is your primary role within your local public health agency? What EOHHS/DPH Region do you belong to? 1. Health Agent/Director 2. Public Health Nurse 3. 4. Sanitarian/Inspector Board of Health member 5. Other 6. I do not work for a local public health agency 35% 15% 16% 12% 12% 10% Health Agent/Director Public Health Nurse Sanitarian/Inspector Board of Health member Other I do not work for a loc.. 1. Boston 2. Central MA 3. 4. Metro West Northeast t MA 5. Southeast MA 6. Western MA 7. Does not apply to me 8. I don t know what region I belong to 23% 22% 17% 13% 11% 8% 3% 2% Boston Central MA Metro West Northeast MA Southeast MA Western MA Does not apply to me I don t know what region I... Massachusetts What activities do you spend most of your time on? Towns and Cities: 351 Local Boards of Health: 351 1. Infectious Disease Surveillance 2. 3. Immunization Inspectional Services 4. Management 5. Emergency Preparedness 6. Tobacco Control 7. Other Infectious Disease S... Immunization 31% 29% 15% 13% 6% 6% 0% Inspectional Services Management Emergency Prepare... Tobacco Control Other 1
Top Ten Activities/Services in MA (191 LHDs surveyed, 2006) Programmatic Challenges Food service regulation/inspection (95%) Septic tank installation (92%) Tobacco retailers regulation/inspection (84%) Solid waste haulers regulation/inspection (77%) Housing inspection (91%) Food safety education (73%) Smoke free ordinances (89%) Infectious disease surveillance (73%) Swimming pools (public) (84%) Adult immunization (71%) Pandemic flu West Nile Virus Asthma Youth smoking rates Racial health disparities Obesity Most local health departments do not have adequate staffing Over 70 percent of local health officials report that they do not have enough staff to consistently fulfill their responsibilities to the public. --CLPH Study, 2006 Budgets Don t Match Needs Budgets vary dramatically: $200 to $900,000 for towns < 40,000 population Competition for limited municipal dollars No direct state support Regional differences Lack of consistency in education of public health workforce Workforce Crisis on Horizon 18% eligible to retire in next 2 years 2
Additional Issues Regionalization as an Approach Surge capacity limitations Unevenness of delivery systems Cross-jurisdictional issues Emerging diseases and new responsibilities Working Group Background & Rationale Coalition of Local Public Health (infrastructure advocacy) Metro-Boston Coalition (anthrax, smoking, West Nile Virus) MDPH Emergency Preparedness Regions Project Summary to Date Please indicate your level of agreement with the following statement: 2005 2006 UMass survey of United States and NACCHO Profile Working Group Steering Committee formation and three meetings Local public health departments are under-staffed, under-funded, underresourced, and cannot provide the most essential public health services to its citizens. 31% 49% 2007 2008 ongoing Progress Report 25+ meetings across the state Steering Committee meeting January Legislative hearings and meetings 2006-2008 NACCHO/RWJF funded consultants 2007-2008 1. Strongly Disagree 2. Disagree 3. Neutral 4. Agree 5. Strongly Agree 6. 6% 6% 7% Strongly Disagree Disagree Neutral 1% Agree Strongly Agree 3
Project Goal Strengthen the Massachusetts public health system by creating a statefunded regional structure for equitable delivery of local public health services across the Commonwealth. Guiding Principles The system must respect existing legal authority of local health agencies (home rule) As a voluntary initiative communities need incentives not mandates to participate One size does not fit all; different models of regional structures and operations will allow communities to cluster in ways that will meet their needs The system will require adequate and sustained state funding The system will augment, not reduce, the existing local public health workforce Which of the project s 5 Guiding Principles do you think is most critical to the success of this project? Please pick one. 1. Regionalization must protect local home rule authority 2. Regionalization must be voluntary 3. Different models must be developed to meet local needs. 4. Regionalization must include adequate and sustained state funding. 5. The system must not reduce existing local workforce. 6. All are equally important and critical. 5% 6% 5% 33% 10% Regionalization must... Regionalization must... Different models mus... Regionalization must... The system must not... All are equally import... 42% Moving Forward: A Systems Approach Define and describe our regional system Address legal, personnel, and financial issues Explore performance standards (agency and staff) Integrate state and local Definitions Region : one of the six existing EOHHS/DPH regions Do you currently have working relationships with neighboring health departments/boards of health? 85% 1. No 2. Yes 15% No Yes 4
Definitions, cont. District A group of communities that establishes formal governance, funding, and/or service arrangements to maximize effective and efficient use of available resources from all sources to protect and promote the health of their combined populations. Proposed Models Full District Shared Services Cafeteria (fee for service) FY 09 Plan FY 10 Plan Update legislation (amendments to MGL Ch 27 and mutual aid) Resolve employment issues Seek funds to: establish a pilot program reopen Office of Local Health at MDPH strengthen emergency preparedness planning and workforce training capacity Further collect and analyze data Examine geographic boundaries Encourage communities to plan for or to share services Finalize a regionalization plan (structure, models, and funding) Establish performance standards (agency and staff) Continue to advocate for updated or new legislation Seek funding for additional pilots (other models) and for sustained state funding for local health Strengthen MDPH Regional Operations Coordinate services delivered through regional offices to provide stronger support for LPH. Provide adequate resources and support for required responsibilities (e.g., body piercing regulations, syringe disposal). Strengthen MDPH Regional Operations (Cont d) Secure funding and/or reallocate resources to increase technical assistance for LPH in areas Improve social marketing about public health. 5
Strengthen MDPH Regional Operations (Cont d) Promote workforce development and training, including strengthening management and operations of the Local Public Health Institute. Integrate MDEP into Institute training. Strengthen MDPH Regional Operations (Cont d) Continue to improve management of emergency preparedness and pandemic flu planning in cooperation with LPH Improve the seasonal flu vaccine purchasing and distribution system Strengthen MDPH Regional Operations (Cont d) Strengthen MDPH Regional Operations (Cont d) Continue to improve respectful communications with and responsiveness to LPH, e.g., through the Local Public Health Advisory Council and CLPH. Integrate with other MDPH systems and structures: CHNAs Regional Centers for Healthy Communities Emergency Preparedness Tobacco Control Purchase of Service (POS) contracted services Economic and Financial Facets of Public Health Regionalization Patrick Michael Bernet, PhD Florida Atlantic University www.healthcarefinance.org Funded for this research provided by the National Association of County and City Health Officials under a grant from The Robert Woods Johnson Foundation. Overview Regionalization is simply the delivery of public health services to a geographic area that had originally been serviced by multiple public health agencies. Regionalization may help individual LPHAs to provide a broader range of services at the same cost. 6
Core Functions Evaluate and improve programs and interventions. Regionalization is one possible path towards improving the quality and cost effectiveness of public health activities. As such, the assessment of regionalization alternatives helps LPHAs address their core function responsibilities. Economic Rationale Economies of Scale Cost per unit decreases as more units are produced. Larger LPHAs provide broader range of services. Smaller LPHAs may be resource constrained. Economic Rationale Public Goods Public goods are things that cost the same, whether for 10 people or 10,000. Information is free to share once produced. Regions could make it easier to share the benefits of such public goods. Public Health Structure About half of all states have a decentralized systems, in which local governments have "home-rule" or direct authority over local health agencies (Forums Institute, 2000). State funding in decentralized states is generally lower than in centralized states. Decentralization and heavy reliance on local funding present both opportunity and challenge that is rooted in local communities and potentially vulnerable to shifting local priorities and economic fortunes (Wall, 1998). State Funding Formulas and Regionalization Connecticut Funding Formula Regionalization incentives Connecticut In states where the regionalization incentives are strong, LPHAs provide a broader range of essential public health services. Provides a financial incentive for LPHAs to regionalize. LPHA population State payment per capita LPHA contribution per capita Up to 4,999 $2.33 $1.00 5,000 and above $1.99 $1.00 Participation is voluntary District inherits much responsibility State specifies governance, cost sharing and administrator qualifications Intra-district costs shared based on population Participation is high. 7
Utah Funding Formula Regionalization incentive included in overall state funding formula. Based on: population, poverty, land area and a district incentive Average regionalization incentive payment: $1.21 per capita (varies from $0.27 to $3.60 per capita assuming no hold harmless) Regionalization appeals to smaller counties Participation is voluntary Utah has staff credentialing and program standards that might encourage smaller counties to regionalize in order to comply in the most cost effective manner. Participation is strong Accreditation Many states are beginning to consider requiring accreditation to qualify for state funds. LPHAs with larger populations are more likely to offer the full range of essential public health services Credentialing minimums already encourage regionalization. If accreditation is based on ability to provide the full range of public health services, smaller LPHAs are not currently ready. Any LPHA can spend their way to fulfilling all essential services but it might be less expensive to do it as part of a region. Summary Please indicate your level of agreement with the following statement: Larger LPHAs provide a broader range of services. Regionalization can help LPHAs fulfill obligations to meet the full range of essential services. Economies of scale make it possible to lower the cost per resident. 'Public goods', such as information, are more efficiently provided to larger populations. Regionalization works in other states Home rule. Provide residents with high quality public health services Spend tax dollars in the most cost effective manner Home rule authority is critical to maintain in my community. 1. Strongly Disagree 2. Disagree 3. Neutral 4. Agree 5. Strongly Agree 6. 10% 9% 6% Strongly Disagree Disagree 32% 42% 2% Neutral Agree Strongly Agree My agency needs the most help in the following area: (Please choose one) 1. Inspectional services (food, septic, swimming pools, etc) 2. Public health nursing activities 3. Follow-up on communicable diseases 4. Fulfilling emergency preparedness obligations 5. Tobacco control 6. Conducting prevention programs (obesity, smoking, etc) 7. My agency needs help with all of the above 8. My agency does not need any help. 10% Inspectional services (food,... Public health nursing activi... Follow-up on communicabl... 16% 17% 46% 5% 3% 2% 2% Fulfilling emergency prep... Tobacco control Conducting prevention pr... My agency needs help with... My agency does not need... Working Group Report Summary of Legal Issues Cheryl Sbarra, J.D. and Laura Richards, J.D. 8
M.G.L. Ch. 111, Sec. 27A Appointment of Health Officer by Two or More Towns... 2 or more towns may by a vote of each, form a district for the purpose of employing a health officer and necessary assistants and clerks. Appointed and removed by a Joint Committee composed of boards of health of said towns.... In so far as their duties in a given town are concerned, [the employees] shall be the employees of and responsible to the regularly constituted board of health of said town. M.G.L. Ch. 111, Sec. 27A (cont.) Governance Joint Committee governs the district Elect a chair and a secretary Committee determines the relative amount of service to be performed in each town of the district by persons employed hereunder. Financial structure Treasurer of one town acts as lead agency. Joint Committee estimates money required to pay costs of the district and determines proportion of costs by respective towns. M.G.L. Ch. 111, Sec. 27A (cont.) Withdrawal Town may withdraw by majority vote taken at annual town meeting. Legal issues with Sec. 27A No board of health involvement in forming a district. No board of health involvement in withdrawing from a district. No means of adding additional towns to district. Does not apply to cities. M.G.L. Ch. 111, Sec. 27B Authorizes 2 or more cities or towns by majority vote of the city council or by vote of a town at a regular annual town meeting to form a regional health district. Composition of regional health district Regional board of health Director of health and staff Regional health district shall have all the powers and shall perform all the duties of the boards of health of member municipalities. M.G.L. Ch. 111, Sec. 27B (cont.) Administration Full-time director of health Physician or 1 year of full-time graduate public health academic training or 2 years full-time experience If physician, not engaged in private practice If lay person bachelor s degree and 5 years of full-time experience in generalized public health programs or 10 years experience in generalized public health programs. Each municipality has at least one representative on board if population is over 10,000 2 representatives. M.G.L. Ch. 111, Sec. 27B (cont.) 3-year terms are staggered. Finances as in Sec. 27A one municipality acts as lead agency Withdrawal by vote of city or town Provided city or town has been a member for at least 5 years. 9
M.G.L. Ch. 111, Sec. 27B (cont.) M.G.L. Ch. 111, Sec. 27C Legal issues with Sec. 27B No board of health involvement in forming regional health district. Legal authority of local boards of health is handed over to the regional health district. Regional health district may, by majority vote delegate certain powers back to member cities and towns. No clarification about how to withdraw from or dissolve a region. Can only withdraw after 5 years. No ability to join a previously formed district Regional health districts; reimbursement Reimbursement for initial expenditures at the rate of 50 cents per inhabitant of the constituent cities and towns. Legal issues: Only addresses start-up costs. 50 cents per inhabitant. Not currently funded. Other legal issues to be included in amendments to 27A, B, and C Other legal issues (continued) Protection of local public health staff Employees of municipalities may become employees of district. Employees can retain rights and benefits in pension, etc. of constituent municipality. In the event of dissolution of the district, employees become employees of constituent municipality. Sec. 27B only addresses full-time employees. They can be brought into the district without loss of civil service, retirement or other rights. No protection for part-time employees. No provision for dissolution or withdrawal. Credentialing--staff Currently, there are no minimum staff credentialing or training requirements. DPH could establish standards through regulations. Standards of Performance--agency Currently, there are no minimum standards of performance. DPH could establish standards through regulations. Clarify that regional health districts are political subdivision. May enter into contracts, etc. Next Legal Steps Do unions play a role in your BOH staffing? Work with DPH attorneys to draft proposed amendments. Work with legislative staff on proposed amendments. Goal create a statutory framework that: Is not prescriptive, but rather allows for various models. Protects home rule and local legal authority. Protects local board of health staff. 1. Yes, all staff are covered by a union 2. Yes, but only some staff are covered by a union 3. No, none of my agency s staff are in a union 4. 43% 36% 16% 5% Yes, all staff are cove... Yes, but only some sta.. No, none of my agen... 10
Regionalization of public health services is the right approach to enhance the delivery of public health services to Massachusetts residents. 1. Strongly Disagree 2. Disagree 3. Neutral 4. Agree 5. Strongly Agree 6. 5% 5% 13% 38% 37% 2% Audience Discussion Strongly Disagree Disagree Neutral Agree Strongly Agree What is your biggest concern about regionalization of public health services in Massachusetts? Should the district workforce meet minimum standards (education, experience, and credentials)? 1. Loss of local home rule authority 2. Loss of local funding 3. Loss of jobs 4. Loss of job authority 5. Meeting accreditation standards 6. Other concern not listed 23% 19% 17% 14% 15% 12% Loss of local home ru.. Loss of local funding Loss of jobs Loss of job authority Meeting accreditation... Other concern not listed 1. No 2. Yes 3. 93% 4% 3% No Yes Should the district meet minimum performance standards? Now is the right time to take on a project aimed at regionalizing public health services in Massachusetts. 1. No 2. Yes 3. 86% 7% 7% 1. Strongly Disagree 2. Disagree 3. Neutral 4. Agree 5. Strongly Agree 6. 4% 46% 25% 12% 10% 3% No Yes Strongly Disagree Disagree Neutral Agree Strongly Agree 11
Panel Discussion Web Resources 1. What are your thoughts? 2. What is needed to make regionalization a reality in Massachusetts? Regionalization Project: http://sph.bu.edu/regionalization Coalition for Local Public Health: http://www.mhoa.com/clph/ NACCHO publications (operational definition, 2005 National Profile) http://www.naccho.org/pubs/ 12