Setting Out the Framework for Public Health Finance: Spotlight on Dr. Peggy Honoré
by Sheryl Monks
“I was the Vice President of Finance and Administration for a two-year campus of a four-year university system. So I understand quite well the role community colleges play in educating the workforce in America, not only the role but the value.” JPHMP Spotlight Peggy Honore
This July, we shine the spotlight on JPHMP editorial board member Dr. Peggy Honoré. Dr. Honoré has been a member of the editorial board since 2005. She is the AmeriHealth Caritas-General Russel Honoré Endowed Professor at Louisiana State University Health Sciences Center School of Public Health and School of Medicine. Her experience spans a diverse range of fields, including higher education, private industry, healthcare, and public health. She is recognized for defining and advancing the study of public health finance, having held executive level corporate and public sector positions that have informed her research and practices in finance and quality improvement in the public health system. At the same time, she has developed healthcare workforce educational programs to promote improvements in individual and population health outcomes while providing the student with a career ladder as a pathway to achieving a better socioeconomic status, in addition to creating academic medical education programs that provide a hands-on opportunity to learn health policy and to integrate public health interventions alongside medical treatments to improve quality, reduce costs, and optimize health outcomes.
I had the opportunity to speak with Dr. Honoré about her impressive career and many accomplishments. Listen to the podcast or read the interview below. JPHMP Spotlight Peggy Honore
Sheryl Monks: You have a multidisciplinary background in higher education, private industry, healthcare and public health. Can you briefly share some of the positions you’ve held in public health finance as well as corporate and public-sector positions that have contributed to your research into public health finance, quality improvement, and workforce development? JPHMP Spotlight Peggy Honore
Dr. Honoré: Yes, I really do have a multidisciplinary background in finance, accounting, and business because my career actually started in private industry where I was a financial analyst, an auditor for Exxon Corporation, USA, auditing Exxon concerns throughout the US. I was also a regional controller over six states for McDonald’s Corporation where I had to critique on a monthly basis the financial position of all franchise McDonald’s restaurants in those six states. In addition, I was the CFO of the medical clinic as well as Vice President for Finance and Administration over two universities. In addition to Division Director of Finance and Administration for a state public health agency. So my background is very, very diverse, and because I got my experience in finance, accounting, and business in private industry, I’ve tried to bring those concepts that I learned through my positions in those industries for financial analysis and management to public health. So that’s really how I got entrenched in this area of research in public health. It was because of my past experiences that I brought to public health.
“[W]e worked very rigorously to educate the public health community about the value of community colleges. And that wasn’t necessarily an easy conversation to have in the beginning because the MPH was always seen as the gateway to a public health career. But when I looked at the data… when I was in the state of Mississippi, I looked at the data on the educational level of the people in the governmental public health workforce, and greater than 50 percent of the people didn’t have an undergraduate degree. It’s very difficult to go from no degree to a master’s degree if we’re saying that the MPH is the entryway.”
Sheryl Monks: In your role at LSU, you’ve created two programs for LSU medical students and residents to help advance knowledge on the integration of public health concepts into healthcare. Can you briefly describe those programs? And why is it important to integrate public health concepts into healthcare?
Dr. Honoré: We’re very excited and pleased with how the programs have gone. For the scholarships, we’re currently in our fourth summer of doing this, and with the population health management clerkship, we’re going into our third year. But the health policy fellowship program is for medical students who have completed their first year of medical school, and they participate in the fellowship in the summer after the completion of their first year but just before their second year of medical school. I created this as a way for medical students to become familiar with health policy and the health policy-making process because that’s typically not something that’s embedded in their medical school curriculum, which naturally is very much science based. But the students get to spend two months in Washington, either in Congress (like a congressional office or congressional committee, like the Energy and Commerce Committee), or with other organizations — I’ve had them with APHA before, the National Academy of State Health Policy, the National Rural Health Association. But typically, six or seven organizations a year. They get to work on policy issues relevant to that organization. They get to attend congressional briefings. In some cases, like those students sitting on the Energy and Commerce Committee, they actually participate in setting up the committee hearings. For instance, the person on the Energy and Commerce Committee got to do a lot around setting up the hearings around opioids. They got to set up hearings and briefings around the 340b prescription drug programs. This year, the person in Senator Cassidy’s office actually had been very involved in the surprise medical billing bill that was passed a week or two ago. One of the best stories I have is that we had a former NFL football player who was a medical student here at LSU. He applied for the program and he actually got to work in the Energy and Commerce Committee since they were the ones doing hearings on concussions. So who better to provide information to the committee on concussions that an LSU medical student who’d been a former NFL football player? And, as you know, policy is one of the essential public health services. So I just saw this as an excellent opportunity to have these medical students learn about the power of policy and how policy really plays a role in the context to which medicine is practiced in the US.
And the program has been very, very successful. Some of the people who have completed the program and have applied for residency… their feedback to me is that during their residency interviews, they get a lot of questions and a lot of interest about their policy fellowship in Washington. The other program is the population health management clerkship. It was actually a Medicaid managed care health plan that came to me and the dean of the medical school asking to create a program where medical schools and residents could rotate through the health plan to learn Medicaid and learn population health management. So a medical student or resident has the ability to do either one or two consecutive blocks at the health plan. And a block is typically four weeks. So they can do four weeks or two consecutive four weeks for an eight week clerkship at the health plan. There are specific areas where they can work. They can work in quality. They can work in behavioral health or medical economics, value-based contracting, health equity. But it gives them the opportunity to also, from a population health management perspective, to review data of the health plan, to identify where there are quality gaps, what is driving costs for the health plan but also for the members, and to develop an integrated plan on how to make an improvement. And in a lot of cases what they’re doing is they’re combining, or making a recommendation for combining, a medical treatment with a public health intervention. So there’s a lot of work that they do around health literacy with the providers but also with the patient population as well. They also do a lot with community engagement. For instance, we have a big problem in Louisiana, like in a lot of other states, around infant mortality and maternal mortality. One group of students developed an engagement process that they called baby showers for pregnant women in the area. And they did a lot of patient education around infant mortality and maternal mortality risk factors. There has been research that shows you have better outcomes if you target a medical condition with not only a medical treatment but also with a public health intervention as well. A paper — “Triangulating on Success: Innovation, Public Health, Medical Care, and Cause-Specific US Mortality Rates Over a Half Century (1950–2000)” — was published almost 10 years ago by Dr. George Rust at Morehouse along with the former Surgeon General Dr. Satcher. And what they did was, over a 50 year period, from 1950 to 2000, they looked at the leading causes of death and they wanted to track improvement, or lack of, those ten leading causes of death. And what they found was that of the ten, the ones that had the most improvement over that period of time, were actually the ones where the was an evidence-based medical treatment combined with an evidence-based public health intervention as well. So something like smoking where you have heavy public health intervention… that had improved, cardiovascular disease … combined with a medical treatment and a public health intervention. It was really obvious that the ones that had medical treatment plus a public health intervention had the greatest improvement over that period of time. So that’s exactly what we try to do with the clerkship… to give the medical student a platform where they can actually do that, before they go out into practice. So they leave their medical school experience actually concretely seeing how that can be accomplished. I’m almost always full in the summertime. It doesn’t start until August, but by the end of summer all my blocks are typically almost always full because it’s such a popular program with students.
Sheryl Monks:You served 8 years in the Department of Health and Human Services. Tell us about your role with HHS and your efforts to develop national concepts for quality in the public health system.
Dr. Honoré: Yes, that was one of my roles there. We really did a lot of work in that area. I think the greatest accomplishment in that was to develop a consensus statement on what exactly do we mean by by quality in the public health system. And what other concepts could be developed to go along with that to promote quality in the public health system? We published a paper in Health Affairs in 2012 to document that and also the document itself, Consensus Statement on Quality in the Public Health System. And that involved engagement from every agency under HHS at the time as well as the national public health organizations, such as NACCHO, ASTHO, APHA. So that consensus definition was developed along with the 9 aims for quality in the public health system as well. Some of that material is still being used in public health and healthcare circles as well. We just updated another chapter in the public health administration textbook, where we updated those public health quality chapters as well.
“It’s not rocket science. You just have to set out the framework that you’re going to base this on and get consensus on doing it.”
Sheryl Monks: While at HHS you funded the development of a Health Navigator Associate’s Degree prototype curriculum. Can you talk about the value of community colleges to educating the public health workforce and your role in promoting public health education in community colleges?
Dr. Honoré: I started writing about the role of community colleges in public health education about 11 or 12 years ago. One of the places where I was the Vice President of Finance and Administration was a two-year campus of a four-year university system. So I understand quite well the role that community colleges play in educating the workforce in America, not only the role but the value of that as well. While at HHS, I teamed up with Dr. Dick Riegelman, who was the founding dean of GW School of Public Health, and we worked very rigorously to educate the public health community about the value of community colleges. And that wasn’t necessarily an easy conversation to have in the beginning because the MPH was always seen as the gateway to a public health career. But when I looked at the data… when I was in the state of Mississippi, I looked at the data on the educational level of the people in the governmental public health workforce, and greater than 50 percent of the people didn’t have an undergraduate degree. It’s very difficult to go from no degree to a master’s degree if we’re saying that the MPH is the entryway. So I funded GW and the lead for innovation in community college to develop a two-year associate’s degree in health navigation. Now health navigation was simply the title of the proposed degree, but a person… once they have a degree could obviously be hired into any position. But we saw that as a way to begin to promote public health education. And that curriculum had public health content and coursework laced throughout the curriculum. So we saw that as a very important, strategic move. And since then a textbook has been written on that topic.
'Until and unless there is some mandate to report #publichealth financial data, it probably isn’t going to happen. It continues to happen with individual local #health depts. But it’s not going to happen across the country until… Click To Tweet What I’m currently very engaged in creating here in Louisiana, with the largest community college in the state, is two programs: one is a health coach certificate program that also has public health content along with content as it relates to chronic disease management and improvement and very heavily on health coaching content. Once a student completes this health coach training at the community college… if they already have an associate’s degree or if they’re already licensed, let’s say someone with a nursing degree, someone with a physical therapy degree, anyone with a degree or a license… they can sit for an exam to become board certified by the National Board of Medical Examiners. A lot of places will hire health coaches who really don’t have any formal training in health coaching, and to my surprise health coaching really is very much professionalized through a national board. The other program is the Health Navigator associate’s degree program, where let’s say a person completes the health coach program but they don’t have an associate’s degree already… they can seamlessly go right into the health navigator associate’s degree program to gain an associate’s degree where they can then sit for the national board exam as well. We see this as being important for two reasons: we see it as important because we’re committed to better patient outcomes, and in a state like Louisiana where we’re dead last, we’re 50th behind all of the other states, we feel like this is important. But also from a social determinants of health perspective, we feel it’s important because we’re giving people a career ladder. They can do the health coach certificate… they can do the associate’s degree… but they don’t have to stop there. They can continue their formal education. And as you know, there is an association to your level of education and your health status. And there are other programs for lay health workers. The distinction that we see is that this is formal, academic coursework that they can use as a career ladder to continue to improve their socioeconomic status. JPHMP Spotlight Peggy Honore
Sheryl Monks: You have been advocating for the implementation of standardized practices for governmental public health agency financial reporting and analysis for a number of years, urging for establishing standards for a uniform chart of accounts in several reports published in the Journal of Public Health Management and Practice. Why has public health lagged so far behind other health care sectors in this area? JPHMP Spotlight Peggy Honore
Dr. Honoré: Yes, that’s a very good question. I did a report in 2010 for the Robert Wood Johnson Foundation, looking at other industries closely related to public health, like medical group management association, the healthcare financial management association, higher education… these professions started to implement these standardized practices… some of them a hundred years ago. And public health, still to this very day, has not implemented something comparable to that. Simple things like ratio and trends analysis that every industry does in order to be able to track performance of individual organizations but of the system as a whole. It’s not rocket science. You just have to set out the framework that you’re going to base this on and get consensus on doing it. Or in the case of community health centers who have been doing this for quite a while now where there’s a law saying that they will report data and they will do standardized analysis, they either do it or else they don’t receive federal funds. It’s just been difficult to get consensus in public health around that. I started writing about a chart of accounts since around 2004-2005. I know there’s some work right now, I think currently being done around that. I’m just not sure people understand the function and use of a chart of accounts. In that a chart of accounts tracks financial information. It’s kind of like the backbone or the infrastructure for your accounting system. I’m not sure if some of the work going on now really understands what a chart of account was created to do but certainly in public health it would be useful if we had something. And I’ve worked, over the years, on a project where we did give some recommendations on how to do that, but it’s been something that I’ve been talking about for quite a long time. JPHMP Spotlight Peggy Honore
“One of the biggest barriers is that unlike community health centers or hospitals or others that are mandated to provide data, there is no law mandating the reporting of public health financial data. And until and unless there is some mandate to do that, it probably isn’t going to happen.” JPHMP Spotlight Peggy Honore
Sheryl Monks: Many have noted that in addition to not having uniform financial systems in place, part of the problem stems from a lack of a skilled workforce. Can you talk about the relationship between workforce development, quality improvement, and public health finance? JPHMP Spotlight Peggy Honore
Dr. Honoré: The quality movement originated decades ago as a means to improve processes within an organization, to improve outcomes while also reducing costs. You can’t do this without the proper financial systems in place to study that, and you have to have a workforce that’s properly educated so they will know how to do this. An example I love to give, and this example is the latest paper that I collaborated on with CDC and NACCHO, and it’s in the July/August 2019 issue of the Journal of Public Health Management and Practice. The illustration I use is from the state of Florida. In 2004, they wrote a journal article for me about a Florida association they created back in the early ’80s of the financial and administrative people in public health in Florida where they developed a financial data collection system that’s used throughout Florida and how they had used that and the chart of accounts with that to study costs within the state of Florida. And it took a properly trained workforce who understand finance and business concepts who were trained in the concepts… it just wasn’t an ad hoc group of other people unfamiliar and untrained in finance and business practices… to develop this comprehensive, statewide system. And they used it for quality improvement. They used it for monitoring costs. But it’s a perfect example, and that’s why I put it in the paper, ow what can happen if you have the competently trained workforce and how it relates so closely to finance and quality improvement as well.
Sheryl Monks: So the paper you’re referring to is “The Public Health Uniform National Data System (PHUND$): A Platform for Monitoring Fiscal Health and Sustainability of the Public Health System.” You and your colleagues provide a 10-year retrospective overview on the development, implementation, and utility of PHUND$, a financial information system for local health departments that advances the application of uniform practices to close financial analytical gaps. What are some of the specific benefits of using PHUND$? And are we any closer in 2019 to closing some of those gaps? I think you’ve already answered that question. JPHMP Spotlight Peggy Honore
Dr. Honoré: Yes, but I can expand on that a little bit. PHUND$ was developed to give local health departments the ability to analyze their financial position… and what I mean by that is are you operating in a surplus or are you operating in a deficit? Do you have enough money anticipated to meet your expenses? The ability to analyze for organizational and financial strengths? Or weaknesses? It not only gives individual public health agencies the ability to do that but also the the entire public health system to do that as well. And in this paper I do give some illustrations. We’ve had several pilot projects across the US as well with additional examples of how they were able to do quality improvement projects as a result of the data they got from the PHUND$ system. One of the biggest barriers is that unlike community health centers or hospitals or others that are mandated to provide data, there is no law mandating the reporting of public health financial data. And until and unless there is some mandate to do that, it probably isn’t going to happen. It continues to happen with individual local health departments. But it’s not going to happen across the country until there’s some mandate to do that. The last count there were about 300 agencies that had reported data into PHUND$, local health agencies, and there always was the intent that once we got a firm grip on local health department reporting that some of the variables within the system could be added for state health department data collection as well. But I firmly believe that until there’s a mandate, I just don’t see that happening on a wide scale.
Sheryl Monks:This year marks the 25th anniversary of the Journal of Public Health Management and Practice. What has JPHMP meant to you as it relates to your work and the field of public health finance?
Dr. Honoré: I have totally enjoyed and feel very grateful to have had this relationship with the journal for that period of time. Dr. Novick has been a mentor and a motivator for me to push forward with the work on public health finance. And it really it really was because of his acceptance and acknowledgement that this is such an important topic and his eagerness to publish on this. I’ll never forget how this happened. I called him in 2004 and had never personally met him to just ask if he had an interest in publishing on public health finance, and he said, yes, of course. Let’s do a special journal issue on this. And the relationship blossomed from there. There has been no other journal that has provided a constant platform for publishing public health finance topics like the Journal of Public Health Management and Practice. So if I have a reputation of advancing work on this topic, it’s because of the acceptance by Dr. Novick and the Journal of Public Health Management and Practice. There’s no other journal that so comprehensively covers topics so relevant to the practice and management of public health that without the Journal of Public Health Management and Practice there really would be a void in this area. So I just can’t say enough about his leadership throughout the years. JPHMP Spotlight Peggy Honore
- The Public Health Uniform National Data System (PHUND$): A Platform for Monitoring Fiscal Health and Sustainability of the Public Health System
- Taking a Step Forward in Public Health Finance: Establishing Standards for a Uniform Chart of Accounts Crosswalk
- Public Health Finance: Contributions From the Journal of Public Health Management & Practice
Read Other Spotlights
- Kate Beatty, PhD, MPH
- Benedict Truman, MD, MPH
- Paul Erwin, MD, DrPH, MPH
- Valerie Yeager, DrPH, MPH
- Philip F. Musa, PhD, MPH, MBA
- Danielle Jake-Schoffman, PhD
Sheryl Monks is the Editorial Associate of the Journal of Public Health Management & Practice. She manages JPHMP Direct.