1. Comparison of two Methods for Estimating the Costs of Environmental Health Services Provided by LHDs in North Carolina Simone Singh 1, Nancy Winterbauer 2 and Ashley Tucker 2 1 University of Michigan Department of Health Management and Policy 2 East Carolina University Department of Public Health

2. Acknowledgements We would like to thank the finance officers and environmental health managers who provided cost information for this study. Funding for this study was provided by the Robert Wood Johnson Foundation (Grant Number 71131).

3. Context All 85 LHDs in North Carolina are required to provide a defined set of mandated public health services. Little is known about the costs of providing these mandated services. Cost information would allow practitioners to: – Make better programmatic decisions – Achieve greater efficiency in the provision of services – Establish a fee schedule that ensures adequate revenues – Demonstrate the need for funding

4. Research Aim Estimate the costs of the mandated public health services using different costing methods Focus of this study was on the following environmental health services: – Food, lodging and institutional sanitation – Individual on-site water supply

5. Data and Sample Data sources: – Cost survey – NC Department of Health – 2010 and 2013 NACCHO Profiles – Census Sample consisted of 15 of the 85 LHDs in NC (serving 18 of a total of 100 counties). Data was collected for fiscal year 2012.

6. Cost Survey Based on Substance Abuse Service Cost Analysis Program (SASCAP) developed by RTI. Asked participating LHDs for the following information, by service line: – Number of services provided – Direct labor costs – Other direct costs (building, supplies, subcontracts, miscellaneous) – Indirect costs

7. Data Collection To date, 15 (of 16) LHDs have completed the tool. – Respondents included finance officer and environmental health manager/staff. – Time required to complete the tool ranged from 2 to 12 hours (median = 4 hours). All LHDs received follow-up phone calls to clarify responses and obtain additional information.

8. Participating LHDs

9. Characteristics of Study Counties CharacteristicStudy Counties (n=18)Total NC Counties (N=100) n%N% Population Size Small (up to 50,000)73947 Medium (50,000 to 100,000)84426 Large (over 100,000)31727 Geographic Region East52841 Piedmont73935 West63324 Population Density Rural (<40)0 010 Semi-Urban (40 to149)12 6654 Urban (≥ 150)6 3436 % of Population classified as Rural < 50% classified as rural63436 ≥ 50 classified as rural126664

10. Results: Services and Staffing Number of Services Median (IQR) Number of FTEs Median (IQR) Number of Services per FTE Median (IQR) Food and lodging 2,442 (1,107 – 3,339) 4.5 (3.0 – 6.0) 495 (350 – 814) Onsite water and wells 5,704 (1,901 – 7,272) 4.5 (3.0 – 6.75) 861 (481 – 1,745) Combined 7,761 (3,980 – 10,719) 9.0 (6.0 – 12.0) 655 (437 – 1,109)

11. Results: Cost Estimates Total Cost Median (IQR) Cost per Service Median (IQR) Cost per Capita Median (IQR) Food and lodging $287,624 ($191,108 - $463,987) $145 ($119 - $186) $3.38 ($3.06 - $4.77) Onsite water and wells $347,153 ($232,236 - $516,574) $82 ($57 - $162) $4.40 ($3.24 - $6.90) Combined $659,873 ($423,344 - $971,982) $105 ($71 - $166) $8.51 ($6.68 - $11.67)

12. Correlation Analysis Food and lodgingNumber of services Number of FTEs 0.67** (0.006) Cost per service-0.48 (0.07) 0.19 (0.51) Note: Tables show Spearman’s correlation coefficients with p-values in parentheses. ** indicates p<1%. Water and wellsNumber of services Number of FTEs 0.43 (0.11) Cost per service-0.75** (0.001) 0.09 (0.76) LHDs that provided more FL services also provided more WW services. LHDs that incurred higher costs per FL service also incurred higher costs per WW service, and vice versa.

13. Relationship between Volume and Costs

15. Cost by LHD Characteristics CharacteristicCost per service Food and lodging Cost per service Onsite water and wells Scale of environmental health service provision Below median (<7,761)$166$137 Above median (>7.761)$142$75 Scope of environmental health service provision Below median (<40%)$232$242 Above median (>40%)$141$77 Percent of total funding obtained from local sources Below median (<70%)$145$118 Above median (>70%)$151$80

16. Cost per Service by Community Characteristics CharacteristicMedian cost per service Food and lodging Median cost per service Onsite water and wells Population size Small (<50,000)$154$105 Med (50,000 – 100,00)$123$74 Large (>100,000)$175$118 Population density Semi-urban (<150/sq mi)$154$80 Urban (>150/sq mi)$145$162 Square footage of service area Small (<550 sq mi)$166$137 Large (>550 sq mi)$143$71

17. Composition of Costs Food and lodging Onsite water and wells Direct costs93.9%94.5% Labor83.7%80.2% Rent2.6%2.4% Supplies 4.8%6.7% Subcontracts 0.0% Miscellaneous 1.3%2.1% Indirect costs 6.1%5.5% Total costs 100%

18. Cross-Validation of Cost Estimates Total Cost Median (IQR) Cost per service Median (IQR) Cost per capita Median (IQR) Survey data $659,873 ($423,344 - $971,982) $105 ($71 - $166) $8.52 ($6.01- $23.85) Administrative data $707,404 ($183,967 – 1,146,056) $109 ($70 - $425) $8.69 ($5.50 - $18.14) Correlation of cost estimates 0.88 (p<0.001) 0.50 (p=0.056) 0.83 (p<0.001)

19. Limitations Sample represented a convenience sample and was small. Data was collected for one year only. Generating cost estimates was complicated as NC LHDs – Use budget procedures that do not easily lend themselves to splitting program costs; – Generally do not pay rent; – Had difficulty identifying indirect/overhead costs. Service lines were aggregate categories of several different services; data did not allow costing each service individually.

20. Understanding costs is crucial for decision making regarding how to best organize and finance public health activities at the local level. Available data often lack the detail needed to allow practitioners to estimate and benchmark their costs. More detailed data can be obtained via costing tools. Completing costing tools is challenging due to lack of uniform approach to report financial information and limited personnel. Implications for Policy and Practice

21. Research Team Researchers – Nancy Winterbauer (Research Co-PI) East Carolina University – Lisa Macon Harrison (Practice Co-PI) Granville-Vance LHD – Simone Singh, University of Michigan – Katherine Jones, East Carolina University – Ashley Tucker, East Carolina University – Patrick Bernet, Louisiana State University Advisory Committee – Local Health Departments: Sue Lynn Ledford, Colleen Bridger, and Amy Belflower Thomas – NC Division of Public Health (DPH): Joy Reed – UNC-Chapel Hill: Dorothy Cilenti (NCIPH)

22. Thank You! Contact information: Simone R. Singh, PhD singhsim@umich.edu (734) 936-1194