Public Health Entrepreneurship Peter D. Jacobson, JD, MPH University of Michigan School of Public Health Jeffrey Wasserman, PhD RAND Corporation Presented to Emerging Findings in PHSSR 24 June 2011

Project Overview Purpose is to describe and classify existing public health entrepreneurship (PHE) Assess feasibility/desirability of PHE PHE defined broadly as generating revenue or efficiencies to invest in new services or improve financial stability Project asks fundamental questions regarding the organization and delivery of public health services

Primary Research Questions Activities public entrepreneurs pursue to generate new sources of revenue/service delivery innovations Resulting organizational adaptations Population health care case for PHE Alternative organizational structures needed to facilitate PHE Internal and external barriers to change

Methods Qualitative interviews o 31 local health departments (LHDs) o 4 public health institutes (PHIs) o 3 fiscal sponsor organizations o 5 health authorities o 3 port authorities o 5 major national public health organizations

Key Findings: Public Health Considerable entrepreneurial activity among health departments o Efficiency improvements in clinical services o Has not generated easily replicable or sustainable strategies o Revenue sources from clinical services, not core/essential public health services o Opportunities include Affordable Care Act provisions if fully funded

Key Findings: Public Health Barriers to PHE o Political constraints o Civil service constraints o Budgetary constraints o Risk-averse culture o Concern that PHE would undermine core values

Key Findings: Alternative Organizations Dominant PHE activity occurs in PHIs, fiscal sponsors, and health authorities o Avowedly entrepreneurial o Represent different model for public health services o Common denominator is some form of political independence Revenue sources primarily back-office support o Funds leveraged to compete for grants/programs

Key Findings: Alternative Organizations Large cultural gap between health departments and other organizational types o Goal for each is to improve population health o Fundamentally different approaches – core public health values vs. entrepreneurial model Politicians may balk at ceding political control or allocating tax revenue

Key Findings: Summary Fundamental shift may be underway o PHIs, etc., as vital feature of governmental public health o Competitors vs. collaborators o Collaboration now dominant, but tension emerging

Questions for Public Health Practitioners and Advocates to Consider Is PHE either desirable or necessary to sustain governmental public health? Which services must remain with government, which can be shifted to private sector? Are PHIs, etc., temporary solutions to short-term fiscal realities, or leading edge of disruptive transformation? Should/can public health be integrated into medical care delivery system without losing core values?

Recommendations: General Convene conference to consider above questions and develop strategy Major national public health organizations should collect data about entrepreneurial activities and results Policymakers need to reconsider the nature of political control over public health

Recommendations: Practitioners Rethink relationships to private medical care sector Examine whether current structure is optimal and sustainable Study whether entrepreneurial organizations provide similar services more efficiently with at least equal outcomes as health departments

Conclusion Population health case for PHE not yet made Changes occurring are potentially disruptive Pressure on governmental public health to show value