Critics blast privatization attempt by state-run public health centers
Pennsylvania pilot project crashes and burns, report charges
When the state of Pennsylvania proposed two years ago to privatize 60 of its public health centers, the intent was to save taxpayers some money. Instead, critics charge, what happened is a case study in what can go wrong when people who don’t understand how public health works try to tinker with it.
At three pilot projects approved by the state legislature, and at 29 other state health centers where staffing was reduced, problems include TB patients lost to follow-up, poor record-keeping, and inadequate TB infection-control practices, says Steve Lopez, the lead investigator and author of a report released late last year, which lambasted the privatization efforts. Lopez, a doctoral candidate in sociology at the University of California at Berkeley, is a research analyst at Keystone Research Center, a nonprofit think-tank based in Harrisburg, PA, which frequently investigates issues related to public health.1
"People we’ve interviewed say these changes may not immediately lead to an outbreak of TB, but that they weaken the infrastructure and reduce our ability to know about one and deal with it if it occurs," explains Lopez.
Other critics are even blunter and say the pilot projects, which were to have been stopped and evaluated by the end of the first year, need to be scuttled altogether. "They should stop the pilots — just shut them down," says Ed Powers, who recently retired from his post as manager of the state health department’s division of sexually transmitted diseases. Powers also was a onetime state health adviser with the Centers for Disease Control and Prevention. As a self-professed advocate of privatization, Powers takes pains to emphasize he’s not opposed to the principle of privatization in public health; he simply disapproves of the way the state has implemented the change. As for the premise that the system in its original form is inefficient and wasteful, he says, "there’s some truth to that."
In addition, the staff cutbacks enacted at many of the remaining health centers were never sanctioned by the legislature, which instead had directed that services should be kept at current levels in all but the pilot programs, Lopez adds.
Lopez and Powers agree that in this case, politicians and health department officials alike proceeded without a clear understanding of how the system worked before they set about dismantling and replacing it.
Understanding the universe of TB
"There’s very little understanding of what public health nurses do," says Powers. "And there’s very little understanding of TB patients and of that whole universe around the TB patient — the tests, the medications, the follow-up, the DOT [directly observed therapy]."
The two say trouble began when the state’s former secretary of health, acting at the behest of the governor, declared that the state-controlled public health system was wasteful and that he intended to replace it with private providers. At first glance, says Powers, the idea looked pretty good; after all, many of the state’s big urban areas (where the majority of TB cases are concentrated) are served by their own county-based public-health clinics. That leaves a mix of mostly rural and urban counties, with relatively few TB cases each year, served by one of the 60 state clinics.
By privatizing those 60 state clinics, the health secretary said, it would be possible to save $1 million the first year and $8 million each subsequent year.
According to Powers, however, the secretary’s announcement of the privatization plans had the effect of swiftly and thoroughly alienating the entire public health infrastructure at the state level: "No matter what the guy said after that, he didn’t have any of them on his side," he says.
In any case, the state legislature put aside wholesale abolition, opting instead to phase in privatization slowly by establishing three pilot projects in three counties. The pilots were to perform screening and administer TB treatment, along with other duties (screening and treatment for sexually transmitted diseases, HIV testing and counseling, and childhood immunizations).
Nonclinical duties were relegated to district-level offices, where public health nurses were supposed to perform follow-up, including DOT, and to keep track of epidemiology.
What happened next was a combination of bad luck and shortsightedness, says Lopez. The three pilots were contracted out to three agencies — two Visiting Nurse Associations and a private hospital. The VNAs, in turn, subcontracted their duties to two branches of Planned Parenthood Federation of America.
But the local Planned Parenthood organization suffered a money crunch that forced it to cut back hours, and the private hospital was gobbled up in a merger. Without a public health clinic to fall back on, the result was chaos, say Lopez and Powers.
For example, even though clients were comfortable with Planned Parenthood staff and knew the clinic locations, the five other locations where patients were directed to go during the Planned Parenthood cutback were less accessible and much less familiar to patients, says Powers.
The private hospital, now swallowed up in the black hole of a merger, in the process had lost a Latino physician whom patients in the city had liked and trusted, Lopez says. To make things worse, adds Powers, "nobody [at the hospital] knew any longer who was in charge of anything; there was nothing solid to go back and touch, no one to say they’d made this [subcontracted] commitment."
In time, a physician on staff was duly appointed to take care of state health center patients, he adds. But again, a lack of understanding of public health posed a stumbling block. "What [private-sector] doctors understand is that when their patients make an appointment, they keep it," Powers says. "What they don’t understand is that a patient who’s got three kids and no income, and whose boyfriend is giving her a hard time, probably isn’t going to keep that TB appointment she’s made, now that she’s feeling better."
The same lack of understanding resulted in occasional bunglings of TB infection-control practices, Powers and Lopez say. In some situations, "they didn’t have the right air exchange," says Powers. "They were going to have their TB clinics next door to the well-baby clinics and the HIV clinics. And why not? That’s not the kind of thing that’s written down somewhere."
At the same time, the state began shifting nurses at approximately half the other state health clinics up to district-office levels, even though those health centers weren’t involved in pilot programs, Lopez says. That had the dual effect of leaving nurses at the local level short-handed, and those bumped up to district level feeling out of sorts for a variety of other reasons, says Lopez.
For one thing, nurses in district offices found they were spending a lot more time driving. In addition, now that they were charged with performing follow-up and DOT on all TB patients in the district, patients began complaining that they disliked being asked the same set of questions by two people in succession, and some patients were lost to follow-up, Lopez says.
Not enough data to evaluate?
Meanwhile, pilot projects also had trouble relaying data to the University of Pittsburgh, where the state had charged researchers to do the officially sanctioned investigation of the pilot projects, Lopez says. Citing a lack of useable data, the university asked for — and received — two substantial extensions for the deadline by which the assessment was to have been completed.
Gary Marsh, PhD, a professor of biostatistics at the university’s graduate school of public health, flatly denies the school has felt pressure (as some critics have charged) to produce a favorable report on the project.
"I have no vested interest at all in this," he says. The problem with information flow is one the state ought to have anticipated, he adds. "A lot of these people [at the pilot projects] simply weren’t trained to provide the information we need in a format we could use," he says. "That’s not uncommon in such situations. But we’ve provided some assistance, and I think we’re over that hump." Marsh also is critical of Lopez’ report. "I wouldn’t place much weight in it," he says. "It’s based on a lot of anecdotal information."
Lopez denies the charge of subjectivity. "To understand how the network is working, you have to talk to people," he says. "We also used Department of Health internal audits. We have hard data on how the number of patients has plummeted by as much as half [in one STD clinic]. There’s nothing biased about that."
"We do feel the keystone report was anecdotal, but that doesn’t mean we’re ignoring it," says Megan Neuhart, a spokeswoman for Gary Gurian, the acting secretary of health. "We’re waiting for the University of Pittsburgh to do a complete and nonbiased study, and we’re going to await judgment until we see that report."
Powers argues that the time has passed for collecting more data. "The state could have done a much better job of looking down its own throat," he says. "We know as much as we need to know that it’s time to shut these pilots down."
Though Powers agrees with Marsh that Lopez’ report is heavily critical, he adds that he made the decision to cooperate with Keystone investigators because he feared the consequences to public health that might otherwise result. "There are no mothers’ marches against TB," he says. "It’s not like fluoride in the water — it doesn’t affect you and me." Nor is privatization by definition a bad thing, he says. "We’ve learned a lot from these pilots. Now we need to take the [idea] back and fix it."
Lopez agrees the pilots should be shut down. Also, his report says the state should conduct an assessment of its public health system to monitor health problems; the department of health should restore staffing in state health centers; a best-practice study in public health delivery should be carried out; and an audit of the true costs of the pilot projects should be conducted. (Ironically, he claims, in at least some instances, the pilots have charged the state more than the health centers for the same services.) Lastly, the report says, hearings should be held "to define a Pennsylvania public health strategy for the 21st century."
[For a copy of the Lopez report, readers can contact Keystone Research Center at (717) 255-7181. Fax: (717) 255-7193. E-mail: [email protected].]
Reference
1. SH Lopez, LM Rhodes, SA Herzenberg. The Quiet Dismantling of Public Health: The Impact of Pennsylvania State Health Center Privatization and Staff Cutbacks. Harrisburg, PA: Keystone Research Center; 1998.
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