RICHMOND – A scathing new report by the Joint Commission on Health Care (JCHC) found that Virginia ranks 38th nationally in public health spending per capita and that the commonwealth is one of just seven states that decreased total public health funding in the months before the COVID-19 pandemic.
According to the report, which JCHC officials presented at a meeting of the bipartisan commission in Richmond last week, there currently is no system in place to hold local health departments accountable. The study also found that many departments are in desperate need of additional support for information technology and workforce, and current state funding of local health departments does not account for the true service costs and community needs, leaving localities to pick up much of the tab.
Colin Greene, the state health commissioner, said in an email that the JCHC report revealed that Virginia is not competing with other states and the private sector on employee compensation. “Less competitive salaries combined with the rigorous demands of public health result in high staff vacancy rates and recruitment challenges. Virginia’s ranking is not a surprise but a somber reminder of the investments we need to make in public health,” Greene said.
To address these findings, JCHC staff has laid out 11 policy options for the commission to consider, among them the recommendation to amend state law to include all core public health areas, direct the Virginia Department of Health (VDH) to design a management process for local health departments, develop a plan for centralized data infrastructure, support recruitment and retention with a student loan repayment program, and have targeted salary increases for employees of local health departments. Staff also recommended increasing environmental health inspection fees and establishing civil monetary penalties for businesses or facilities in violation as a means to create more revenue.
“The goals of the study were to catalog and compare public health services provided by local health departments across the state, identify standards used to evaluate the quality of local health departments, and identify if Virginia health departments are meeting these standards, compare local health departments’ structure and financing to other states to identify advantages and disadvantages, and recommend any necessary changes to how Virginia structures and finances public health,” Kyu Kang, associate health policy analyst with the JCHC, told the commission at last week’s meeting.
Virginia currently has 118 local health departments that are organized into 35 health districts. Each district is led by a health director, who reports to the deputy commissioner of Community Health Services at the VDH. While the staff at local health departments and district managers report to their health director, they also maintain relationships with central office staff.
Most Virginia health districts are multi-jurisdictional, meaning they have anywhere from two to 10 localities and local health departments within them. Of the 35 health districts, 11 are single jurisdictions with only one locality and one local health department.
“Every local health department operates via a Local Government Agreement, which is a contract between the VDH central office and each locality. The agreement outlines how much funding each locality receives, as well as the state-mandated services and the locally required services the department provides,” Kang said.
There are four main governing structures states can use to manage and administer their governmental public health – centralized, decentralized, mixed and shared. “The different models are distinguished by whether the state or local government ultimately is responsible for leadership, issuing public health orders, and making fiscal decisions,” Kang said.
Virginia currently follows a largely centralized governing structure. All but two local health departments are led and managed by the state. Only Fairfax and Arlington are locally administered, meaning that while they still operate via contract with the VDH, the localities take on the primary responsibility for cost and infrastructure, including employee salaries. Three additional localities – Manassas and Loudoun and Prince William counties – are currently in the process of moving to become locally administered.
“In assessing how Virginia structures public health, JCHC staff found there is no recognized best model for local health departments,” Kang said. “There are potential advantages and disadvantages of each model, and regardless of structure, there are nationally recognized frameworks that outline the best practices for what governmental public health departments should be doing.”
While there is no right way to structure local health departments, there are nationally recognized standards for what they should be doing – all of which were developed in 2013 by the Public Health National Center for Innovations (PHNCI) to define a minimum package of public health capabilities and programs that no jurisdiction should be without. For example, localities should provide access to communicable disease control, environmental public health and maternal, child and family health.
They should also provide access to clinical care – which is not currently required under Virginia law – and chronic disease and injury prevention, which are largely not addressed either. “As a result, local health departments are not consistently providing programs and services in these areas,” Kang said.
While local government agreements do require local health departments to provide some direct clinical services, with a few exceptions most do not require any referral or linkage services.
And in recent years, local health departments have slowly moved away from providing direct services, such as primary care, prenatal care and dental care in favor of making referrals to other community providers, such as the local health system or a nearby free clinic, Kang said.
“Local health departments are more likely to continue to provide services and act as the provider as a last resort in communities where other providers are not available. If they can’t make a referral, they will continue to provide services,” she said, adding that VDH doesn’t require local health departments to provide services directly, only to ensure that services are available in the community, regardless of who is providing that service.
Another program area gap – chronic disease and injury prevention – is largely not addressed by local health departments either. “The code of Virginia does not specifically address chronic diseases, though it does outline specific state-level injury prevention programs,” Kang said.
Similarly, JCHC staff analysis of the local government agreements found few requirements for chronic disease or injury prevention work. “Only a small number of localities list some optional services related to diabetes prevention or hypertension screening,” Kang said.
To address these shortcomings, the report recommends that JCHC could introduce legislation to amend state law requiring local health departments to ensure the availability of clinical services – either by the department or by other providers – and facilitate access to clinical care, as well as address chronic disease and injury prevention.
In order to support all of this program work, local health departments need some core foundational capabilities, Kang said. The PHNCI’s Foundational Public Health Services (FPHS) model outlines eight key foundational capabilities that should be present. “These are core organizational skills and capacities that local health departments should have to support their work.”
According to this model, three areas need attention in Virginia – accountability and performance management; information and technology services; and workforce development. “These are issues that significantly impact the effectiveness of Virginia’s local health departments,” Kang said.
Four additional areas need at least some support, including financial management and contract and procurement services; communications; community partnership and development; and policy development and support. “These are issues that would further enhance the work that local health departments are doing, but are of lower priority,” Kang said.
The report found that Virginia currently has no system to manage accountability and performance of local health departments. “The local government agreements are contracts that outline all state and locally mandated services that local health departments will provide. While the local government agreements between the state and localities could be a primary accountability mechanism, currently they are treated more as a formality,” Kang said. “It’s just paperwork that is processed every year,” she said.
There is also a large amount of data being collected related to local health department programs and services, but the metrics are primarily administrative – meaning they are program specific and don’t provide insight into the health department’s overall performance. “This means it’s difficult to identify which local health departments are generally doing well and which are struggling. When asked which are the best health departments in the state, answers are mainly anecdotal,” Kang said.
Some states have taken a different approach to monitoring their local health departments. Ohio, for example, requires all local departments to apply for national accreditation, while Iowa, North Carolina and Michigan have established their own accreditation programs. And in Washington state, lawmakers have codified a limited set of core public health services that must be present in every community.
In order to streamline the oversight of health departments in Virginia, the JCHC proposes to introduce legislation directing the VDH to design a state performance management process for each local health department, with the goals of assessing the ability of each to meet minimum capacity requirements, assisting in continuous quality improvement, and providing a transparent accountability mechanism to ensure that public health functions are being met.
“As a centralized public health system, local health departments are an extension of the Virginia Department of Health,” Kang said. “The state should have an understanding of what is happening at the local level.”
Another challenge is the local health departments’ siloed and outdated data systems that often hinder effective service delivery. While the VDH has been working to improve the state’s data systems, local health departments often operate without the appropriate technology and data supports that would be expected in 2022, the report found.
“None of the state administered local health departments have an electronic health record system. All medical records are still on paper, and if patients are going to be seen in a different office, those records have to physically be driven between offices,” Kang said.
And because in rural localities broadband access is still a fundamental challenge, local health departments in those areas cannot fully utilize any new or updated IT solutions.
“All this means, the VDH central office cannot easily access data from all localities and from all programs in one centralized system,” Kang said. “This limits data sharing internally, between departments, as well as externally with the public and other stakeholders.” To address these gaps, the JDHC proposes legislation to direct the VDH to develop and submit a plan by Nov. 1., 2023, for the development of a centralized data system.
Finally, the local health department workforce requires immediate attention, the report found. “In the last 10 years, we have seen an 11% decline in full-time salaried VDH central office and local health department staff,” Kang said. “This isn’t surprising, as there has been a general national decrease following the Great Recession. However, nationally there has been an upward trend since 2016 in staffing numbers that we have not seen in Virginia.”
The recruitment and retention of employees remains a significant challenge in the commonwealth. In Fiscal 2022, the vacancy rate was 18.6%, or 701 positions at the VDH central office and across local health departments. In Fiscal 2020 – prior to the pandemic – vacancy within districts ranged from 4.6% in Piedmont to 35.2% in Southside.
“These vacancies put additional pressure on remaining staff for often traveling long distances sometimes between local health departments in their district to provide coverage for each other,” Kang said. “The problem also affects the leadership level, as health departments continue to struggle to fill empty health director positions.”
Earlier this year, the General Assembly passed Senate Bill 192, which expands the qualifications of health directors from physicians only to include applicants with advanced public health degrees. “It’s still too early to tell whether this legislation has helped with director recruitment, but as of this summer, there were 10 multi-jurisdictional health districts comprising 35 local health departments that were operating with temporary leadership,” Kang said, adding that this issue is “particularly relevant” in Southwest Virginia, where one director covers four districts, “pretty much everything left of Roanoke City.”
Cardinal News first reported last November that three health districts in Southwest Virginia had no permanent director, and the state continues to have trouble filling these vacancies. This left Dr. Noelle Bissell, who is in charge of the New River Health District, with also taking on the leadership roles – in acting capacity – of the Mount Rogers, Cumberland Plateau and Lenowisco districts, the latter being more than 150 miles from Radford, where Bissell is based.
“Health departments rely heavily on their directors for day-to-day operations,” Kang said. “Long-term experienced directors are able to provide stability, more established community relationships, and institutional knowledge to their staff.”
Exit data for VDH employees also shows that resignation rates have increased in the last decade and are highest for public health nurses and office services specialists. According to the data, between 2012 and 2021 resignation rates for the latter have increased from 3 to 14% and for the latter from 6 to 14%.
The JCHC report has identified low pay as the primary reason for why the VDH cannot fill these vacancies, followed by budget and funding issues.
Reasons local health districts cannot fill open positions
“One of the things that I have seen at the local health departments in Northern Virginia is that the salaries that are set by the state for the people who work in the local health departments are not adequate to be able to fill those positions,” said Sen. George Barker, D-Alexandria, chairman of the commission.
Local health departments have difficulty competing with other healthcare providers, in particular for nurses and environmental specialists who require specialized training, making high turnover a significant challenge. And office services staff service all the departments and are responsible for multiple, critical administrative responsibilities, but they make a median state salary of less than $35,000.
“Specific barriers for recruitment and retention differ for each position type, but ultimately come back to compensation,” Kang said. “A targeted salary increase for a local health department employee would assist with both recruitment and retention. It would not only improve satisfaction for tenured staff, but it would also allow local health departments to make more competitive offers closer to industry averages.”
And John Littel, Virginia Secretary of Health and Human Resources, told the panel that the problem of vacancies affects the VDH central office as much as the local health departments.
“One specific example is our office of Chief Medical Examiner; we have eight vacancies out of 20, those vacancies have been there for 14 months. So you can imagine we still have the death rate that we have to keep up with,” Littel said.
Virginia’s medical examiners are often being recruited by neighboring states offering a salary increase of 100%, Littel said. “It’s very difficult to maintain the professionalism that we need in the health department both at the local level and the state level. So a lot of these recommendations also apply to the state.”
In addition to salary increases, JCHC staff believes that student loan repayment programs could support workforce retention, because research of physician retention programs found these programs to be an effective incentive more so than offering scholarships to students to commit them ahead of time.
“VDH could offer a loan repayment program grant to public employees who agree to work full time in a local health department for a specific contract period,” Kang said. For example, each employee could receive $5,000 in loan repayment for every year they sign with a local health department, with a maximum cap of $20,000 over four years.
The report found Virginia currently ranks 38th nationally in terms of public health spending per capita, based on combined federal and state spending, although measuring public health spending across the states is not precise, because there are differences in how states structure public health or what states consider included in public health.
However, the majority of public health funding comes from federal dollars. When adjusted for inflation, general health fund appropriations have stayed relatively flat with minimal variation year over year. Non-general funds tend to fluctuate but increasingly make up a larger share of the VDH’s total budget. “In 2021, the department saw a large infusion of federal COVD-19 pandemic funding,” Kang said.
Del. Sam Rasoul, D-Roanoke, a member of the commission, called Virginia’s low ranking very concerning, “especially not only with the large reserves that we have, but the excess funds.”
Virginia needs to make significantly more investments in public health, especially in Southwest Virginia, Rasoul said. “We’re just not investing in our people. It is clear that someone can take a lower skilled position and make about the same amount of money that they would make in public health,” he said. “We absolutely cannot be funding tax cuts that primarily help the upper class while we have so many investments that we have to make. We need to be smart, especially after just having $4 billion worth of tax cuts just this year.”
But state Sen. David Suetterlein, R-Roanoke County, who also sits on the commission, said that Virginia can do both.
“Secretary Littel talked about the need in the last few years, separate from the pandemic, to bolster the resources we have there, and I think the Youngkin administration is going to work hard on that,” Suetterlein said. “And at the same time we can provide tax relief, because there has been substantial systematic overtaxation here in the commonwealth, and a lot of it is the working folks, and that’s why we would like to see the standard deduction increased. We had some success moving it, but we should continue doing so.”
Funding per capita looks very different across local health departments and is based on three main funding sources – state general funds, matching funds from their local governments and self-generated revenue. These three sources make up the cooperative budget. “The majority of health departments have $20-39 per capita in coop budget funding,” Kang said.
There are three key factors that explain why there are such variations in funding across localities.
“The size of localities makes a difference. In rural localities where the population may be smaller there tends to be a higher per capita funding number, which could indicate there are some core function structures that are just fixed cost,” Kang said.
Secondly, localities vary in their ability to provide local funds. The state and local governments determine how much proportionally they will each contribute to the local health department budget. Even if the state is willing to provide additional funding, in some cases the locality can’t provide their appropriate determined proportional match, prompting the state to reduce how much funding to give to the local health department until the appropriate state-local match balance is achieved.
Another factor is that community needs and availability of providers vary quite a bit. “Rural areas rely quite a bit more on their local health departments to provide some service, and those health departments are more likely to generate their own revenue based on environmental and clinic services they are providing, because they can’t refer patients out,” Kang said. “Even though all these factors may change over time as communities grow and localities’ taxes situations change, multiple department funding has been pretty consistent, they are based on historic numbers and current needs.”
A possible solution would be to monitor these variations in funding in relation to each locality’s needs, because it would help VDH officials understand whether there are funding disparities that need to be addressed. “The JCHC could introduce a bill directing the VDH to track cooperative budget funding per capita, and make appropriate adjustments as additional funding is made available,” Kang said.
Local health departments could also generate their own revenue sources from vital record requests for residents, like death certificates; long term services and support screenings paid by Medicaid, fees and inspections from regulated industries – such as restaurant inspections – and insurance reimbursements from Medicaid and commercial insurance for clinical services.
“Clearly the legislature can step in and address some of these issues,” Barker, the panel’s chairman, said in an interview after the meeting. “What I talked about with the local supplements here, why are we telling the localities that they are on their own? We’re not sharing in getting the salaries up to where they should be. We might do that in the next session.”