1. Nathan Hale, PhD Assistant Professor (Research) Deputy Director, South Carolina Rural Health Research Center

2.  Population based public health =  Current landscape – many remain DSP 50% Family Planning 46% Immunizations 33% EPSDT 20% Managed Care (Medical Home)

3.  Economic Recession Driven further into clinical services?  Healthcare Reform Catalyst for re-examining priorities – discontinue?  Transitions occurring more frequently

4.  Two critical questions: What happens when the transition is made? o Receipt of services? o Population based health outcomes? o Different for rural communities? How do you mitigate the potential impact?

5. Hale, N. Smith, M, Hardin, J. Martin, A. American Journal of Public Health. 2015 Apr;105 Suppl 2:S330-6

6.  SCDHEC – State public health agency 1995 -> SCDHEC 40% of EPSDT Market Mid 1990’s -> Transitioned EPSDT services Some targeted transitioning -> mostly attrition

8.  Data Retrospective cohort of infants enrolled in Medicaid 1995-2010 Eligibility / billing data Continuous Medicaid enrollment for 12 months  Data Structure Repeated Cross-sectional Rolling Panel

9.  Dependent Any EPSDT visit (dichotomous) Ratio of Observed to Expected EPSDT visits  Independent Time (0-15) SCDHEC Market Share o High (>60%) | Average (20-59%) | Low (<20%) Rural Residence (Urban Influence Codes) o Urban o Rural

10. Time Invariant  Maternal race/ethnicity  Maternal age  Maternal education  Special health care needs Time Variant  FQHC/RHC penetration  Private sector capacity  Managed Care penetration  Medicaid enrollment  Reimbursement

11.  Growth Curve Models Fixed o Time | SCDHEC Market Share | Rural o Other Time-variant | Time-invariant Random o County | Time 3-way interaction (Time | SCDHEC | Rural)  Stata – xtmelogit | xtmixed Predicted probabilities | Marginal means

13. UrbanRural Any EPSDT # of EPSDT Visits

14.  Urban -> stabilized -> ultimately improved Primary Care Infrastructure  Rural -> steady deterioration -> yet to recover Historically underserved | limited primary care Note: Rural = 10% of the study population

15.  Rural LHDs & ACA (tough position) Increased demand + constrained supply = deeper into safetynet & direct service provision  Transition may be very difficult Potential to exacerbate existing resource voids  FQHC | Medical home initiatives

16.  Retraction of clinical services = Impact  Real Question – What is tolerable impact?  PPACA + Recession -> Increasing demand How can LHDs really make this transition? Targeted retraction of clinical services probably the more likely scenario (ie Family Planning Study)  PPACA + Recession -> Increasing opportunity FQHC | Medical Home | Population health funding

17. Nathan Hale, PhD. Research Assistant Professor, Dept of Health Services Policy & Mgmt Deputy Director, South Carolina Rural Health Research Center halen@mailbox.sc.edu (803) 576-7384