Budget Cuts: Friend or Foe to Population Health Collaboration?

The articles by Costich, Scutchfield, and Ingam thoughtfully discuss the complexity of public health agency (PHA)–accountable care organization (ACO) partnerships.^1,2 Throughout, financial constructs oscillate between inhibitors and activators of PHA–ACO collaboration. On one hand, “the business case and financing mechanism” is the most difficult challenge to forging a relationship.¹ On the other hand, austerity for public health funding can motivate PHAs to explore such partnerships.^2,3 Yet the nuanced consideration not raised by these authors is how shrinking public health budgets can damage the formation and sustainability of such collaboration.

Consider tobacco cessation treatment, which is often cited as the gold standard of preventive services because evidence-based treatments are highly cost-effective.⁴ Yet providers, including ACOs, struggle with how to implement these services systematically. The Institute of Medicine identified cardiovascular health promotion, including tobacco cessation, as an area ripe for partnership, and a key recommendation of the Clinical Practice Guideline focuses on utilizing health care to increase access to quitlines, which exist in every state.^4,5 With this opportunity for PHA–ACO collaboration, providers can partner with quitlines and “actively refer” patients for telephone counseling. Studies of patients’ engagement in treatment with such partnerships are promising.⁶

Integration to address tobacco cessation requires redesigning components of clinical care. At best this means an automated digital referral via an electronic medical record, but most often require a more time-consuming manual referral process. At a time when clinical team capacity is strained, new tasks must be added cautiously and workflow changes take time to plan, negotiate, and implement. What if, after establishing a PHA–ACO partnership, there is a budget cut, as occurred in Illinois earlier this year, causing severe disruption to quitline service?⁷ This uncertainty could undermine the trust, hard-work, and financial investment that created the partnership. Once done, this interference cannot be easily undone, and may cause unwillingness to explore future integration.

True, collaboration may result in new revenue streams down the road for PHAs, but this partnership needs to be built on sound financial infrastructure during planning and implementation. At a time when state budgets are in dire straits, states cannot afford to interfere with the financial stability required to promulgate PHA–ACO collaboration and its promise of the triple aim.

Building the foundation of an PHA–ACO collaboration requires fiscal stability on which to cultivate innovation. That is why the shrinking public health budget is both a friend and foe to integration.