The economic returns from investments in physical and mental health: a case study of migrant farmworkers in rural New York

Spiraling costs of medical care services and limited federal and state resources necessitate discriminating and cost-effective strategies for financing health care to indigent populations. Thus, while the selection among intervention strategies is aided by information on both the cost and benefits of program alternatives, data on the latter aspect is more difficult to obtain. Human capital research provides a mechanism for assessing one of the multifarious aspects of the benefits of medical services. Research suggests that labor market earnings opportunities are affected by health status. The present study explores this relationship for migrant farmworkers in a vegetable production county (Orange County) in upstate New York. Multivariate analysis indicated that mental well-being was an important predictor of earnings for migrant farmworkers. Directions for public health policy intervention strategies are also discussed.     

Medicaid coverage of abortions in New York City: costs and benefits

New York was among the first states to provide Medicaid financing of abortions for needy women. This was begun in July 1970 when the liberalized state abortion law took effect. Each year since, nearly 40% of the New York City abortion patients have been funded by Medicaid. There is evidence that Medicaid funding of abortions for indigent women has had a favorable impact on improving the health and welfare of these women. There are attempts nationwide to cut off or restrict Medicaid financing for abortions. Results of a cutback on funding will be 1) many septic and incomplete illegal abortions, 2) an increase of 10,000-15,000 births in New York City, and 3) added costs to federal, state, and local relief funds for delivery services, foster care, welfare payments, and day care facilities for these added births. Additional costs to government health and welfare organizations in the first year would be from 7-10 times what Medicaid coverage of abortions would cost.     

Design and implementation of a citywide breastfeeding promotion program: the New York City approach

Breastfeeding has regained more popularity in the US since 1970, but there has been a definite disparity in its resurgence among minority, poor, and less educated mothers. This article outlines the history of breastfeeding prevalence in the US and New York City as an introduction to explaining the design and implementation of New York City's breastfeeding promotion program. In 1982, the Steering Committee to Promote Breastfeeding in New York City was generated and it designed task forces to address each of their defined barriers to breastfeeding promotion (e.g. lack of relevant data, centralized compilation, data analysis, health care professional education, inhibitory practices by hospitals and ambulatory services, public misinformation, and unsupportive public policy). The Research Task Force, Professional Education Task Force, Hospital Practices Task Group, Policy and Legislation Task Group, and Public Information Task Group were outlined and some policies, strategies, and practices they have enacted were described. Some of their accomplishments include: educational kits on breastfeeding for health care professionals, guidelines for work-site health and nutrition programs for pregnant and lactating workers, research on the economics of breastfeeding, breastfeeding information posters on the subway, and establishment in 1984 of a breastfeeding coordinator in each municipal hospital. These strategies demonstrate a successful model for breastfeeding promotion in large urban areas as seen by the rise in breastfeeding at the time of newborn discharge from New York City hospitals.     

The development of the U.S. Health Care System and the contemporary role of the public health department

The absence of national health care reform and the growing number of uninsured individuals in the United States have prompted states to develop plans to provide medical care for the low income and the indigent. Many local health departments are not only responsible for the core public health functions; but they are increasingly called upon to provide person health care services for those who cannot afford it. This article chronicles the development of the health care system in the United States and describes the contemporary role of the local public health department.     

Insurance coverage of special foods needed in the treatment of phenylketonuria.

Optimal medical management of phenylketonuria (PKU) requires the use of special low-phenylalanine foods for many years. For women with PKU, elevated maternal blood levels of phenylalanine even at conception can lead to fetal damage. Despite this need, private health insurance, Medicaid, and other public health programs often exclude the cost of these foods from their benefits. The New York State Department of Health conducted a survey of metabolic disorders treatment centers to elucidate the problems PKU patients have obtaining and paying for the special foods essential to their care. Payment for special foods was denied to nearly half of those with private health insurance policies and was covered for only 10 percent of Medicaid-eligibles. A public program for children with special health care needs covered these food costs in upstate New York but not in New York City. There is no program of assistance for adults who are not eligible for Medicaid and who do not have private insurance coverage of special foods. At present, many private health insurance policies and public programs do not cover the costs of low-phenylalanine foods other than infant formula. Payment for this essential part of the management of PKU should be mandated for all public programs for persons with chronic illnesses, public medical assistance (Medicaid) programs, and private health insurance. There is a need for a public program to assist adults with PKU who are not eligible for Medicaid and who do not have health insurance that covers these costs.     

Partnering with communities to improve health: The New York City turning point experience

Concurrent with the New York City Department of Health’s reorganization efforts, the Robert Wood Johnson and W.K. Kellogg Foundations launched Turning Point, a national initiative designed to strengthen the nation’s public health system. The Turning Point initiative has emphasized broad-based partnership building and planning as key prerequisites for improving public health practice. In response to the foundations’ request for proposals, the department formed a New York City Public Health Partnership, which in turn applied for and was granted a Turning Point planning grant. This funding allowed New York City Turning Point to initiate a public health planning process, part o f which involved convening forums in each of the five boroughs. With over 1,100 community participants, these forums provided both a starting point for establishing public health priorities and an interactive setting for sharing health and demographic data. Included among the issues that emerged as priorities were: access to care, environmental health, mental health, housing, asthma, education, and dietary issues. Building on the forum outcomes, the New York City Public Health Partnership developed a public health system improvement plan. The goals delineated in this plan are: (1) to create and support public health partnerships at the community, borough, and citywide levels; (2) to identify community health concerns and develop strategies responsive to these concerns; and (3) to develop policies to support and sustain a community health approach to improve health status. This article also discusses possible roles for local health departments in promoting a community health approach to address public health concerns.     

Health care for the indigent: overview of critical issues.

Health care for the indigent is a major problem in the United States. This review of the literature on health care for the indigent was undertaken to determine which major questions remain unresolved. Overall, this article finds that a very large pool of individuals under age 65 are at risk of being medically indigent. A myriad of health programs for some economically disadvantaged individuals do exist, but their level of funding has fluctuated over time--and many poor individuals must rely entirely on the generosity of a relatively small number of hospitals and other providers for their care. Economic pressures on these providers as well as structural changes in the health care sector can only adversely affect the amount of charity care that they offer. It is clear that a well-planned solution to indigent care in the United States, rather than a piecemeal approach, is needed.     

Medicaid managed care partnerships to improve perinatal outcomes.

New York State's Prenatal Care Assistance Program, and enhanced care program based on public health principles, is in the process of being transformed into Medicaid managed care. The program described in this article, namely, a Medicaid managed care health maintenance organization and its interaction with one hospital's care of women, especially pregnant women, serves to illustrate how traditional public health values and managed care principles may be linked. This linkage is a starting point to developing a community's involvement in its own health, although it is too early from our experience to note a lasting effect on improved pregnancy outcomes.     

Quality oversight and improvement in Medicaid managed care.

New York State has been collecting performance data from managed care plans that serve the Medicaid population since 1993. The data come to the state via the Quality Assurance Reporting Requirements--a series of quality of care, access, and utilization measures, largely based on the Health Plan Employer Data and Information Set, as well as several New York State-specific measures. In addition to collecting the data, the state publishes the information, works with plans that have below average rates of performance and provides a number of program and financial rewards to plans for rates that demonstrate high quality care. An analysis conducted on quality of care measures indicates that: (1) performance rates are increasing over time, (2) Quality Assurance Reporting Requirements rates are generally higher than national benchmarks, (3) the disparity between commercial plan rates and Medicaid rates is diminishing, and (4) the variability in performance across plans is decreasing. The analysis conducted indicates that the performance measurement system constructed in New York is an effective means to monitor health plan performance, while at the same time enabling the state and local health units to monitor population health and accomplishment of key public health objectives (complete immunization, cancer screening, etc.)     

Strengthening Public Health and Primary Care Collaboration Through Electronic Health Records

Electronic health records (EHRs) have great potential to serve as a catalyst for more effective coordination between public health departments and primary care providers (PCP) in maintaining healthy communities.As a system for documenting patient health data, EHRs can be harnessed to improve public health surveillance for communicable and chronic illnesses. EHRs facilitate clinical alerts informed by public health goals that guide primary care physicians in real time in their diagnosis and treatment of patients.As health departments reassess their public health agendas, the use of EHRs to facilitate this agenda in primary care settings should be considered. PCPs and EHR vendors, in turn, will need to configure their EHR systems and practice workflows to align with public health priorities as these agendas include increased involvement of primary care providers in addressing public health concerns.Electronic health records (EHRs) have great potential to serve as a catalyst for more effective coordination between public health departments and primary care providers in maintaining healthy communities. As prominent health risks to the community continue their shift from contagious diseases to chronic illnesses, public health departments are increasingly focused on conditions such as diabetes and obesity. At the same time, serious threats persist from traditional public health concerns, such as communicable disease outbreaks.Primary care providers, and particularly community health centers (CHCs), that provide care for low-income populations are on the front lines in treating and containing both communicable diseases and chronic illnesses that are more prevalent in these communities. Traditional models of primary care are also evolving, with increased focus on community-based approaches in response to changing financial incentives and formal recognition programs, such as the Patient-Centered Medical Home certification offered by the National Committee for Quality Assurance and the Joint Commission.1,2 Use of these models is facilitated by the parallel increase in adoption of EHRs.Federal incentive programs have been a proponent of EHR implementation and “meaningful use” of EHRs among primary care providers, with targeted funding to support their adoption among CHCs.3 The promotion of health information technology to improve the public’s health is 1 of 5 focus areas for meaningful use of EHRs. Finally, 1 of the 3-part aims of the Centers for Medicare and Medicaid Services (CMMS) is the improvement of population health—a goal that will only be met through improved coordination of primary care and public health.4,5In 2003, the potential for addressing community health needs with the aid of EHR data exchange initiated a partnership between The New York City Department of Health and Mental Hygiene (NYC DOHMH) and The Institute for Family Health. Together, these organizations have developed, tested, implemented, and monitored the use of an EHR in meeting public health and primary care goals. NYC DOHMH is one of the world’s largest public health agencies, operating programs in disease control, environmental health, epidemiology, health care access, health promotion and disease prevention, and mental hygiene. It also makes public health-enabled EHRs available to over 2500 primary care providers throughout New York City as part of its Primary Care Information Project (PCIP).The Institute for Family Health is a nonprofit organization that provides care to more than 80 000 patients in 26 federally qualified health center sites in New York City and New York State’s Mid-Hudson Valley. The Institute’s goal in establishing an EHR system was not only to enhance the quality of patient care in its own practices, but also to improve the health of the communities it serves. Recognizing that the 2 organizations had parallel missions to maintain healthy communities, the Institute and NYC DOHMH partnered in EHR data exchange initiatives to meet the shared goals of improving the surveillance and management of both communicable disease and chronic disease. Projects addressing these goals are described below.     

Enrolling and Retaining Uninsured and Underinsured Populations in Public Health Insurance Through a Service Integration Model in New York City

Innovative strategies to identify uninsured and underinsured populations are critical to successful enrollment and retention in public health insurance. The New York City Department of Health and Mental Hygiene’s Office of Health Insurance Services has partnered with the department’s Early Intervention Program to implement a Service Integration Model to enroll special needs children, aged 0 to 3 years, into public health insurance. This model uses data from program databases and staff from children’s programs to proactively identify uninsured and underinsured children and facilitate their enrollment into public health insurance. The model overcomes enrollment barriers by using consumer-friendly enrollment materials and one-on-one assistance, and shows the benefits of a comprehensive and collaborative approach to assisting families with enrollment into public health insurance.

KEY FINDINGS

■ Partnerships across government programs and agencies offer opportunities to enroll hard-to-reach populations into public health insurance.■ The Office of Health Insurance Services Service Integration Model has 3 key components allowing for comprehensive and continuous coverage for children with special health care needs: integration of program messages within the Early Intervention Program, data matching with child program data (Early Intervention data, Medicaid data), and incorporation of program staff (Office of Health Insurance Services child benefit advisors) to work directly with parents.■ The combination of access to child program data to identify children and one-on-one assistance to complete public health insurance applications has successfully assisted more than 5000 families in the New York City Early Intervention Program.IN NEW YORK STATE, AN estimated 12.7% of children have special health care needs.1 According to McPherson et al., children with special health care needs are defined as

those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.2 ^(p.138)

The 2005–2006 National Survey of Children With Special Health Care Needs found that 38% of families with special needs children had inadequate health insurance coverage.1 Data indicate that 16% of children with special health care needs did not receive any health care services in the past year; 45% of uninsured children with special health care needs needed at least 1 service not received, compared with 22% of publicly insured children, 19% of children with dual coverage (public and private), and 11% of privately insured children. Services not received included dental care, mental health care, therapies, and specialty care.In New York City, almost 40 000 children per year with a diagnosed developmental delay or disability receive services through the Early Intervention Program—a federal entitlement program for children aged 0 to 3 years. In New York City, the Early Intervention Program is administered through the New York City Department of Health and Mental Hygiene (DOHMH). Programs for children with special health care needs, such as the National Early Intervention Program, have been created to ensure that infants and children with developmental disabilities or delays receive needed services. To be eligible for services, children must be younger than 3 years and have a confirmed disability or established developmental delay, as defined by the state, in 1 or more of the following areas of development: physical, cognitive, communication, social-emotional, and adaptive.3 These children receive services free of charge for developmental disabilities or delays. The Early Intervention Program bills the child’s health insurance if the program is aware of the health insurance status of the child, including Medicaid and private or employer-based insurance. Parents are not responsible for paying for any services received through the Early Intervention Program. However, the Early Intervention Program does not cover services for routine medical care or specialized medical services (non-developmental disabilities or delays).The Office of Health Insurance Services at the New York City DOHMH was created to expand the city’s health insurance enrollment capacity, maximize client choice regarding health plan and provider selection, and promote health care use and preventive health behaviors. Since 2000, the Office of Health Insurance Services has been a New York State–approved facilitated enrollment lead agency in New York City. The New York State Department of Health–facilitated enrollment program provides funding, through a Request for Application process, to community-based organizations and local entities to provide eligibility screening and application assistance services to New York State residents applying for public health insurance.In 2009, the Office of Health Insurance Services assisted more than 10 000 applicants throughout New York City with a 97% enrollment success rate. The Office of Health Insurance Services maintains a presence at 9 New York City DOHMH centers and serves clients throughout the 5 boroughs, from all racial and ethnic backgrounds and with limited English proficiency.The challenge of ensuring that children with special health care needs receive comprehensive and continuous health insurance coverage requires innovative strategies. Although New York State has made considerable progress in reducing barriers to enrollment in public health insurance for adults and children, challenges remain. To maximize comprehensive insurance coverage for children with special health care needs, a Service Integration Model was formed between the Office of Health Insurance Services and the Early Intervention Program at the New York City DOHMH.

INCLUSION OF INFORMATION ON SERVICES PROVIDED BY THE OFFICE OF HEALTH INSURANCE SERVICES TO THE EARLY INTERVENTION PROGRAM

Information about services provided by Office of Health Insurance Services included in Early Intervention Program trainings and print materials“Early Intervention Welcome Letter” to parents“NYC Early Intervention Program Policy and Procedure Manual” for Early Intervention Program provider agenciesOffice of Health Insurance Services brochure and poster for Early Intervention Program provider agenciesLetter to Early Intervention Program providersData MatchingEarly Intervention Program dataNew York State Medicaid dataCensus dataIncorporation of Office of Health Insurance Services Staff to Work Directly With Parents of Children in Early Intervention ProgramOne-on-one in-person or telephone assistanceAvailable in multiple languagesAvailable at hours and locations convenient to parentsEducate families on public health insurance productsHelp them apply for coverage     

Linking public health and the emergency care community: 7 model communities

Public health and the emergency care community must work together to effectively achieve a state of community-wide disaster preparedness. The identification of model communities with good working relationships between their emergency care community and public health agencies may provide useful information on establishing and strengthening relationships in other communities. Seven model communities were identified: Boston, Massachusetts; Clark County, Nevada; Eau Claire, Wisconsin; Erie County, New York; Louisville, Kentucky; Livingston County, New York; and Monroe County, New York. This article describes these communities and provides a summary of common findings. Specifically, we recommend that communities foster respectful working relationships between agency leaders, hold regular face-to-face meetings, educate each other on their expertise and roles during a disaster, develop response plans together, work together on a day-to-day basis, identify and encourage a leader to facilitate these relationships, and share resources.     

Mandatory HIV testing of newborns in New York State: what are the implications?

This paper presents an analysis of a public health law (Maternal-Pediatric HIV Prevention and Care Program) enacted by New York State in 1997 and how it strives to reduce the vertical transmission of AIDS. This policy is twofold. First, it strongly encourages voluntary HIV testing of all pregnant women. Secondly, it mandates HIV testing for all newborns. Those found to be positive are referred for medical care. This paper analyzes the State's implementation of this law to determine if it will: exert control over poor, mostly minority women; provide health care for infected woman and infants; protect public health; prevent the spread of HIV/AIDS; or sacrifice a woman's privacy. The potential benefits and shortfalls of this policy are discussed as other states may consider adopting similar legislation.     

The primary care delivery system in New York’s low-income communities: Private physicians and institutional providers in nine neighborhoods

Despite a recent policy emphasis on managed care as the preferred method of financing and delivering care to Medicaid beneficiaries and other indigent populations, there is little information on the availability or the characteristics of primary care providers in low-income neighborhoods. Data from two independent surveys of primary care were analyzed. A 1998 street canvass of each of nine neighborhoods identified 367 primary care offices and 567 private-practice primary care physicians. Survey data on primary care were collected from a total of 280 ambulatory care sites across the city in 1997 and 1999. Information on services, hours, and other data on primary care offered at sites in these nine neighborhoods was compiled to develop a profile of the primary care delivery system. There are relatively few private practice physicians providing primary care in these neighborhoods. While there are considerably more primary care physicians at the ambulatory care sites, there is a wide variation in supply across neighborhoods, driven largely by the presence of sizeable safety-net facilities in several of the neighborhoods. Several indicators of access to primary care across these neighborhoods show similar neighborhood variations. Without primary care availability, managed care’s promise of greater access to quality care for low-income populations may fall short. This research was supported in part by the Commonwealth Fund, The Altman Foundation, The Engelberg Foundation, JP Morgan, The New York Community Trust, Pfizer Inc., and the United Hospital Fund.     

Privatization of a public hospital: a quality improvement strategy

Public hospitals face mounting challenges posed by the rise of managed care, increasing hospital competition, growing responsibilities in indigent care, and stagnant public sector revenues. Privatization exists as a viable strategy for reengineering the structure and operation of public hospitals to meet the new demands of quality and efficiency imposed by a rapidly changing health care environment.     

Local access to care programs (LACPs): new developments in the access to care for the uninsured

Context: New, locally based health care access programs are emerging in response to the growing number of uninsured, providing an alternative to health insurance and traditional safety net providers. Although these programs have been largely overlooked in health services research and health policy, they are becoming an important local supplement to the historically overburdened safety net. Methods: This article is based on a literature review, Internet search, and key actor interviews to document programs in the United States, using a typology to classify the programs and document key characteristics. Findings: Local access to care programs (LACPs) fall outside traditional private and publicly subsidized insurance programs. They have a formal enrollment process, eligibility determination, and enrollment fees that give enrollees access to a network of providers that have agreed to offer free or reduced‐price health care services. The forty‐seven LACPs documented in this article were categorized into four general models: three‐share programs, national‐provider networks, county‐based indigent care, and local provider–based programs. Conclusions: New, locally based health access programs are being developed to meet the health care needs of the growing number of uninsured adults. These programs offer an alternative to traditional health insurance and build on the tradition of county‐based care for the indigent. It is important that these locally based, alternative paths to health care services be documented and monitored, as the number of uninsured adults is continuing to grow and these programs are becoming a larger component of the U.S. health care safety net.     

Public health campaign funds provide a "safety net" for indigent tuberculosis patients at the Mount Sinai Hospital.

This article describes the development of a partnership between a voluntary health care institution and a state agency for a focused public health program providing vital clinical, public health, and social supportive services. In addition to the historical development of this alliance, the article illustrates joint problem-solving processes to address complex issues. Since its inception in 1992, this collaboration has resulted in significant improvements in the health status of a high-risk, difficult-to-serve, indigent population that would otherwise pose a public health threat to the community. Demographics of 17 indigent patients are described. Nine have completed treatment for tuberculosis under directly observed therapy and completion is in sight for six others. None have been lost to follow-up.     

Indigent health care: the increasing contribution of AIDS to the health care budget deficit

With the number of AIDS cases in the United States exceeding 100,000 and rising, it is becoming more of a financial burden to take care of this population. The Regional Medical Center at Memphis, like most hospitals providing indigent care, sustains annually a large deficit for both outpatient and inpatient care of AIDS patients. With the establishment of a dedicated AIDS clinic, it is hoped to maximize outpatient care and the utilization of available financial resources. Implementation of this model may help obviate the financial disaster that is impending for the already overburdened public hospitals and their patients.     

The New York State Optometry Workforce Study

This study presents an analysis of the current optometry workforce, both as a unique profession and more broadly within the context of all eye care providers (optometry and ophthalmology) in New York State. The supply and distribution of eye care practitioners provides useful information for policy makers while providing insights as to the impact of the one optometry school within the state. Several databases were employed and a web based survey was developed for completion by all optometrists. The questionnaire included demographic data, whether they were actively practicing in New York State or any other state, were they full time or part time, their primary mode of practice, or if they provided care within institutional settings. Access to care was gauged by the respondents’ availability for appointments during evenings or weekends. Access to eye care services in New York State has improved significantly during the past 30 years as the supply of optometrists increased. Before this study was conducted it was generally believed that there were more optometrists than ophthalmologists in every state of the nation except New York, Maryland and the District of Columbia. Findings of this study demonstrate there are 37% more optometrists in New York State than ophthalmologists and more evenly distributed as optometrists are located in almost every county of the state. Sixteen counties have no ophthalmologists. This is attributed to the presence of the College of Optometry established in 1971. More than 60% of all optometrists in the state are SUNY College of Optometry graduates.