Saturday, April 4, 2015

Cross-Jurisdictional Sharing

The State Innovation Model
Banner of State Innovation Model Report

I want to return to an important topic: the fact that the way in which preventive services are delivered is undergoing a profound change in Michigan, as it is in most states. In particular, I want to focus on one way in which local health departments can get ready for these changes called Cross Jurisdictional Sharing. The Cross Jurisdictional Sharing (CJS) model helps health departments find ways to maintain or expand services by sharing them (I'll define "sharing" below).  It was developed by the Center for Sharing Public Health Services with funding from the Robert Wood Johnson Foundation and has been championed by our professional association, the National Association of County and City Health Officials (NACCHO). But I further want to argue that we often misunderstand the sharing of services as simply being a way to make due with less, when in fact, sharing can be one way to truly realize healthier communities by meaningfully expanding the services we offer. Health departments that want to grow their capabilities need to be thinking about sharing.

Many changes in health and health care are being driven by the Affordable Care Act, which aims to improve health while reducing the cost of health care. In Michigan one of the most important manifestations of the Affordable Care Act (the Act or Obamacare) is the State Innovation Model, The State Innovation Model (Innovation Model) is a detailed blueprint for how public health and health care will work together in the future to truly achieve a healthier population. Other examples of the Act at work in Michigan include Pathways to Better Health projects, increasing reliance by local health departments on billing for services, changes in the way programs are funded, partnerships between health departments and hospitals in community health assessment and improvement, and more. These changes are compelling health departments to rethink how they are organized. The CJS model says health departments need to share, that is, to adopt more programmatic and administrative innovations that extend beyond their local jurisdictions and more often include partners outside public health. Cross jurisdictional innovations may allow public health to fully play its designated role in assuring that robust population health services endure and opportunities for preventing disease and injury increase, so that the goals of the Affordable Care Act are realized.

CJS is often promoted by State or local governments primarily as a search for increased efficiencies due to decreasing budgets. The goal is to maintain a basic set of traditional preventive services like food and water programs, communicable disease, immunizations, and a few others by delivering the same amount of services at lower cost per unit. These are the traditional public health services developed in the 19th and 20th centuries which led to steep declines in mortality. In Michigan the delivery of these services was generally governed locally by cities and counties and that is more or less the basis of local public health today. Let’s call this the scarcity model of CJS. Honestly, the scarcity approach has accomplished some great things.  It has led to some of the most important innovations in public health in Michigan, including the formation of district health departments (like the Mid-Michigan District Health Department, where I work) involving multiple counties, and some health departments have reworked and automated business processes to gain efficiencies. Indeed, at least in the data we have looked at, health departments are maintaining service levels at a reduced cost.


However, CJS may also be looked upon as creating opportunities for public health to expand into new areas of work to meet modern public health challenges, and we can call this the expansive model of CJS. Expansive CJS may include alternative governance models such as intergovernmental agreements, the creation of new not-for-profit organizations and public-private partnerships. Examples of the expansive view of CJS in Michigan include the development of a network of public dental clinics associated with health departments, local health led federally qualified health centers and school-based clinics, the cooperative establishment of funds for the private financing of health department construction, the establishment of county health plans to provide a health benefit for uninsured people, hospital partnerships for health assessments and the sharing of personnel, and participation in the Pathways projects. Obviously there isn’t a simple distinction between the two visions of CJS—efficient health departments are probably more able to innovate—the point is the expansive form of CJS already has deep roots in Michigan.

Now public health is being challenged to respond to new demands for leadership and innovation. The Innovation Model envisions a network of Community Health Innovation Regions that both complement and support clinical medicine. Community Health Innovation Regions (Innovation Regions) will complement traditional health care by providing community-based population health services, and Innovation Regions will support traditional medicine by participating in care-coordination activities, particularly those that provide community-based supports for basic needs and lifestyle changes that are required meet the goals of primary prevention. It is clear in the Innovation Model that health departments will not be the Innovation Regions. Rather the Regions will be broad-based, inclusive collaboratives. Health departments will perform the fundamental public health function of assurance—assuring that Innovation Regions exist, and providing leadership where required.

What local health departments will have to do in the Innovation Regions will be completely different from what they did in the past. In the 19th and 20th centuries the role of health departments was based their statutory authority to compel people to stop doing things that made other people sick. For example they could quarantine a person with a communicable illness, or stop someone from serving contaminated food. These functions are still important, but the future will demand much more.  In an Innovation Region, a health department will need to be able to act as the public health component of an integrated system of preventive care that sprawls across political jurisdictions following medical trading areas. For example, in an Innovation Region, health departments will need to work on developing an enhanced capability to manage population health data; electronically exchange data on shared clients with health care systems; demonstrate the return on investment of community-based prevention to Region investors; or bill for services to sustain care coordination activities. In most health departments these capabilities are just beginning to be developed, and the capability to do it regionally has only been experimental.

I want to close by pointing out that it is not a simple thing to move from the jurisdictions of the 20th century to some new, future configurations.  For example, at Mid-Michigan, we just examined the financial benefit to our counties of being part of our district health department. We discovered that each county is probably saving half a million dollars by being part of the district health department versus going it alone. You can look at this in two ways: one is that with that kind of benefit at stake, counties will be reluctant to experiment with CJS. But the other way to look at it is that it is proof of the value of sharing, and that even more benefits are possible if we search for them.

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