Strengthening New York's Public Health System for the 21st Century
REPORT OF THE PUBLIC HEALTH INFRASTRUCTURE WORK GROUP TO THE PUBLIC HEALTH COUNCIL
VI. THE NEW YORK STATE PUBLIC HEALTH SYSTEM
New York's public health system includes a large number of private, voluntary and public organizations including state and local government agencies, health care providers and insurers, and community organizations. The New York State Department of Health (NYS DOH) and 58 local health departments have the primary responsibility to promote and protect the health of the public.
The State Health Department's mission is to "protect and promote the health of New Yorkers through prevention, science and the assurance of quality health care delivery." Public Health Law defines the broad responsibilities of the NYS DOH. PHL §201 (1) (a) provides that "the Department shall, as provided by law: supervise the work and activities of the local boards of health and health officers throughout the state, unless otherwise provided by law." The law also provides that the DOH oversees reporting and control of disease, maintains vital records, and promotes the prevention and control of disease. The authority of the State Health Commissioner is described in PHL §206 and includes investigating epidemics and causes of disease, enforcing the Public Health Law and the State Sanitary Code and inspecting State Institutions.
The New York State Public Health Council advises the Department of Health. The Public Health Council includes the Commissioner of Health and 14 members appointed by the Governor with the advice and consent of the New York State Senate. The Public Health Council duties are described in Public Health Law §225 and include any matter related to the preservation and improvement of public health, appointing advisory committees expert in the major areas of public health concern and submitting recommendations on public health concerns to the Commissioner. The Public Health Council can also establish, amend and repeal the State Sanitary Code subject to approval by the Commissioner of Health.
2. Program and Services
The New York State Department of Health has over a 100-year history of providing public health services. The Department administers a wide range of public health programs directly or through contracts that address disease prevention and control, environmental health protection, promotion of healthy lifestyles, and emergency preparedness and response. The Department also conducts health care surveillance in the state's hospitals, home care agencies and nursing homes, conducts research at the Wadsworth Laboratory, manages the state Medicaid program, administers health insurance programs for the uninsured and operates five health care institutions.
The State Department of Health (SDOH) employs over 4,300 people in its central, four regional offices, three field offices and nine district health offices across the state. An additional 2,000 individuals work in the five DOH-operated health care institutions. Almost three-quarters (72%) of the SDOH employees are professionals, while the remainder or 28% are paraprofessionals, technical and support staff. In fiscal year 2003-04, the Department of Health's budget totaled $39.3 billion. Of this amount, approximately $37.8 billion was Medicaid-related, $1.4 billion supported public health activities and $0.1 billion supported the institutions operated by the Department.
The constitution of the United States describes a system of federalism that invests in the states the authority to determine what responsibilities they retain and what responsibilities are delegated to the local level in public health. There is no consistent organizational design or mandate for how public health services are delivered by states and localities across the country. The most recent Institute of Medicine publication has stated, "...In the American system, local governments are the creatures of state government, from which they get their authority and resources (or authority to raise revenues)."18 The IOM goes on to observe that, as a consequence, "...their policy-making and managerial capacity is... variable, as are their capacities and resources in health."19 In New York, fifty-seven county health departments and the New York City Department of Health and Mental Health have the major responsibility for provision of public health services at the local level. New York is one of 26 states where the provision of public health services is decentralized; local public health departments operate under the administrative authority of local governments.20 While federal and state public health statutes and regulations guide services, each local health department is best suited to address the needs of its own community. In 28 counties, the county legislature serves as the governing authority of the local health department while a local board of health governs fourteen counties. In 11 counties, the Legislature and Board of Health serve as the governing authority together; in 4 counties, the County Board of Supervisors is the governing authority, and in one county, both the County Executive and County Legislature serve as the governing authority.21 Public health regulations in NYS require that counties with more than 250,000 persons be led by a Commissioner of Health who must be a medical doctor and have a combination of a master's degree in public health or a related field and 3 years administrative experience in public health. Commissioners lead twelve local health departments in NYS. Public health directors lead the remaining 46 local health departments. Public health directors are required to have a master's degree in public health or a related field and three years of public health experience or an appropriate combination of education and experience.22 Variability does exist across the county spectrum. Seven local health departments (including the NYC Department of Health and Mental Health) serve counties with more than 450,000 people including populations living in the state's largest cities. Eight local health departments serve counties with populations ranging from 200,000 - 450,000, and 43 local health departments serve primarily rural populations or counties with populations less than 200,000.
2. Programs and Services
Local health departments (LHDs) provide a variety of services and programs to protect and promote the health of the communities they serve. All local health departments offer core public health services that include assessing the health of the community, disease control and prevention, family health services, and health education. An additional core service, environmental health, is provided directly by 37 local health departments. The other 21 local health departments rely on the NYS Department of Health to provide environmental health services in their counties.
In addition to the core responsibilities, many other services are provided. For example, 47 local health departments operate certified home health agencies, 53 administer the Early Intervention program, 32 operate well child clinics, 30 operate comprehensive diagnostic and treatment clinics, 20 manage Women, Infant and Children (WIC) nutrition programs, and 10 oversee public health laboratories.23 Local health departments also manage public health programs as contractors of the State Department of Health (SDOH). Local health departments are among SDOH contractors in the Tobacco Control, Healthy Heart, and Lead Poisoning Prevention Programs, to name a few.
3. The New York City Department of Health and Mental Hygiene
The New York City Department of Health and Mental Hygiene deserves particular mention in this review of local governance and services. It is one of the world's largest public health agencies, with nearly 7,000 employees and an annual budget of $1.3 billion. The Department's mission is to protect and promote the health and mental health of all New Yorkers, to promote the recovery of those with mental illness and chemical dependencies and to promote the realization of full potential for those with mental retardation and developmental disabilities. Serving the more than eight million people who make New York City their home, in addition to those three million persons who work in the city or travel there each year, the Department's programs encompass areas of disease control, environmental health, epidemiology, health care access and improvement, health promotion and disease prevention, and mental hygiene services.
Local health departments rely on a combination of local appropriations, grants, state aid and revenue from third party reimbursement and fees to support local public health services. In calendar year 2001, total resources equaled almost $990 million.
|Source: NYS DOH|
Article 6 of the Public Health Law provides statutory authority for state aid for general public health work (GPHW). The GPHW program provides partial reimbursement for expenses incurred by local health departments for five basic public health areas as defined in law: community health assessment, family health, disease control, health education and environmental health. Reimbursement is also provided for optional public health services that may include emergency medical services, certified home health agencies, public health laboratories and some environmental health services. These services are considered optional since localities are not required to provide them.
Article 6 reimbursement is provided based on the net expenses of each LHD determined by subtracting revenues obtained from third party reimbursement, fees and grants from a county's gross expenditures for public health services. Full service local health departments - those providing all five basic services - are eligible to receive a base grant of up to $0.45 per capita or $450,000 per county, which ever is greater and 36% thereafter. Optional services are reimbursed at 30%. Less than full service local health departments - those not providing environmental health services - are eligible to receive a base grant of $360,000, and 36% thereafter for basic services. Optional services provided by less than full service counties are also reimbursed at 30%.
Between 1996 and 2001, state aid reimbursement increased 43%, local revenue decreased by 22%, grants increased by 21%, and the local county share increased by 69%. County governments have noted that their ability to invest in local public health programs and services is limited because of mandated county spending for Early Intervention services and Medicaid. The average increase in state aid reimbursement is about 9.5% each year in this period.
New York City accounted for 46% of state aid costs in 2001. The next 6 largest counties (Suffolk, Nassau, Erie, Westchester, Monroe and Onondaga) accounted for an additional 22% of state aid costs. Together these seven counties, which account for 72% of the state's population, accounted for 70% of the state aid to local health departments.
A survey of local health departments conducted in 2001-02 provided in-depth data on the size and composition of the workforce.24 Approximately 7,270 full time equivalent (FTE) public health workers are employed at LHDs across the state and nearly 69% of them worked in LHDs in urban counties. The survey provided information on the composition of the workforce:
- Nurses represented 22% of the total LHD workforce. They accounted for 42% of FTEs in rural LHDs, but only 14% of FTEs in urban LHDs. The large number of nurses in rural health departments is due, in part, to the fact that rural health departments, more often than urban health departments, operate Certified Home Health Agencies, which depend on nursing staff.
- Scientific/investigative staff comprised 20% of the total LHD work force. This included environmental health staff (i.e., engineers, sanitarians, and environmental technicians) that alone represented 15% of the total public health workforce. However in the 21 counties where environmental health services are provided by the NYS Department of Health, environmental health staff are not employed by the LHD.
- Epidemiologists, communicable disease staff and disease control investigators represented 5% of the total LHD work force.
- Education/outreach staff comprised 10% of the total LHD workforce, while health educators who were included in this category were only 2% of the total LHD work force.
- Physicians comprised 1% of the total LHD work force.25
- Support personnel, including program aides and public health assistants, comprised nearly 28% of the total LHD workforce.
The NYS Health Department and local public health agencies work with a multitude of community health partners to identify and address public health issues. Partners include hospitals, health care providers, other local government agencies such as schools, fire and police departments, community based organizations, insurers, local community leaders and academic institutions. In 1997, following the release of the Public Health Council's report, Communities Working Together for a Healthier New York, the Department provided small grants to local health departments to establish community-based partnerships to identify community health priorities or to implement strategies to address already established priorities. The Department also began to require as part of specific grant applications that localities establish partnerships to address some specific health problems including cardiovascular disease, tobacco, obesity and nutrition issues, and youth development. A survey of 44 community-based partnerships by the NYS Community Health Partnership in 2000 found that many community health partnerships that were established in the late 1990s were still in existence. It also determined that government investment is an important source of funding and often a catalyst for private support. Moreover it established that coalitions need technical assistance on a host of issues including outreach, leadership, outcome monitoring and evaluation.26 In 1999, the state obtained a grant from the Robert Wood Johnson Turning Point Initiative to strengthen the capacity of community-based organizations and local health departments to address public health issues. The State Turning Point Initiative has initiated many training opportunities for the public health work force, including the "Third Thursday Breakfast Broadcast Series", a monthly one-hour satellite broadcast featuring experts on current public health issues that is watched by 300-800 public health professionals in NYS every month. The Turning Point Initiative has had a special focus on strengthening community health partnerships. In the end, community partnerships are at the heart of an effectively working public health enterprise. The Institute of Medicine's report may have said it best:
"A community's right to self-determination, its knowledge of local needs and circumstances, its human, social and cultural assets, including the linkages among individuals, businesses, congregations, civic groups, schools and innumerable others, are all important motivations for community health action."27
The public health infrastructure in New York State is making notable progress in upgrading its data and information systems. An electronic health information initiative was adopted in 1996. Its goal is to improve the health of New Yorkers by enabling effective interchange of data, information, and knowledge with its information trading partners. The trading partners include LHDs, hospitals, nursing homes, diagnostic and treatment centers, physicians, laboratories, provider networks such as managed care organizations, federal agencies (CDC, CMS), and even local entities like pharmacies. The system is enterprise-wide, Internet based with web-enabled applications, secure file interchange and access control. Additional attributes are that the system provides for a centrally integrated database with backup/fail-over redundancy and offsite disaster recovery. Three networks sit on this platform: the Health Provider Network (HPN), the Health Information Network (HIN), and the Health Alert Network (HAN). The first two serve discrete private and public trading partners which represent over 12,000 accounts as of early 2002; the third is a subset of these two, taking advantage of their intersecting network information to provide emergency health alerts. The applications of the network are:
- Health Provider Network: Integrated Information Systems, Electronic Surveillance and Reporting for Health Care Providers;
- Health Information Network: Integrated Information Systems, Electronic Surveillance and Reporting for Local Health Departments; and
- Health Alert Network: Bioterrorism and Emergency Preparedness Communication.
The uses of these networks span the full spectrum of public health's essential services. They include laboratory reporting, surveillance (West Nile Virus, STD and TB case reports), physician profiles, managed care network surveys, nursing home and hospital cost reports, vital records and hospital/emergency room admission reports, and birth/death data to cite only a few.
At the same time, New York State has been involved in the implementation of a national data and information system through the National Electronic Disease Surveillance System (NEDSS). NEDSS will provide a standardized national database, reporting system and interchange for all public health information. The vision for such a system is an inter-operable, complementary architecture to assist in ongoing analyses of trends and emerging public health problems. It will also provide necessary data to inform public policy.
At the national level, recent attention has focused on the skills and knowledge, or competencies, of public health workers. Only 44% of public health workers nationally had formal academic training in public health and in 1997, 78% of local health department executives nationally did not have graduate degrees in public health.28
In New York State, a 2001 survey of 32 local health departments on emergency preparedness found that there is an urgent need for training in biological, chemical and radiological emergency preparedness for a wide range of staff in local health departments and other settings. The survey also found that among those responding, there are public health personnel shortages of nurses and epidemiologists.29 Surveys in 1998 and 1999 found that training is needed to strengthen capacity for conducting health assessments; that public health workers require training in a variety of disciplines; that working with community partners is especially challenging to local health workers; and additional training is needed.30
In recent years, efforts have been made to strengthen continuing education opportunities for the public health work force. The NYS DOH established a Memorandum of Understanding (MOU) with the State University of New York at Albany School of Public Health to support the development of a wide range of continuing education opportunities. These include a basic public health course that covers the history and mission of public health, an environmental health course required of sanitarians employed by local health departments and a Surveillance Academy that trains the state public health work force employed to conduct hospital and nursing home surveillance. The MOU also supports the Third Thursday Breakfast Broadcast series. New York is the host of the Northeast Public Health Leadership Institute that trains public health leaders annually. New York is the home of two Centers for Public Health Preparedness (Columbia University and the State University of New York at Albany School of Public Health) and the New York/New Jersey Public Health Training Center, each aimed at strengthening the skills and competencies of public health workers in two states and New York City.
18 The Future of the Public's Health in the 21st Century. Institute of Medicine 2002. National Academy Press. p. 167.
19 Ibid. p. 167.
20 National Association of County and City Health Officials, Research Brief, October 1998, Number 2. All services are decentralized. However in 21 counties, the NYS Department of Health provides environmental health services because the local health department has opted out of that service.
21 New York State Association of County Health Officials, Local Health Department Survey, 2003
22 NYCRR Part 11.11, 11.182
24 DiManno, Pirani, Williams, Young, PHLI, 2001. Surveys were received from 54 of 58 LHDs, for a response rate of over 93%. Professionals working exclusively in the Early Intervention Program and Certified Home Health Agencies were not included in the totals.
25 Includes physicians in clinical titles only.
26 Ibid. NYS Community Health Partnership, 2000.
27 The Future of the Public's Health in the 21st Century. Institute of Medicine 2003. National Academy Press. P. 205.
28 Ibid. HRSA 1992 and Gerzoff, Richards, J Public Health Mgmt Practice 1997.
29 Local Emergency Preparedness Needs in NYS, Results of a Survey of LHDs, Center for Health Workforce Studies, SUNY Albany SPH 2001.
30 NYS DOH Assessment Initiative Survey (1999), NY Turning Point Strategic Plan (1999).