Suppt A_Understanding Changes to Local Health Department Clinical Service Provision

Understanding Changes to Local Health Department Clinical Service Provision
ASPE Generic Information Collection Request
OMB No. 0990-0421

Supporting Statement – Section A

Submitted: October 13, 2015

Program Official/Project Officer
Amanda Cash
Senior Health Policy Analyst
U.S. Department of Health and Human Services
Office of the Assistant Secretary for Planning and Evaluation
200 Independence Avenue SW, Washington DC 20201
202.260.0362
Amanda.Cash@hhs.gov

Section A – Justification
1. Circumstances Making the Collection of Information Necessary
Background
Historically, many local health departments (LHDs) have been an important provider of
clinical services such as immunizations, tests for sexually transmitted diseases, and
tuberculosis tests. LHDs that provide these services are found particularly in rural and
underserved communities; however, we have heard anecdotally that state and local health
departments are under increasing pressure to discontinue clinical services and re-orient
services towards population based public health services. Further complicating the ability for
LHDs to maintain services is health care reform implementation, Medicaid Managed Care
(MMC) expansion, and the turbulent state of Medicaid expansions. Although health care
reforms will extend health insurance to more individuals, provider supply may remain
constrained, particularly in rural areas where issues around access have not necessarily
changed. The extent to which the existing provider infrastructure has the ability to absorb
increased demand remains to be seen, particularly in rural, underserved communities with a
limited safety net. This exploratory project will use a positive deviance approach to identify
and learn from those LHDs who have been able to continue providing clinical services in the
current policy environment through key informant interviews. We aim to examine where
supply of clinical services delivered by LHDs are meeting potential demand for these services
as well as any policy or programmatic changes that happened to ensure the delivery of clinical
services by LHDs.
2. Purpose and Use of the Information Collection
The aims of this project are to:
 Examine the geographic distribution of clinical service provision for clinical services among
LHDs.
 Identify the contextual factors conducive for LHDs to operate as a clinical service provider,
particularly in highly vulnerable communities (positive deviants).
 Identify contextual factors that may have lead LHDs to stop or change their clinical service
delivery patterns.
 Determine the internal and external mechanisms used by positive deviant LHDs to support
clinical service provision.
Aims 1&2: The 2013 State Profile Survey data from the National Association of County and
City Health Officials (NACCHO) will be used to examine the geographic distribution of clinical
service provision among LHDs. These data will be linked with the Area Resource File (ARF) to
identify additional county-level contextual factors reflective of the need for LHDs to act as a
clinical service provider. A subset of the linked file specific to states that have implemented
Medicaid Managed Care will also be examined to identify LHDs who have maintained clinical
service provision within a Managed Care environment. We will use the ARF to identify highly
vulnerable counties based on population demographics, provider capacity and access to primary
care services and examine the role of LHDs within these counties. Positive deviants will be
identified as LHDs in high-need areas that that have maintained clinical services.
Aim 3: We will conduct 1-hour semi-structured telephone key informant interviews with staff
from positive deviant LHDs. Of particular interest are the strategies by which LHDs have
maintained clinical services. Informants will be in a supervisory role in the LHD with

knowledge of the finance and reimbursement systems. All notes will be coded in Atlas.ti within
24 hours of each interview, and thematic analysis will be used to identify consistent strategies
used by positive deviant LHDs that can be shared with similar LHDs struggling to maintain
clinical services.
This work will not be used to inform policy decisions; it is exploratory in nature. We may share
the results so other researchers may begin to identify and potentially validate questions that may
capture some of the information we collect in this study at other points in time. Any efforts of
that nature will be a separate information collection that will likely not be conducted by HHS.
3. Use of Improved Information Technology and Burden Reduction
Data will be collected via telephone interviews. We will use computers to take notes and
qualitative data analysis software (Atlas.ti) to conduct data analysis.
4. Efforts to Identify Duplication and Use of Similar Information
To our knowledge, there is no information that has been or is currently being collected
similar to these. This is an exploratory study to answer questions that we currently do not
have the data to answer.
5. Impact on Small Businesses or Other Small Entities
No small businesses will be involved in this data collection.
6. Consequences of Collecting the Information Less Frequently
This request is for a one time data collection.
7. Special Circumstances Relating to the Guidelines of 5 CFR 1320.5
There are no special circumstances with this information collection package. This request
fully complies with the regulation 5 CFR 1320.5 and will be voluntary.
8. Comments in Response to the Federal Register Notice and Efforts to Consult Outside
the Agency
This data collection is being conducted using the Generic Information Collection mechanism
through ASPE – OMB No. 0990-0421.
9. Explanation of Any Payment or Gift to Respondents
We will not be providing incentives for this study.
10. Assurance of Confidentiality Provided to Respondents
We are not asking any personally identifiable information of respondents, but rather only
about their experience in their professional capacity. All data will be de-identified so as not
to reveal the respondent.

11. Justification for Sensitive Questions
We will not be asking any questions of a sensitive nature.
12. Estimates of Annualized Burden Hours and Costs
The key informant interviews will take approximately one hour to complete.
Table A-12: Estimated Annualized Burden Hours and Costs to Respondents
Average
No. of
No. of
Burden
Total
Hourly
Type of
Respondent Responses per
per
Burden
Wage
Respondent
s
Respondent
Response
Hours
Rate
(in hours)
Local Health
Department
40
1
1
40
$34.21
Staff
TOTALS

40

40

40

Total
Responden
t Costs

$1,368.40
$1,368.40

13. Estimates of Other Total Annual Cost Burden to Respondents or Record Keepers
There will be no direct costs to the respondents other than their time to participate in the
data collection.
14. Annualized Cost to the Government
Table A-14: Estimated Annualized Cost to the Federal Government
Staff (FTE)
Social Science Analyst, GS 11
Social Science Analyst, GS 15

Average
Hours per
Collection
20
20

Average
Hourly
Rate
33.00
76.00

Estimated Total Cost of Information Collection

Average
Cost
$660
$1,520
$2,180

15. Explanation for Program Changes or Adjustments
This is a new data collection.
16. Plans for Tabulation and Publication and Project Time Schedule
Aim 1: Examine the geographic distribution of clinical service provision for maternal and child
health services among LHDs.

The 2008, 2010, and 2013 State Profile Survey data from the National Association of County
and City Health Officials (NACCHO) will be used to examine the geographic distribution of
billable clinical service provision among LHDs. These data have been requested directly
from NACCHO, along with more specific identifiers not included in the publically available
files. These identifiers will be used to crosswalk LHD zip codes and county FIPS codes for
each of the LHDs included in the sample.
Within the NACCHO profile data, we will examine responses from the Core profile sent to all
LHDs that provide insight into 1) the current landscape of clinical service provision, 2) how
this has changed during 2008-2010 and 2010-2013, and 3) LHDs that remain consistent
providers of clinical services and currently receive reimbursement for clinical services.
Individual LHD responses over the three waves will be linked, and changes in the following
variables will be examined.


Sources of Revenue (Medicaid & other clinical)



Activities performed by LHDs (most relevant to clinical services and billing capacity)
o Family planning
o Prenatal care
o Obstetrical care
o EPSDT
o Well child clinics
o Comprehensive primary care
o Home healthcare







Additional time-invariant variables will also be examined and include:
State
Governance classification/structure
Region or county reporting classification
Organization structure
Population size served by LHD (7 level categorical variable)
The primary limitation of linking multiple waves of profile data and using crosswalk files to
determine zip codes and county FIPS codes is missing data. Consistent responses across
LHDs for all three waves remain an unknown at this point. However, should this become an
issue we will consider using 2 time points, or possibly limiting the analysis of the abovementioned variables to the 2013 profile. The ability to measure change longitudinally may
be compromised by missing data, but the ability to identify LHDs providing clinical services
and recouping some form of reimbursements is not.
Aim 2: Identify LHDs that operate as a clinical service provider for maternal and child health
and other reimbursable services, particularly in highly vulnerable communities (positive
deviants).
In the context of this study, positive deviants will be defined as those LHDs that have
maintained clinical services provision over time—particularly those operating in highly
vulnerable communities with limited primary care capacity. A two-tiered stratification
approach will be used to identify and contextualize the role of LHDs as a clinical service
provider.

The first level of stratifications relates to Medicaid Managed Care (MMC) and Medicaid
Expansion under the Affordable Care Act. Given the challenges of maintaining clinical
services provision in the context of MMC, the analysis will be stratified by states that have
implemented a robust Medicaid Managed Care initiative and those that do not currently
have a Managed Care initiative. This will allow for examining changes within a varying
policy environment that may influence LHDs ability to provide clinical services. Also
relevant to the analysis are the states that expanded Medicaid or implemented an
alternative program under the 1115 Demonstration Waiver. State decisions related to
Medicaid expansion reflect an additional layer of complexity that could ultimately influence
the role of LHDs as a clinical service provider. We are specifically interested in identifying
the mechanisms that allow LHDs to bill for clinical services within this challenging
environment.
The second tier of stratification provides an additional layer of context for comparing LHDs
that are similar to one another by considering area deprivation, community vulnerability,
and health system capacity. These factors are conductive for examining the intersection of
need or demand for clinical services with the role of LHDs as a clinical service provider in
these communities.
An area-deprivation index developed by the co-investigator will be used to characterize the
underlying level of vulnerability of the communities in which the LHDs operate—
particularly as is relates to clinical service provision. The index collapses multiple social
determinants into a single measure that can be interacted with other variables of interest
(e.g., rurality) to examine selected outcomes of interest within comparable levels of
vulnerability. To derive the index, the NACCHO data files will be linked with the Area Health
Resource File (AHRF) and includes the following measures:






Income (median per capita income, f1322611)
Poverty (percent of population below 100% poverty, f1332111)
Education (percent of population with no high school diploma, f1448006)
Unemployment (percent unemployed, f0679511)
Single parent homes (percent female head of household, f0874610)

In addition, measures of adequate primary care capacity also derived from the AHRF will
also be included to examine the underlying health system capacity in a given county served
by the LHD (Health Professional Shortage Area designation, the presence of at least 1
Federally Qualified Health Centers and/or Rural Health Clinic, and primary care physicians
per capita).
The data examining the role of LHDs as a clinical service provider will be stratified by the
contextual factors noted in the deprivation index and embedded on these larger policy
environments (MMC/Medicaid expansion). A series of tables/cross-tabulations of clinical
service provision within each level of the contextual factors of interest will be provided and
used to identify positive deviants. Examining the role of LHDs as a clinical service provider
within these three contexts allows for the identification of positive deviants that are drawn
from comparable contextual environments. Given the aggregate nature of the NACCHO
profile data and the scope of the study, these analyses are sufficient to adequately identify a
sample of positive deviants.

This approach to identifying positive deviants also has limitations. Although the ability to
identify positive deviants based on the provision of clinical services is not compromised,
using county-level data to characterize the environment in which LHDs operate could
exclude some valuable information. LHDs can be county, city, township, or multijurisdictional, and aggregating community vulnerability to the county level may not fully
reflect the true underlying level of vulnerability or primary care capacity in communities
served by LHDs. (For example, approximately 8% of LHDs responding to the 2013 profile
survey were part of a multi-county jurisdiction.) As these LHDs are identified, data for
counties within the jurisdiction will be combined to better approximate the underlying level
of vulnerability. In addition, the analysis will also be limited to only county health
departments (60% of all LHDs) and findings compared to the total sample. This approach
will provide a general sense of larger circumstances in which LHDs likely operate.
Aim 3: Develop an Interview Guide to better understand the practices used by positive deviant
LHDs to maintain reimbursable services.
We have developed a draft guide for key informant interviews to be administered to staff
from LHDs identified as positive deviants. We do not know how many positive deviants
(PDs) will be identified; however, it is likely that there will be more PDs than we are able to
interview. As such, we will identify the interview participants by stratifying PDs by
contextual factors as outlined above in order to get as varied a sample of interviewees as
possible. We anticipate a sample of 30-40 LHDs to be targeted for interviews. The point of
contact for the LHDs will be the health officer or their designate. We are also open to
speaking with more than one representative from the LHD.
We have developed a telephone interview guide (not more than 1 hour in length) that will
focus on the following topics: types of services provided, changes in service provisions over
the past 5 years, LHD funding sources, changes in funding over the past 5 years, interactions
with payers (Medicaid, private payers, etc.), and challenges to service provisions and
reimbursement, among other topics. We have convened an expert panel of federal staff with
expertise in LHD services and billing for feedback on the interview guide prior to
implementing it. We will pilot the interview guide prior to administering it to participants.

Timeline:
Completion
Date
October 2015

Major Tasks/Milestones
Submit request for OMB approval under an existing generic PRA
clearance
Submit project for IRB Approval
Recruit Expert Panel
Link Datasets
Draft Interview Guide; send to Expert Panel for review

November 2015

Complete positive deviant identification
Receive Expert Panel feedback for Interview guide
Receive OMB approval under an existing generic PRA clearance
Receive IRB Approval

November 2015

Receive comments from ASPE on draft list of positive deviants and
draft interview guide

November 2015

Identify LHDs for Interviews

December 2015 –
April 2016

Conduct Interviews

April – July 2016

Qualitative Data Analysis

August – October
2016

Finalize results

17. Reason(s) Display of OMB Expiration Date is Inappropriate
We are requesting no exemption.
18. Exceptions to Certification for Paperwork Reduction Act Submissions
There are no exceptions to the certification. These activities comply with the requirements
in 5 CFR 1320.9.
LIST OF ATTACHMENTS – Section A
Note: Attachments are included as separate files as instructed.
A. Interview guide