The Evolution of Public Health–Hospital Collaboration in the United States

Collaboration refers to relationships in which two or more independent parties voluntarily decide to work together to address a common purpose. Collaborative arrangements take many forms, from informal, nonbinding agreements for information sharing on topics of mutual interest to formal alliances that entail the creation of new organizational entities, substantial financial investments, and long-term legal commitments.

In the health field, the spectrum of collaborative endeavors is wide and diverse. An important segment of this spectrum consists of collaborative arrangements among public health agencies, hospitals, and other parties (e.g., school systems and businesses) that unite to address one or more health issues and improve the culture of health in their communities. Evidence suggests that such collaborative partnerships can have beneficial collective impact. ^{1 –3} Our work focuses on public health–health care collaboration and not the broader issue of public health–health care integration.

The history of collaboration between the public health and hospital sectors is mixed at best; although close, mutually beneficial partnerships exist in some U.S. communities, they are not prevalent across the United States. We offer our perspective on past collaboration between the public health and hospital sectors, review emerging patterns, and discuss future prospects for these patterns.

Past Public Health–Hospital Collaboration

Between the 1930s and 1990s, a schism developed between the public health sector and the hospital and medical care sector. ^4,5 Among the contributing factors to this rift were (1) the development of employer-sponsored health insurance plans during and after World War II focused almost exclusively on financing hospital and medical services; (2) the enactment of the Social Security Amendments of 1965, ⁶ which established the Medicare and Medicaid programs and infused vast resources into the hospital and medical care sectors; (3) continuing advancements in medical science and technology that have captured public interest and generated increasing demand for hospital and medical services; and (4) growing asymmetry in funding, prestige, and societal views of private-sector medicine and hospitals in relation to public health. Over time, these developments contributed to growing disparities in funding support, differing priorities, gaps in communications and mutual understanding, and cultural rifts that impeded cooperation and collaboration. ⁷ For the most part, the public health sector and the hospital and medical care sectors coexisted in different worlds, aware of each other’s existence but largely working independently.

Recognizing the Need and Opportunities for Collaboration

By the 1990s, the gulf between the public health and health-care sectors and the potential benefits of building bridges between them had become apparent. For example, in 1994, the American Public Health Association and the American Medical Association established the Medicine/Public Health Initiative with the purpose of determining why public health and medicine were functioning as “separate and virtually independent components of the American health system” and identifying opportunities for closer working relationships. ⁸ Unfortunately, these early initiatives did not endure, and meaningful multisector collaboration developed slowly in most parts of the United States. ^9,10

In recent years, however, mounting evidence suggests that fundamental changes in America’s health policies and practices are needed to reduce health expenditures and create a healthier population. A striking paradox in America’s health-care system exists: although U.S. per-capita health-care expenditures exceed that of other developed nations, our population’s health on most indicators is substantially lower. It is clear that:

Our traditional focus on the care and treatment of individuals, although worthy and beneficial in some ways, has not resulted in an efficient health-care system. To overcome this deficiency, we must place greater importance and exert greater effort on population health approaches that assess and improve the health of defined population groups and communities. ¹¹

Achieving long-term impact on the health of population groups demands focused attention on the full range of factors—educational, environmental, genetic, lifestyle, and socioeconomic—that influence them. ¹² Improving access to medical and hospital services and striving to enhance the efficiency and quality of those services are both important but, individually, are insufficient strategies. ³

In both the public and private sectors, addressing these imperatives will require better communication and more collaboration among the public health community, hospitals, and key stakeholders in the business, health insurance, education, social services, and other sectors. This need is emphasized in reports by the American Hospital Association, ¹³ the Institute of Medicine, ^{14 –16} the Robert Wood Johnson Foundation, ¹⁷ and the Trust for America’s Health. ¹⁸

The value of collaboration between public health agencies and hospitals was recognized in the Patient Protection and Affordable Care Act of 2010. ¹⁹ As a result of one provision, the Internal Revenue Service (IRS) now requires tax-exempt hospitals to conduct community health needs assessments at least every three years in cooperation with people and groups, including a public health department or equivalent agency, that represent the broad interests of the community. The IRS also requires the development of plans that address priority needs and public access to these plans. In a complementary fashion, the Public Health Accreditation Standards require local health departments to assess, prioritize, and address community health needs in cooperation with other regional stakeholders. ²⁰

Several states, including Maryland and New York, adopted policy positions and instituted programs aimed at facilitating collaboration among health agencies, hospitals, and other local stakeholders as community health improvement plans are conceived. ³ Similar policy initiatives are underway or being planned in other states. ²¹ The growing interest in multisector initiatives is also reflected in private foundations’ establishment of programs that fund collaborative efforts to improve community health in selected communities around the country. ^{22 –27} The hope is that these grant programs will accelerate the development of successful collaboration in several communities and, over time, yield knowledge, experience, and tools that will be useful in other U.S. communities.

Similarly, the Association of State and Territorial Health Officials (ASTHO), working with Duke University and the de Beaumont Foundation, developed the ASTHO Integration Forum to promote discussion on primary care and public health collaboration. ²⁸ In addition, several federal agencies established initiatives focused on collaboration; for example, the Agency for Healthcare Research and Quality developed metrics for integration, and the Centers for Medicare & Medicaid Services designed models for improving coordination between health care and public health, including the State Innovation Models Initiative ²⁹ and the Accountable Health Communities model. ³⁰

A complete inventory of collaborations that involve public health agencies, hospitals, and other stakeholders devoted to assessing and improving the health of their communities is not available. In addition, no systematic process is in place to track the establishment or performance of such collaborations. Growing interest in and support is based on potential benefits to the community and participating organizations. However, establishing and maintaining collaborative partnerships is challenging. Studies in business, health, higher education, and other sectors indicate that about half of the partnerships involving multiple independent organizations fail. For example, in a study of 661 multisector partnerships created to improve community health in several U.S. locations, only 297 (45%) were successful. ^2,3 The likelihood of success may depend on such elements as a clear statement of the partnership’s mission and goals, trust and respect among the partners, qualified leaders who encourage collaboration and are dedicated to accomplishing the organization’s goals, metrics for evaluating objectives, and a process for ongoing reflection and improvement. ³

In a study we conducted in 2013–2014, we examined 12 successful partnerships that involved public health departments, hospitals, and other stakeholders devoted to addressing health issues and improving the health of their communities. Although the 2013–2014 study was limited in scope, we identified key lessons learned from the collective experiences of these multisector partnerships, all of which had been in operation for several years, and we generated evidence-based recommendations for establishing multisector partnerships. ^31,32

Objective information on the operational performance and effectiveness of multisector partnerships and their impact on community health targets is scarce. Agreed-upon metrics and processes for assessing the performance of partnerships are not in place. ^33,34 Many partnerships in our study cited the development of meaningful metrics and objective measurement of their partnerships’ impact on the health of their communities as one of their greatest operational challenges. ³

Future Prospects and Priorities

A major paradigm shift is taking place in the United States: health service providers, public and private payers, state and federal policy makers, and the general public understand that improving the health of our nation depends on changing the way we practice, organize, and structure our health delivery and evaluation systems. The arguments for developing collaborations among public health agencies, hospitals, and other stakeholders are powerful. The recent groundswell of interest in and support for multisector partnerships is encouraging, and the prospects for collaboration are bright in many communities.

However, in many other communities, communication and collaboration among public health agencies, nongovernmental hospitals, and other stakeholders are weak. Where multisector partnerships do exist, solid, objective data demonstrating their impact on key measures of community health are limited. We need better, more useful metrics and methods to establish targets for community health improvements. The organizations that establish and operate collaborative partnerships, the parties that provide economic and non-economic support, and the communities they serve deserve objective information on the impact of multisector partnerships on community health and cost measures.

Progress has been made in improving tools for setting targets and measuring progress. For example, the Institute of Medicine’s 2015 report, “Core Metrics for Health and Health Care Progress,” ³⁵ and the Robert Wood Johnson Foundation’s 2015 report, “From Vision to Action: Measures to Mobilize a Culture of Health,” ³⁶ help set targets for community health improvement and measure progress toward their achievement. However, much work remains.

Systematic evaluation of the performance of existing partnerships is necessary to demonstrate their value and justify sustained funding. These evaluation processes also will generate knowledge, lessons, and tools that can be invaluable in developing successful multisector collaboration in other communities. At the local and state levels, public health leaders have an opportunity to play a critical role in stimulating and guiding these evaluation efforts and ensuring that the findings are shared widely and used carefully to shape the future development of multisector collaboration focused on improving the health of communities in the United States.