Illinois Breast and Cervical Cancer Program: Implementing Effective Public-Private Partnerships to Assure Population Health Arden S. Handler, DrPH; Vida A. Henderson, PharmD, MPH, MFA; Amy Rosenfeld, MPH; Kristin Rankin, PhD; Brenda Jones, DHSc, MSN, RN; L. Michele Issel, PhD, RN rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr
ith the implementation of the Affordable Care Act (ACA), it is essential for the public health sector to elucidate its role with respect to its mission of assuring population health, and to clarify its role with respect to the private health care system. To that end, we examined the value added to the population health enterprise of successful public-private partnerships (PPPs) such as those found in the Illinois Breast and Cervical Cancer Program (IBCCP), the Centers for Disease Control and Prevention’s (CDC’s) National Breast and Cervical Cancer Early Detection Program (NBCCEDP) in Illinois. Key Informant (KI) interviews focused on IBCCP implementation were conducted with IBCCP lead agency (LA) program coordinators (n = 35/36) in winter 2012-2013. Analysis was conducted using Atlas.ti software. The KI interviews revealed the existence of highly developed PPPs between the IBCCP LAs and individual medical providers and hospitals across Illinois. The data suggest that the small amount of funding provided by IBCCP to each LA in Illinois has been used to build and sustain robust PPPs in the majority of the IBCCP communities. The PPPs developed through the IBCCP can be seen as an unplanned benefit of CDC’s investment in breast and cervical health through the NBCCEDP. While the IBCCP/NBCCEDP might be considered a “boutique” categorical program which some may consider no longer necessary as individuals gain insurance under the ACA, the KI data underscore the critical role of public sector dollars, not only to serve individuals and communities directly but also to mobilize the private health care sector to act in partnership with public entities and become advocates for underserved communities.
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J Public Health Management Practice, 2015, 21(5), 459–466 C 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
KEY WORDS: breast cancer, cervical cancer, public-private
partnerships
Over the last several years, the public health sector has been facing the dual challenge of diminished resources and a changing health care landscape brought about by the Affordable Care Act (ACA). With the ACA potentially reducing the number of uninsured Americans by 31 million,1 the role of the public health sector with respect to the mission of assuring population health may be changing.2,3 Thus, the public health sector needs to clarify its role with respect to its non-public health care partners, particularly those engaged in the delivery of clinical care. Historically, one approach to engaging the private sector has been to establish publicprivate partnerships (PPPs) to achieve shared objectives, and/or to share responsibility for the delivery of health care, and/or increase the efficient use of scarce
Author Affiliations: Division of Community Health Sciences, School of Public Health, University of Illinois at Chicago (Drs Handler and Henderson); Maternal and Child Health Program, School of Public Health, University of Illinois at Chicago (Dr Handler); NORC at the University of Chicago, Chicago, Illinois (Ms Rosenfeld); Illinois Department of Public Health, Chicago (Dr Jones); Division of Epidemiology, School of Public Health, University of Illinois at Chicago (Dr Rankin); and College of Health and Human Services, University of North Carolina at Charlotte (Dr Issel). The study authors acknowledge the program coordinators of the IBCCP lead agencies as well as the staff of the IBCCP program at the Illinois Department of Public Health. Funding for this work was received from the Illinois Department of Public Health through the Centers for Disease Control and Prevention. The authors declare no conflicts of interest. Correspondence: Arden S. Handler, DrPH, Community Health Sciences, University of Illinois School of Public Health, 1603 W Taylor, Chicago. IL 60612 ([email protected]). DOI: 10.1097/PHH.0000000000000191
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460 ❘ Journal of Public Health Management and Practice resources.4,5 In the public health system, fulfilling the assurance function2,3 often requires partnerships and collaborations between publicly funded agencies (eg, local health departments) or publicly funded programs (eg, Vaccines for Children) and privately owned, not-for-profit or for-profit organizations to assure delivery of health care to vulnerable populations. Examining PPPs currently operating within the health system has the potential to clarify the role of the public health sector in the changing health care delivery landscape. Reich defined a PPP as one that involves at least 1 private for-profit entity and at least 1 not-for-profit or public entity that share objectives, efforts, and benefits for the creation of social value, often for disadvantaged populations.4 Using this definition, we use Key Informant (KI) interview data to illustrate how the Illinois Breast and Cervical Cancer Program (IBCCP) as the public entity, has partnered with private physicians, community clinics, and hospitals to effectively deliver breast and cervical cancer services to low-income women across Illinois. On the basis of these data, we also describe the benefits and challenges of the IBCCP PPPs. We conclude by discussing the value-added to the population health enterprise of successful PPPs operating across the health system.
● The IBCCP The Centers for Disease Control and Prevention (CDC) funds states to implement statewide programs that follow the guidelines issued by the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). The IBCCP is one such program, administered by the Illinois Department of Health (IDPH). The mission of the program is to reduce breast and cervical cancer mortality in Illinois women by providing quality screening and diagnostic services that promote early detection of breast and cervical cancer. The program’s goals are presented in Table 1. Although federal guidelines establish eligibility for the NBCCEDP as uninsured and underinsured women at or below 250% of the federal poverty level (FPL), the Illinois program also serves uninsured and underinsured women with incomes greater than 250% FPL using state dollars. Uninsured and underinsured women residing in Illinois are eligible for IBCCP services if they are 40 to 64 years old (for breast cancer screening services) or 35 to 64 years old (for cervical cancer screening services); younger uninsured women with symptoms are also eligible. Women diagnosed with breast or cervical cancer are referred to the state’s Medicaid program for payment for treatment (Public Law 106-354-October 24, 2000).
TABLE 1 ● Specific Program Goals of IBCCP (IDPH 2013 Grant Application) qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq
IBCCP Program Goals To reduce breast cancer deaths to no more than 20.6 per 100 000 women and to reduce cervical cancer deaths to no more than 2.2 per 100 000 by the year 2020 (Healthy People 2020 Objectives). To provide breast and cervical cancer screening services to eligible Illinois women, with an emphasis on women of low income, racial/ethnic minorities, rarely or never screened, and older women. To increase access and utilization of early detection measures. To reduce barriers that keep Illinois women from seeking services. To provide appropriate referrals, when needed. To ensure appropriate and timely follow-up, diagnosis, and treatment through case management. To develop and disseminate culturally sensitive public information and education programs.
The IBCCP has been in existence since 1995, was expanded to the entire state in 2000, and underwent an even larger expansion in 2007 when eligibility was expanded to women with incomes more than 250% of FPL. As of early 2013, across Illinois, 36 Lead Agencies (LAs) were implementing the IBCCP program. Each has an established formal agreement with IDPH and has designated IBCCP staff. Lead Agencies are local health departments, federally qualified health centers, not-for-profit hospitals, and community-based organizations. In Fiscal Year 2013, each LA grantee was given a target caseload volume ranging from 158 to 4428 women; budgets per LA ranged from $71 429 to $2 097 710. Lead Agencies establish and maintain formal contracts with local medical providers in their communities or nearby communities to provide the needed screening and diagnosis services to IBCCP participants. On the basis of 2013 data, more than 3600 medical care providers (both individuals and organizations) delivered breast cancer screening and diagnostic services and 2724 medical care providers provided cervical cancer screening and diagnostic services that were funded by IBCCP. The staff of IBCCP at each LA provide CDC breast and cervical cancer care updates to these contracted providers, reimburse them for services rendered, and ensure that the contracted providers adhere to CDC NBCCEDP standards. They also provide care coordination and case management services, assisting women to navigate the service delivery system, as they move from provider to provider to receive all of the necessary screening and diagnostic services, as well as referral to treatment, if needed. Contracted medical care providers in turn refer uninsured women to the IBCCP and/or provide screening and diagnosis services when IBCCP enrolled women are referred to them.
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Illinois Breast and Cervical Cancer Program
● Methods As part of a larger ongoing evaluation of the IBCCP, KI interviews were conducted with all available program coordinators of the IBCCP LAs in Winter/Spring 2012-2013. Institutional review board approval was obtained from the University of Illinois for the interviews in November 2012.
Key informant interviews Lead agency program coordinators were interviewed either via a face-to-face meeting or telephone; each interview lasted between 45 to 60 minutes. All LA program coordinators who agreed to participate in the interviews were given an information sheet prior to the interview about their rights to refuse to participate in the entire interview or respond to any particular questions. The interviews were conducted by members of the evaluation team (A.H., M.I., K.R.) using a semistructured interview guide, which consisted of openended questions related to how each LA implements each of the main components of the IBCCP (described in the Introduction). The interviewers used an iterative approach, modifying the interview questions to validate understanding gained from previous interviews. This approach enriched the interviews, ensured the validity and appropriateness of questions, and increased the participants’ comfort with sharing their experiences and insights about IBCCP. The interviews were digitally recorded, then transcribed verbatim, and the transcripts were verified for accuracy.
Sample Thirty-five of 36 IBCCP LA program coordinators participated in the KI interviews. Although qualitative data from all interviews were initially included in the development of themes, as interview coding progressed, the research team found considerable redundancy across the interviews and therefore decided to select a sample of interviews (11/35, or 31%) for in-depth coding. To select the analysis sample, the 35 LAs were organized into 7 strata based on the geographic setting (metropolitan and non-metropolitan), agency type (local health department, federally qualified health center, hospital, or community-based organization), and interviewer. Because only 1 LA is a community based organization and is colocated with a hospital, it was grouped with hospitals for sample size purposes. The 11 selected LAs represent urban/suburban areas (n = 5), small/medium metropolitan areas (n = 2), and rural areas (n = 4) and are generally representative of the 35 LAs in the program (Table 2). All
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TABLE 2 ● Characteristics of All Lead Agencies and Lead Agencies Sampled for Analysis, Illinois Breast and Cervical Cancer Program qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq
Lead Agency Characteristics Overall Lead agency type Local health department Federally qualified health center Hospital/community-based organization Geographic setting Chicago Suburban Small/medium metropolitan area Rural
All Lead Agencies, n (%)
Sample Lead Agencies, n (%)
35 (100)
11 (100)
19 (54.3) 10 (28.6)
5 (45.5) 2 (18.2)
5 (14.3)
4 (36.4)
10 (28.6) 8 (22.9) 7 (20.0)
3 (27.3) 2 (18.2) 2 (18.2)
10 (28.6)
4 (36.4)
program coordinators in the subsample of 11, except 1, were female and 9 were individuals of color (African American = 2, Asian = 3, Hispanic = 4). The average length of time in their position as a program coordinator was 8.1 years.
Data analysis A data analysis codebook was developed for the KI interview data using an inductive and iterative process. Based on reviewing an initial set of interviews, 3 researchers (A.H., K.R., and M.I.) each independently developed a list of codes, which were then compared and integrated into a comprehensive set of codes. Detailed coding of the 11 interviews was then conducted by 2 research team members (A.R. and V.H.) using Atlas.ti software. Once intercoder reliability of 75% was reached, the remaining transcripts (of the 11) were divided between the 2 coders. The coders confirmed that saturation was reached after coding the 11 sampled interviews. Themes were then identified by examining the frequency and patterns of codes; specifically, we examined codes and quotations that described categories (eg, LA type, geography), causes or explanations (eg, impact of funding on provider networks), and relationships (eg, interactions between IBCCP staff, LA program coordinators, and providers). Patterns of codes were then clustered into themes and salient concepts were identified. Through this process, a key theme emerged: IBCCP LAs and their associated medical care provider networks have developed and are maintaining multiple PPPs throughout the state of Illinois. This theme and related subthemes are the focus of this article. As such, representative quotes that support this
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462 ❘ Journal of Public Health Management and Practice overarching theme and subthemes were extracted from the 11 transcripts. As we considered the PPPs that have emerged from relationships developed between IBCCP LAs and their associated medical care provider networks, we believed it was important to quantitatively summarize the program coordinators’ reports of the quality of their interactions with the health care provider networks. To conduct this more focused analysis of the KI interview data, we identified and cataloged all program coordinators’ quotes describing their associated health care provider networks. For the 11 sampled LAs, there was a mean of 27 quotes per agency (range = 10-40). The program coordinators’ perceptions and comments about the quality of their relationships with the health care provider networks were classified as being positive, negative, or neutral. If the data revealed more positive than negative quotes about the relationship with the provider networks, the LA-network relationships/ PPPs were rated robust; if neutral quotes exceeded positive or negative quotes, the LA-network relationships/PPPs were rated sufficient, and if negative quotes exceeded positive quotes, the LA-network relationships/PPPs were rated insufficient. Quotes were assigned values by a main rater and were then rerated by another independent rater for verification. The percent intercoder agreement regarding assignments of positive, neutral, or negative labels to the quotes ranged from 84.6% to 100% per LA, with a mean of 91.1%.
● Results The analysis of the 11 IBCCP KI interviews yielded 1 overarching theme, the existence of PPPs between the LAs and multiple health care providers, with 4 subthemes that detail characteristics and processes related to these partnerships.
Overarching theme: PPPs in support of breast and cervical cancer are present throughout Illinois Throughout the interviews, IBCCP LA program coordinators detailed their partnerships with a variety of different health systems, hospitals, individual physician providers, health departments, and community clinics to serve women enrolled in or in need of IBCCP services in their communities. These partnerships range in size and complexity. Some program coordinators described relationships with networks involving hundreds of providers and dozens of hospitals, while others from smaller counties described relationships with 1 or 2 hospitals that provide services with only a handful of appropriate specialists available; a small number
of the 11 LAs, all of which were located in hospitals, provided all or most services in-house. Five of the 11 LAs were coded as having robust LA provider relationships and 5 were coded as sufficient; only 1 was coded as having an insufficient provider network relationship (Table 3). Of the 5 robust characterizations, 3 of these were from LAs located within hospitals and 2 in federally qualified health centers. The LAs with robust network relationships were located in a variety of geographic settings across the state. The 1 LA whose network relationship was coded as insufficient is located in a small/medium metropolitan area of the state (geographic data not shown). Despite some variation in provider arrangements across the state, most IBCCP LA program coordinators reported that they were able to successfully connect IBCCP clients with appropriate services and develop and maintain relationships with a provider network that meets the needs of their clients. The support that LAs receive from private providers is reflected in provider referrals to the IBCCP; buy-in of the providers with respect to IBCCP program objectives; and confidence in the mission, functions, and effectiveness of the IBCCP. Program coordinators explain: R: I think one thing that’s worked really well is, provider buy-in you know providers understand that this is a really great service, this is something that our patients can really benefit from. So that’s, that’s been great. I think we’ve a very dynamic team . . . there’s provider buy-in and then there’s agency buy-in. [7] R: . . . in an area where we’re at, there are a lot of facilities that have closed so [providers] understand that there’s not that many people that have insurance anymore. And our biggest referral source is from the providers. They will call us on a weekly basis we’ll get several different phone calls wanting to make a referral, “Hey I saw this woman, she had this problem but I know she has not had a mammogram in years, can you see if she qualifies so we can get services.” [2]
Subtheme: interpersonal relationships are key to the success of PPPs During the KI interviews, LA program coordinators described the process of contacting health care providers and their office staff to provide updates to the CDC and IDPH guidelines for care as well as billing. They also described the back and forth communication that exists between LA staff and health care providers in their networks related to the care of particular patients. Regardless of the size of the provider network, partnership success was dependent on personal relationships that developed between LA staff and the health care providers. This is illustrated in the following quotes: R: Probably about a hundred and fifty providers in the nine county area, I have independent providers too, through the
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Illinois Breast and Cervical Cancer Program
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TABLE 3 ● Classification of Quotes About Public-Private Partnerships as Reported in Key Informant Interviews for a Sample of Lead Agencies (n = 11), IBCCP Evaluation qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq
Overall Classification Robust
Robust
Robust
Robust
Robust
Sufficient
Sufficient
Sufficient
Sufficient
Sufficient
Insufficient
Percent of Quotes With Each Rating Assigned
Total No. of Quotes About Public-Private Partnerships
Lead Agency, #a
Agency Type
68.2% POS 31.8% NEU 0.0% NEG 67.2% POS 25.9% NEU 6.9% NEG 60.0% POS 20.0% NEU 20.0% NEG 50.0% POS 42.3% NEU 7.7% NEG 42.2% POS 39.1% NEU 18.8% NEG 41.9% POS 51.6% NEU 6.5% NEG 36.7% POS 51.7% NEU 11.7% NEG 28.9% POS 63.5% NEU 7.7% NEG 27.5% POS 65.0% NEU 10.0% NEG 11.9% POS 69.1% NEU 19.1% NEG 26.3% POS 32.5% NEU 42.5% NEG
33
2
Hospital/CBO
29
4
FQHC
10
7
FQHC
26
6
Hospital/CBO
32
3
Hospital/CBO
31
8
LHD
30
1
LHD
26
9
LHD
20
5
Hospital/CBO
21
11
LHD
40
10
LHD
Abbreviations: CBO, community-based organization; FQHC, community health center; LHD, local health department; NEG, negative comments; NEU, neutral comments; POS, positive comments. a Lead agency numbers correspond to the bracketed numbers in quotations.
years I have met with all of them personally and explained our role and what we do for women and how they can help us. [3] R: Yes, usually I go around to the providers and do updates on any changes they made within the agency or the CDC recommendations because those have been changing a lot lately in the past few years. [1]
Subtheme: private health care providers rely on public sector to fill gaps for their patients Many LA program coordinators described instances in which women seek services from providers in the care system due to breast or cervical health concerns but find
they do not have sufficient financial resources to move forward with medical care; in these cases, their medical providers often refer them to IBCCP for support. This is revealed in the following quote: R: Our biggest referral source right now is actually from physicians and contracted providers that women, you know go into the office for maybe this same screening or maybe another healthcare need. And it’s learned through the health history that they haven’t had these services for a while, “oh call this number, and you know they can help you pay for it.” [3]
In other instances, women who would not typically seek the type of support offered by IBCCP or “public
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464 ❘ Journal of Public Health Management and Practice assistance” were encouraged to do so by their medical providers and as a result were more willing to receive the services and funding offered by IBCCP, a public sector program. Lead agency program coordinators described specific instances in which women sought IBCCP services specifically because they trusted their medical providers: R: I think that gives validity to the patient that this is a legitimate agency, I can trust them that my doctor’s told me about them. ‘Cause sometimes people will think, oh that’s too hard to believe that they’re gonna pay for a mammogram for me, there’s gotta be a catch . . . But if the doctor says upfront, “They can help you. Here’s their phone number.” That, there’s some trust right there. [2]
Subtheme: private providers often “donate” services in their role as a member of a PPP As reported by the LA program coordinators, at times the commitment of the health care providers to serving the women in need actually overrode their contractual financial agreements with the LA. When IBCCP funding was not available, when reimbursements were not timely, or when the IBCCP funding mechanism did not provide support for a clinical approach suggested by the medical provider, the longstanding relationship these providers have with the LAs meant that women’s needs were still addressed. R: There are some wonderful breast surgeons, and they will make every effort to be available when the lady needs to be available. They themselves that are passionate about something that they think, she needs follow-up sooner but our guidelines says in 6 months, they will call and say well I really think, you know, so and so needs to come in sooner, she doesn’t have the resources to pay for this. They’ve done, they’ve seen ‘em . . . before without pay for follow-up visits. [2] R: Our medical providers really, I mean talk about a team sport you know they really have, you know they’re so committed to this, and you know they wait for their money, and that’s hard to do. [6]
Subtheme: challenges to the PPPs As described earlier, PPPs can result in many benefits to vulnerable populations. Nonetheless, these partnerships face challenges, both internal and external. One set of challenges for the LA health care provider PPP revolves around the often limited amount of financial resources for reimbursement and fear of untimely compensation as reflected in the following quote: R: I used to have one with all 3 hospitals, but one of the county hospitals a few years ago when the state was so far behind paying bills, severed the contract because of late payments. [1]
Another challenge to the PPPs is that IBCCP providers sometimes fear losing their autonomy because of requirements to follow screening algorithms set forth by CDC as conditions for participating in the national program. As one LA program coordinator stated when asked about provider contracts: R: I mean we’re trying to get them in to . . . follow the algorithms. Many times we have to direct the physicians, you always have some physicians that understand and want to follow, but you have so many physicians that are um . . . scared of the algorithm processes and they deem that they have a better way. And then we have to tell them, well you can do that but we can’t pay for that, this is what we can pay for. [10]
Shortages of medical providers in certain areas served by IBCCP and difficulties in procuring contracts with existing local health care providers can lead to longer wait times for women seeking care and can result in women having to travel to other counties for screening, diagnostic services, and treatment. As noted: R: In the rural areas, there are fewer providers and it does make it more difficult ‘cause there’s less, fewer options. We do give the women the option to come to the bigger city, but it’s a lot of times, it can be over an hour drive and they don’t want to do that so, those would be challenges. Transportation, lack of providers. And we did have one group of doctors discontinue with the program. They no longer participate because the state takes oh, five months to reimburse. [11]
● Discussion The KI interviews with IBCCP LA program coordinators revealed the existence and nature of highly developed PPPs between IBCCP LAs (the public entities) and individual medical providers and other health organizations including hospitals (the private entities), locally and across the state of Illinois. The data suggest that the CDC’s Breast and Cervical Cancer Program in Illinois is not just a publicly funded safety net program but, in fact, is the progenitor of multiple PPPs throughout the state of Illinois. These PPPs help ensure that lowincome and uninsured women do not “fall through the cracks” of the health care delivery system and are consequently provided access to needed breast and cervical cancer screening, diagnosis, and treatment. The KI data suggest that despite challenges, a mutual reliance based on strong interpersonal relationships is the lynchpin of these partnerships. In general, PPPs render benefits to the health care system and population health and can result in direct and indirect cost-savings to the public.6 They also offer the opportunity for mutual learning among partners by stimulating the creation of new knowledge and infrastructure, as well as increasing transparency,
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Illinois Breast and Cervical Cancer Program
which can result in greater accountability, public confidence, and higher quality of care.6,7 Public-private partnerships can also build meaningful connections and relationships within communities through the development of collaborations and coalitions that have mutually beneficial goals.7 It is of interest that community-wide health care service delivery networks in Illinois focused on the delivery of breast and cervical cancer services have emerged as the result of the leveraging of a relatively small amount of public funds. As such, the PPPs developed and implemented through the IBCCP program might be considered an unplanned benefit of the CDC/NBCCEDP’s investment in breast and cervical health. Although we did not initially set out to examine the existence and nature of PPPs implemented through IBCCP, it appears that these partnerships fit Reich’s4 notion of PPPs, entities based on shared objectives, shared efforts, and shared benefits for the creation of social value, often for vulnerable populations. Our data suggest that the PPPs established in many of the IBCCP LA’s communities also represent movement toward an organized delivery system, as defined by Shortell et al: “a network of organizations that provides or arranges to provide a coordinated continuum of services to a defined population and is willing to be held clinically and fiscally accountable for the outcomes and health status of the populations served.”8(p7) The delivery systems that are part of the IBCCP are not fiscally or managerially organized in ways typically seen in other health system entities such as HMOs or Accountable Care Organizations, yet the IBCCP “seed” funding has led to the development of PPPs with a mission and sense of responsibility to ensure that low-income and vulnerable women’s breast and cervical health needs are met. Existing roles and relationships between public health programs and their clinical partners within the health care delivery system may change in the next decade with the full implementation of the ACA. However, even with the implementation of the ACA, some women will remain uninsured or underinsured, including undocumented individuals and those who live in states without the expansion of Medicaid. In addition, as suggested by the data presented here, public sector programs such as IBCCP not only serve individuals and communities directly but, in fact, mobilize the private sector to act and become advocates for underserved communities. And while not presented in these results, the KI interviews also documented that the IBCCP has a deep wealth of experience and expertise with respect to a variety of system enabling roles (eg, care coordination, case management); IBCCP may be called upon along with other public sector programs to continue to play these types of essential roles to assist individuals to
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navigate a complex medical system. Thus, we suggest that while programs such as IBCCP may change over time in terms of population served and mission, they will continue to remain an important part of the health delivery landscape for a considerable period into the future.9 This study has some limitations. It was not designed to explicitly examine PPPs and thus specific questions about PPPs were not included in the interview guide. Consequently, details about the PPPs that might be informative in the current health care climate were not available including specifics of the economic relationship between the private providers and the LAs. However, our interview approach included asking probing questions when relationships between the LAs and their partners were described, which yielded the particulars about the PPPs reported here. We also acknowledge that the data reflect only the LA program coordinators’ perspectives with respect to PPPs. A more complete understanding of the PPPs would require obtaining the perspective of providers who comprise the other half of the PPPs described. In addition, these data are based on reports of only 11 individuals involved with the IBCCP; the staff at IDPH and other IBCCP staff at each LA might have different perspectives than this sample of program coordinators. Finally, although having data from all programs within Illinois allows us to speak confidently about 1 state, we are reluctant to draw conclusions for other states or the nation as a whole. The generalizability of the findings would also be enhanced if we had been able to gather comparable data from other states with CDC funding.
● Conclusion Even with the implementation of the ACA, millions of women will remain uninsured, some will remain underinsured, and the type of categorical funding represented by the IBCCP/NBCCEDP, with its history of service delivery in communities throughout the United States, is likely to remain an essential part of the health care delivery landscape. Although the NBCCEDP breast and cervical cancer programs throughout the United States are thought of as categorical “safety net” programs that are potentially redundant with the launch of health insurance expansion through the ACA, our data reveal that the IBCCP provides an “unseen” and to date “unvalued” benefit of the CDC’s investment, by serving the function of mobilizing vast networks of health care providers to deliver care to a vulnerable population. In a climate in which insurance will become more widespread, the public health sector will be repositioning itself with respect to
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466 ❘ Journal of Public Health Management and Practice ensuring access to care. Our data suggest that publicly funded health programs may still play a vital role in partnership with private providers to ensure that women and others with newly acquired financial access are able to successfully navigate a newly configured and possibly even more complex health care delivery system. REFERENCES 1. Rosenbaum S. The Patient Protection and Affordable Care Act: implications for public health policy and practice. Public Health Rep. 2011;126(1):130-135. 2. Institute of Medicine. The Future of Public Health. Vol 88. Washington, DC: National Academies Press; 1988. 3. Institute of Medicine. Primary Care and Public Health: Exploring Integration to Improve Population Health. Washington, DC: National Academies Press; 2012.
4. Reich M. Public-Private Partnerships for Public Health. Cambridge, MA: Harvard Center for Population and Development Studies; 2002. 5. Shortell SM, Zukoski AP, Alexander JA, et al. Evaluating partnerships for community health improvement: tracking the footprints. J Health Politics, Policy and Law. 2002;27(1):49-91. 6. Bloomfield P. The challenging business of long-term publicprivate partnerships: reflections on local experience. Public Admin Rev. 2006;66(3):400-411. 7. Minow M. Public and private partnerships: accounting for the new religion. Harvard Law Rev. 2003;116:1229-1270. 8. Shortell SM, Gillies RR, Anderson DA, Erickson KM, Mitchell JB. Remaking Health Care in America: Building Organized Delivery Systems. San Francisco, CA: Jossey-Bass; 1996. 9. Levy AR, Bruen BK, Ku L. Health care reform and women’s insurance coverage for breast and cervical cancer screening. [Erratum appears in Prev Chronic Dis. 2012;9. http://www. cdc.gov/pcd/issues/2012/12 0069e.htm.] Prev Chronic Dis. 2012;9:120069.
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ith the implementation of the Affordable Care Act (ACA), it is essential for the public health sector to elucidate its role with respect to its mission of assuring population health, and to clarify its role with respect to the private health care system. To that end, we examined the value added to the population health enterprise of successful public-private partnerships (PPPs) such as those found in the Illinois Breast and Cervical Cancer Program (IBCCP), the Centers for Disease Control and Prevention’s (CDC’s) National Breast and Cervical Cancer Early Detection Program (NBCCEDP) in Illinois. Key Informant (KI) interviews focused on IBCCP implementation were conducted with IBCCP lead agency (LA) program coordinators (n = 35/36) in winter 2012-2013. Analysis was conducted using Atlas.ti software. The KI interviews revealed the existence of highly developed PPPs between the IBCCP LAs and individual medical providers and hospitals across Illinois. The data suggest that the small amount of funding provided by IBCCP to each LA in Illinois has been used to build and sustain robust PPPs in the majority of the IBCCP communities. The PPPs developed through the IBCCP can be seen as an unplanned benefit of CDC’s investment in breast and cervical health through the NBCCEDP. While the IBCCP/NBCCEDP might be considered a “boutique” categorical program which some may consider no longer necessary as individuals gain insurance under the ACA, the KI data underscore the critical role of public sector dollars, not only to serve individuals and communities directly but also to mobilize the private health care sector to act in partnership with public entities and become advocates for underserved communities.
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J Public Health Management Practice, 2015, 21(5), 459–466 C 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
KEY WORDS: breast cancer, cervical cancer, public-private
partnerships
Over the last several years, the public health sector has been facing the dual challenge of diminished resources and a changing health care landscape brought about by the Affordable Care Act (ACA). With the ACA potentially reducing the number of uninsured Americans by 31 million,1 the role of the public health sector with respect to the mission of assuring population health may be changing.2,3 Thus, the public health sector needs to clarify its role with respect to its non-public health care partners, particularly those engaged in the delivery of clinical care. Historically, one approach to engaging the private sector has been to establish publicprivate partnerships (PPPs) to achieve shared objectives, and/or to share responsibility for the delivery of health care, and/or increase the efficient use of scarce
Author Affiliations: Division of Community Health Sciences, School of Public Health, University of Illinois at Chicago (Drs Handler and Henderson); Maternal and Child Health Program, School of Public Health, University of Illinois at Chicago (Dr Handler); NORC at the University of Chicago, Chicago, Illinois (Ms Rosenfeld); Illinois Department of Public Health, Chicago (Dr Jones); Division of Epidemiology, School of Public Health, University of Illinois at Chicago (Dr Rankin); and College of Health and Human Services, University of North Carolina at Charlotte (Dr Issel). The study authors acknowledge the program coordinators of the IBCCP lead agencies as well as the staff of the IBCCP program at the Illinois Department of Public Health. Funding for this work was received from the Illinois Department of Public Health through the Centers for Disease Control and Prevention. The authors declare no conflicts of interest. Correspondence: Arden S. Handler, DrPH, Community Health Sciences, University of Illinois School of Public Health, 1603 W Taylor, Chicago. IL 60612 ([email protected]). DOI: 10.1097/PHH.0000000000000191
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460 ❘ Journal of Public Health Management and Practice resources.4,5 In the public health system, fulfilling the assurance function2,3 often requires partnerships and collaborations between publicly funded agencies (eg, local health departments) or publicly funded programs (eg, Vaccines for Children) and privately owned, not-for-profit or for-profit organizations to assure delivery of health care to vulnerable populations. Examining PPPs currently operating within the health system has the potential to clarify the role of the public health sector in the changing health care delivery landscape. Reich defined a PPP as one that involves at least 1 private for-profit entity and at least 1 not-for-profit or public entity that share objectives, efforts, and benefits for the creation of social value, often for disadvantaged populations.4 Using this definition, we use Key Informant (KI) interview data to illustrate how the Illinois Breast and Cervical Cancer Program (IBCCP) as the public entity, has partnered with private physicians, community clinics, and hospitals to effectively deliver breast and cervical cancer services to low-income women across Illinois. On the basis of these data, we also describe the benefits and challenges of the IBCCP PPPs. We conclude by discussing the value-added to the population health enterprise of successful PPPs operating across the health system.
● The IBCCP The Centers for Disease Control and Prevention (CDC) funds states to implement statewide programs that follow the guidelines issued by the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). The IBCCP is one such program, administered by the Illinois Department of Health (IDPH). The mission of the program is to reduce breast and cervical cancer mortality in Illinois women by providing quality screening and diagnostic services that promote early detection of breast and cervical cancer. The program’s goals are presented in Table 1. Although federal guidelines establish eligibility for the NBCCEDP as uninsured and underinsured women at or below 250% of the federal poverty level (FPL), the Illinois program also serves uninsured and underinsured women with incomes greater than 250% FPL using state dollars. Uninsured and underinsured women residing in Illinois are eligible for IBCCP services if they are 40 to 64 years old (for breast cancer screening services) or 35 to 64 years old (for cervical cancer screening services); younger uninsured women with symptoms are also eligible. Women diagnosed with breast or cervical cancer are referred to the state’s Medicaid program for payment for treatment (Public Law 106-354-October 24, 2000).
TABLE 1 ● Specific Program Goals of IBCCP (IDPH 2013 Grant Application) qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq
IBCCP Program Goals To reduce breast cancer deaths to no more than 20.6 per 100 000 women and to reduce cervical cancer deaths to no more than 2.2 per 100 000 by the year 2020 (Healthy People 2020 Objectives). To provide breast and cervical cancer screening services to eligible Illinois women, with an emphasis on women of low income, racial/ethnic minorities, rarely or never screened, and older women. To increase access and utilization of early detection measures. To reduce barriers that keep Illinois women from seeking services. To provide appropriate referrals, when needed. To ensure appropriate and timely follow-up, diagnosis, and treatment through case management. To develop and disseminate culturally sensitive public information and education programs.
The IBCCP has been in existence since 1995, was expanded to the entire state in 2000, and underwent an even larger expansion in 2007 when eligibility was expanded to women with incomes more than 250% of FPL. As of early 2013, across Illinois, 36 Lead Agencies (LAs) were implementing the IBCCP program. Each has an established formal agreement with IDPH and has designated IBCCP staff. Lead Agencies are local health departments, federally qualified health centers, not-for-profit hospitals, and community-based organizations. In Fiscal Year 2013, each LA grantee was given a target caseload volume ranging from 158 to 4428 women; budgets per LA ranged from $71 429 to $2 097 710. Lead Agencies establish and maintain formal contracts with local medical providers in their communities or nearby communities to provide the needed screening and diagnosis services to IBCCP participants. On the basis of 2013 data, more than 3600 medical care providers (both individuals and organizations) delivered breast cancer screening and diagnostic services and 2724 medical care providers provided cervical cancer screening and diagnostic services that were funded by IBCCP. The staff of IBCCP at each LA provide CDC breast and cervical cancer care updates to these contracted providers, reimburse them for services rendered, and ensure that the contracted providers adhere to CDC NBCCEDP standards. They also provide care coordination and case management services, assisting women to navigate the service delivery system, as they move from provider to provider to receive all of the necessary screening and diagnostic services, as well as referral to treatment, if needed. Contracted medical care providers in turn refer uninsured women to the IBCCP and/or provide screening and diagnosis services when IBCCP enrolled women are referred to them.
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Illinois Breast and Cervical Cancer Program
● Methods As part of a larger ongoing evaluation of the IBCCP, KI interviews were conducted with all available program coordinators of the IBCCP LAs in Winter/Spring 2012-2013. Institutional review board approval was obtained from the University of Illinois for the interviews in November 2012.
Key informant interviews Lead agency program coordinators were interviewed either via a face-to-face meeting or telephone; each interview lasted between 45 to 60 minutes. All LA program coordinators who agreed to participate in the interviews were given an information sheet prior to the interview about their rights to refuse to participate in the entire interview or respond to any particular questions. The interviews were conducted by members of the evaluation team (A.H., M.I., K.R.) using a semistructured interview guide, which consisted of openended questions related to how each LA implements each of the main components of the IBCCP (described in the Introduction). The interviewers used an iterative approach, modifying the interview questions to validate understanding gained from previous interviews. This approach enriched the interviews, ensured the validity and appropriateness of questions, and increased the participants’ comfort with sharing their experiences and insights about IBCCP. The interviews were digitally recorded, then transcribed verbatim, and the transcripts were verified for accuracy.
Sample Thirty-five of 36 IBCCP LA program coordinators participated in the KI interviews. Although qualitative data from all interviews were initially included in the development of themes, as interview coding progressed, the research team found considerable redundancy across the interviews and therefore decided to select a sample of interviews (11/35, or 31%) for in-depth coding. To select the analysis sample, the 35 LAs were organized into 7 strata based on the geographic setting (metropolitan and non-metropolitan), agency type (local health department, federally qualified health center, hospital, or community-based organization), and interviewer. Because only 1 LA is a community based organization and is colocated with a hospital, it was grouped with hospitals for sample size purposes. The 11 selected LAs represent urban/suburban areas (n = 5), small/medium metropolitan areas (n = 2), and rural areas (n = 4) and are generally representative of the 35 LAs in the program (Table 2). All
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TABLE 2 ● Characteristics of All Lead Agencies and Lead Agencies Sampled for Analysis, Illinois Breast and Cervical Cancer Program qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq
Lead Agency Characteristics Overall Lead agency type Local health department Federally qualified health center Hospital/community-based organization Geographic setting Chicago Suburban Small/medium metropolitan area Rural
All Lead Agencies, n (%)
Sample Lead Agencies, n (%)
35 (100)
11 (100)
19 (54.3) 10 (28.6)
5 (45.5) 2 (18.2)
5 (14.3)
4 (36.4)
10 (28.6) 8 (22.9) 7 (20.0)
3 (27.3) 2 (18.2) 2 (18.2)
10 (28.6)
4 (36.4)
program coordinators in the subsample of 11, except 1, were female and 9 were individuals of color (African American = 2, Asian = 3, Hispanic = 4). The average length of time in their position as a program coordinator was 8.1 years.
Data analysis A data analysis codebook was developed for the KI interview data using an inductive and iterative process. Based on reviewing an initial set of interviews, 3 researchers (A.H., K.R., and M.I.) each independently developed a list of codes, which were then compared and integrated into a comprehensive set of codes. Detailed coding of the 11 interviews was then conducted by 2 research team members (A.R. and V.H.) using Atlas.ti software. Once intercoder reliability of 75% was reached, the remaining transcripts (of the 11) were divided between the 2 coders. The coders confirmed that saturation was reached after coding the 11 sampled interviews. Themes were then identified by examining the frequency and patterns of codes; specifically, we examined codes and quotations that described categories (eg, LA type, geography), causes or explanations (eg, impact of funding on provider networks), and relationships (eg, interactions between IBCCP staff, LA program coordinators, and providers). Patterns of codes were then clustered into themes and salient concepts were identified. Through this process, a key theme emerged: IBCCP LAs and their associated medical care provider networks have developed and are maintaining multiple PPPs throughout the state of Illinois. This theme and related subthemes are the focus of this article. As such, representative quotes that support this
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462 ❘ Journal of Public Health Management and Practice overarching theme and subthemes were extracted from the 11 transcripts. As we considered the PPPs that have emerged from relationships developed between IBCCP LAs and their associated medical care provider networks, we believed it was important to quantitatively summarize the program coordinators’ reports of the quality of their interactions with the health care provider networks. To conduct this more focused analysis of the KI interview data, we identified and cataloged all program coordinators’ quotes describing their associated health care provider networks. For the 11 sampled LAs, there was a mean of 27 quotes per agency (range = 10-40). The program coordinators’ perceptions and comments about the quality of their relationships with the health care provider networks were classified as being positive, negative, or neutral. If the data revealed more positive than negative quotes about the relationship with the provider networks, the LA-network relationships/ PPPs were rated robust; if neutral quotes exceeded positive or negative quotes, the LA-network relationships/PPPs were rated sufficient, and if negative quotes exceeded positive quotes, the LA-network relationships/PPPs were rated insufficient. Quotes were assigned values by a main rater and were then rerated by another independent rater for verification. The percent intercoder agreement regarding assignments of positive, neutral, or negative labels to the quotes ranged from 84.6% to 100% per LA, with a mean of 91.1%.
● Results The analysis of the 11 IBCCP KI interviews yielded 1 overarching theme, the existence of PPPs between the LAs and multiple health care providers, with 4 subthemes that detail characteristics and processes related to these partnerships.
Overarching theme: PPPs in support of breast and cervical cancer are present throughout Illinois Throughout the interviews, IBCCP LA program coordinators detailed their partnerships with a variety of different health systems, hospitals, individual physician providers, health departments, and community clinics to serve women enrolled in or in need of IBCCP services in their communities. These partnerships range in size and complexity. Some program coordinators described relationships with networks involving hundreds of providers and dozens of hospitals, while others from smaller counties described relationships with 1 or 2 hospitals that provide services with only a handful of appropriate specialists available; a small number
of the 11 LAs, all of which were located in hospitals, provided all or most services in-house. Five of the 11 LAs were coded as having robust LA provider relationships and 5 were coded as sufficient; only 1 was coded as having an insufficient provider network relationship (Table 3). Of the 5 robust characterizations, 3 of these were from LAs located within hospitals and 2 in federally qualified health centers. The LAs with robust network relationships were located in a variety of geographic settings across the state. The 1 LA whose network relationship was coded as insufficient is located in a small/medium metropolitan area of the state (geographic data not shown). Despite some variation in provider arrangements across the state, most IBCCP LA program coordinators reported that they were able to successfully connect IBCCP clients with appropriate services and develop and maintain relationships with a provider network that meets the needs of their clients. The support that LAs receive from private providers is reflected in provider referrals to the IBCCP; buy-in of the providers with respect to IBCCP program objectives; and confidence in the mission, functions, and effectiveness of the IBCCP. Program coordinators explain: R: I think one thing that’s worked really well is, provider buy-in you know providers understand that this is a really great service, this is something that our patients can really benefit from. So that’s, that’s been great. I think we’ve a very dynamic team . . . there’s provider buy-in and then there’s agency buy-in. [7] R: . . . in an area where we’re at, there are a lot of facilities that have closed so [providers] understand that there’s not that many people that have insurance anymore. And our biggest referral source is from the providers. They will call us on a weekly basis we’ll get several different phone calls wanting to make a referral, “Hey I saw this woman, she had this problem but I know she has not had a mammogram in years, can you see if she qualifies so we can get services.” [2]
Subtheme: interpersonal relationships are key to the success of PPPs During the KI interviews, LA program coordinators described the process of contacting health care providers and their office staff to provide updates to the CDC and IDPH guidelines for care as well as billing. They also described the back and forth communication that exists between LA staff and health care providers in their networks related to the care of particular patients. Regardless of the size of the provider network, partnership success was dependent on personal relationships that developed between LA staff and the health care providers. This is illustrated in the following quotes: R: Probably about a hundred and fifty providers in the nine county area, I have independent providers too, through the
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Illinois Breast and Cervical Cancer Program
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TABLE 3 ● Classification of Quotes About Public-Private Partnerships as Reported in Key Informant Interviews for a Sample of Lead Agencies (n = 11), IBCCP Evaluation qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq
Overall Classification Robust
Robust
Robust
Robust
Robust
Sufficient
Sufficient
Sufficient
Sufficient
Sufficient
Insufficient
Percent of Quotes With Each Rating Assigned
Total No. of Quotes About Public-Private Partnerships
Lead Agency, #a
Agency Type
68.2% POS 31.8% NEU 0.0% NEG 67.2% POS 25.9% NEU 6.9% NEG 60.0% POS 20.0% NEU 20.0% NEG 50.0% POS 42.3% NEU 7.7% NEG 42.2% POS 39.1% NEU 18.8% NEG 41.9% POS 51.6% NEU 6.5% NEG 36.7% POS 51.7% NEU 11.7% NEG 28.9% POS 63.5% NEU 7.7% NEG 27.5% POS 65.0% NEU 10.0% NEG 11.9% POS 69.1% NEU 19.1% NEG 26.3% POS 32.5% NEU 42.5% NEG
33
2
Hospital/CBO
29
4
FQHC
10
7
FQHC
26
6
Hospital/CBO
32
3
Hospital/CBO
31
8
LHD
30
1
LHD
26
9
LHD
20
5
Hospital/CBO
21
11
LHD
40
10
LHD
Abbreviations: CBO, community-based organization; FQHC, community health center; LHD, local health department; NEG, negative comments; NEU, neutral comments; POS, positive comments. a Lead agency numbers correspond to the bracketed numbers in quotations.
years I have met with all of them personally and explained our role and what we do for women and how they can help us. [3] R: Yes, usually I go around to the providers and do updates on any changes they made within the agency or the CDC recommendations because those have been changing a lot lately in the past few years. [1]
Subtheme: private health care providers rely on public sector to fill gaps for their patients Many LA program coordinators described instances in which women seek services from providers in the care system due to breast or cervical health concerns but find
they do not have sufficient financial resources to move forward with medical care; in these cases, their medical providers often refer them to IBCCP for support. This is revealed in the following quote: R: Our biggest referral source right now is actually from physicians and contracted providers that women, you know go into the office for maybe this same screening or maybe another healthcare need. And it’s learned through the health history that they haven’t had these services for a while, “oh call this number, and you know they can help you pay for it.” [3]
In other instances, women who would not typically seek the type of support offered by IBCCP or “public
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464 ❘ Journal of Public Health Management and Practice assistance” were encouraged to do so by their medical providers and as a result were more willing to receive the services and funding offered by IBCCP, a public sector program. Lead agency program coordinators described specific instances in which women sought IBCCP services specifically because they trusted their medical providers: R: I think that gives validity to the patient that this is a legitimate agency, I can trust them that my doctor’s told me about them. ‘Cause sometimes people will think, oh that’s too hard to believe that they’re gonna pay for a mammogram for me, there’s gotta be a catch . . . But if the doctor says upfront, “They can help you. Here’s their phone number.” That, there’s some trust right there. [2]
Subtheme: private providers often “donate” services in their role as a member of a PPP As reported by the LA program coordinators, at times the commitment of the health care providers to serving the women in need actually overrode their contractual financial agreements with the LA. When IBCCP funding was not available, when reimbursements were not timely, or when the IBCCP funding mechanism did not provide support for a clinical approach suggested by the medical provider, the longstanding relationship these providers have with the LAs meant that women’s needs were still addressed. R: There are some wonderful breast surgeons, and they will make every effort to be available when the lady needs to be available. They themselves that are passionate about something that they think, she needs follow-up sooner but our guidelines says in 6 months, they will call and say well I really think, you know, so and so needs to come in sooner, she doesn’t have the resources to pay for this. They’ve done, they’ve seen ‘em . . . before without pay for follow-up visits. [2] R: Our medical providers really, I mean talk about a team sport you know they really have, you know they’re so committed to this, and you know they wait for their money, and that’s hard to do. [6]
Subtheme: challenges to the PPPs As described earlier, PPPs can result in many benefits to vulnerable populations. Nonetheless, these partnerships face challenges, both internal and external. One set of challenges for the LA health care provider PPP revolves around the often limited amount of financial resources for reimbursement and fear of untimely compensation as reflected in the following quote: R: I used to have one with all 3 hospitals, but one of the county hospitals a few years ago when the state was so far behind paying bills, severed the contract because of late payments. [1]
Another challenge to the PPPs is that IBCCP providers sometimes fear losing their autonomy because of requirements to follow screening algorithms set forth by CDC as conditions for participating in the national program. As one LA program coordinator stated when asked about provider contracts: R: I mean we’re trying to get them in to . . . follow the algorithms. Many times we have to direct the physicians, you always have some physicians that understand and want to follow, but you have so many physicians that are um . . . scared of the algorithm processes and they deem that they have a better way. And then we have to tell them, well you can do that but we can’t pay for that, this is what we can pay for. [10]
Shortages of medical providers in certain areas served by IBCCP and difficulties in procuring contracts with existing local health care providers can lead to longer wait times for women seeking care and can result in women having to travel to other counties for screening, diagnostic services, and treatment. As noted: R: In the rural areas, there are fewer providers and it does make it more difficult ‘cause there’s less, fewer options. We do give the women the option to come to the bigger city, but it’s a lot of times, it can be over an hour drive and they don’t want to do that so, those would be challenges. Transportation, lack of providers. And we did have one group of doctors discontinue with the program. They no longer participate because the state takes oh, five months to reimburse. [11]
● Discussion The KI interviews with IBCCP LA program coordinators revealed the existence and nature of highly developed PPPs between IBCCP LAs (the public entities) and individual medical providers and other health organizations including hospitals (the private entities), locally and across the state of Illinois. The data suggest that the CDC’s Breast and Cervical Cancer Program in Illinois is not just a publicly funded safety net program but, in fact, is the progenitor of multiple PPPs throughout the state of Illinois. These PPPs help ensure that lowincome and uninsured women do not “fall through the cracks” of the health care delivery system and are consequently provided access to needed breast and cervical cancer screening, diagnosis, and treatment. The KI data suggest that despite challenges, a mutual reliance based on strong interpersonal relationships is the lynchpin of these partnerships. In general, PPPs render benefits to the health care system and population health and can result in direct and indirect cost-savings to the public.6 They also offer the opportunity for mutual learning among partners by stimulating the creation of new knowledge and infrastructure, as well as increasing transparency,
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Illinois Breast and Cervical Cancer Program
which can result in greater accountability, public confidence, and higher quality of care.6,7 Public-private partnerships can also build meaningful connections and relationships within communities through the development of collaborations and coalitions that have mutually beneficial goals.7 It is of interest that community-wide health care service delivery networks in Illinois focused on the delivery of breast and cervical cancer services have emerged as the result of the leveraging of a relatively small amount of public funds. As such, the PPPs developed and implemented through the IBCCP program might be considered an unplanned benefit of the CDC/NBCCEDP’s investment in breast and cervical health. Although we did not initially set out to examine the existence and nature of PPPs implemented through IBCCP, it appears that these partnerships fit Reich’s4 notion of PPPs, entities based on shared objectives, shared efforts, and shared benefits for the creation of social value, often for vulnerable populations. Our data suggest that the PPPs established in many of the IBCCP LA’s communities also represent movement toward an organized delivery system, as defined by Shortell et al: “a network of organizations that provides or arranges to provide a coordinated continuum of services to a defined population and is willing to be held clinically and fiscally accountable for the outcomes and health status of the populations served.”8(p7) The delivery systems that are part of the IBCCP are not fiscally or managerially organized in ways typically seen in other health system entities such as HMOs or Accountable Care Organizations, yet the IBCCP “seed” funding has led to the development of PPPs with a mission and sense of responsibility to ensure that low-income and vulnerable women’s breast and cervical health needs are met. Existing roles and relationships between public health programs and their clinical partners within the health care delivery system may change in the next decade with the full implementation of the ACA. However, even with the implementation of the ACA, some women will remain uninsured or underinsured, including undocumented individuals and those who live in states without the expansion of Medicaid. In addition, as suggested by the data presented here, public sector programs such as IBCCP not only serve individuals and communities directly but, in fact, mobilize the private sector to act and become advocates for underserved communities. And while not presented in these results, the KI interviews also documented that the IBCCP has a deep wealth of experience and expertise with respect to a variety of system enabling roles (eg, care coordination, case management); IBCCP may be called upon along with other public sector programs to continue to play these types of essential roles to assist individuals to
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navigate a complex medical system. Thus, we suggest that while programs such as IBCCP may change over time in terms of population served and mission, they will continue to remain an important part of the health delivery landscape for a considerable period into the future.9 This study has some limitations. It was not designed to explicitly examine PPPs and thus specific questions about PPPs were not included in the interview guide. Consequently, details about the PPPs that might be informative in the current health care climate were not available including specifics of the economic relationship between the private providers and the LAs. However, our interview approach included asking probing questions when relationships between the LAs and their partners were described, which yielded the particulars about the PPPs reported here. We also acknowledge that the data reflect only the LA program coordinators’ perspectives with respect to PPPs. A more complete understanding of the PPPs would require obtaining the perspective of providers who comprise the other half of the PPPs described. In addition, these data are based on reports of only 11 individuals involved with the IBCCP; the staff at IDPH and other IBCCP staff at each LA might have different perspectives than this sample of program coordinators. Finally, although having data from all programs within Illinois allows us to speak confidently about 1 state, we are reluctant to draw conclusions for other states or the nation as a whole. The generalizability of the findings would also be enhanced if we had been able to gather comparable data from other states with CDC funding.
● Conclusion Even with the implementation of the ACA, millions of women will remain uninsured, some will remain underinsured, and the type of categorical funding represented by the IBCCP/NBCCEDP, with its history of service delivery in communities throughout the United States, is likely to remain an essential part of the health care delivery landscape. Although the NBCCEDP breast and cervical cancer programs throughout the United States are thought of as categorical “safety net” programs that are potentially redundant with the launch of health insurance expansion through the ACA, our data reveal that the IBCCP provides an “unseen” and to date “unvalued” benefit of the CDC’s investment, by serving the function of mobilizing vast networks of health care providers to deliver care to a vulnerable population. In a climate in which insurance will become more widespread, the public health sector will be repositioning itself with respect to
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466 ❘ Journal of Public Health Management and Practice ensuring access to care. Our data suggest that publicly funded health programs may still play a vital role in partnership with private providers to ensure that women and others with newly acquired financial access are able to successfully navigate a newly configured and possibly even more complex health care delivery system. REFERENCES 1. Rosenbaum S. The Patient Protection and Affordable Care Act: implications for public health policy and practice. Public Health Rep. 2011;126(1):130-135. 2. Institute of Medicine. The Future of Public Health. Vol 88. Washington, DC: National Academies Press; 1988. 3. Institute of Medicine. Primary Care and Public Health: Exploring Integration to Improve Population Health. Washington, DC: National Academies Press; 2012.
4. Reich M. Public-Private Partnerships for Public Health. Cambridge, MA: Harvard Center for Population and Development Studies; 2002. 5. Shortell SM, Zukoski AP, Alexander JA, et al. Evaluating partnerships for community health improvement: tracking the footprints. J Health Politics, Policy and Law. 2002;27(1):49-91. 6. Bloomfield P. The challenging business of long-term publicprivate partnerships: reflections on local experience. Public Admin Rev. 2006;66(3):400-411. 7. Minow M. Public and private partnerships: accounting for the new religion. Harvard Law Rev. 2003;116:1229-1270. 8. Shortell SM, Gillies RR, Anderson DA, Erickson KM, Mitchell JB. Remaking Health Care in America: Building Organized Delivery Systems. San Francisco, CA: Jossey-Bass; 1996. 9. Levy AR, Bruen BK, Ku L. Health care reform and women’s insurance coverage for breast and cervical cancer screening. [Erratum appears in Prev Chronic Dis. 2012;9. http://www. cdc.gov/pcd/issues/2012/12 0069e.htm.] Prev Chronic Dis. 2012;9:120069.
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