The Wide World of Public Health: Spotlight on Dr. JP Leider

JPHMP Spotlight JP Leider

“[A]s an undergraduate I studied ethics and genetics, so not terribly applied in the way that public health is, and I found that that’s what I loved about it, that there were things that you could do that would really impact a population and that the questions were really tough.”

Today, we are shining the spotlight on Dr. JP Leider, a new member of the editorial board of the Journal of Public Health Management and Practice. Jonathon P. (JP) Leider is an independent consultant in the public health and health policy space, as well as a Senior Lecturer at the University of Minnesota and Associate Faculty at the Johns Hopkins Bloomberg School of Public Health. He has active projects and collaborations with foundations, national public health organizations, public health researchers and academics, and public health practitioners. His current projects focus on public health systems, the public health workforce, and public health finance. He holds a PhD in Health Policy and Management from the Johns Hopkins Bloomberg School of Public Health.    JPHMP Spotlight JP Leider

In his previous position at the de Beaumont Foundation as Senior Research and Evaluation Officer, Dr. Leider was responsible for supporting grantees’ research and evaluation needs, project management, and leading the foundation’s intramural research efforts. Previously, Dr. Leider worked as a core team member in the Office of Population Health Improvement at the Maryland Department of Health and Mental Hygiene and in the Office of Public Health Training and Practice at Johns Hopkins. He has a BA in Philosophy and a BS in Genetics, Cell Biology and Development from the University of Minnesota.

I spoke with Dr. Leider about his role as a consultant and his academic appointments. Listen to the podcast or read the interview below. JPHMP Spotlight JP Leider

JPHMP Direct: Your expertise is in health policy management with a focus on public health systems, workforce, and finance. You were Senior Research and Evaluation Officer at the de Beaumont Foundation before starting your own public health research consultancy firm. You also currently hold positions at the University of Minnesota and Johns Hopkins SPH. Can you tell us a bit about your career path as well as some of the projects you’re working on?  JPHMP Spotlight JP Leider

Dr. Leider: My career in public health has been pretty varied, like a lot of folks. I’ve seen public health from the side of a national funder, from public health practice, now from academia and the private sector. My entree into public health was as an undergraduate, I was really fortunate to work on a pandemic planning project. This was well before swine flu. We’re talking more about avian H1N1/SARS kind of days. And it was a real eye-opener because as an undergraduate I studied ethics and genetics, so not terribly applied in the way that public health is, and I found that that’s what I loved about it, that there were things that you could do that would really impact a population and that the questions were really tough. They were abstract academic questions about the basic sciences, which are important. But I found that I was much more engaged around policy, practice, research, and resource allocation. So I went to grad school at Johns Hopkins in Baltimore. I was fortunate to go there to work on these issues more. I learned a lot about the wide world of public health and worked at what is now called the Maryland Department of Health (then called the Department of Health and Mental Hygiene). So that’s where I kind of found my love for practice. After grad school and working at MDH, I became the senior research and evaluation office for the de Beaumont Foundation and was really fortunate to be able to help craft some of the early work of the foundation along its intramural research lines, working on things like the Public Health Workforce Interests and Needs Survey, and supporting the work of leadership there in furthering their vision for how to invest in public health systems. Now I’m at the University of Minnesota. I’m the Director of Evaluation for the Region 5 Public Health Training Center. So I have a good connection to practice in that way, but I’m no longer at a health department so a lot of what I do is public health systems research. I connect and work with practitioners, and I’d love to talk to you more about practice.

“Folks were saying we need training and budgeting in financial management, but instead of designing trainings in budgeting and financial management for epidemiologists and maternal child health folks, the de Beaumont leadership realized there was this wide need.”

JPHMP Direct: Let’s talk about PH WINS, the Public Health Workforce Interests and Needs Survey, a national survey of state and local public health agency employees that captures detailed demographics as well as perspectives on issues such as workforce engagement, morale, training needs, and emerging concepts in public health. You helped design, field, and analyze the survey, along with members of the de Beaumont Foundation, ASTHO, and NACCHO. The survey was first fielded in 2014 and then again in 2017. What’s new? Will you talk about some of the survey’s key findings? Were there any surprises?

Dr. Leider: Yeah, absolutely. PH WINS has been one of my favorite projects that I’ve worked on. It started as a collaboration between the de Beaumont Foundation and ASTHO when folks in the field talked about all these crosscutting workforce needs. So there was a summit in 2013, I believe, where some of these major priorities were talked about. Folks were saying we need training and budgeting in financial management, but instead of designing trainings in budgeting and financial management for epidemiologists and maternal child health folks, the de Beaumont leadership realized there was this wide need. We heard that from leadership, but we hadn’t heard things from individual staff. So PH WINS was conceived to be able to measure training needs, to, for the first time, understand perceptions of the workplace environment from the individual employee’s perspective. So fielded in 2014 and in 2017 fielded again. Almost a 100,000 people were invited. Forty-seven thousand responded. So it’s one of the largest surveys of its kind. And in 2017, I think the really substantial change is that now we have nationally representative samples from both the state health agency central office and local health departments. So we can speak to both state and local governmental public health for the first time. In terms of findings, I think what’s really changed between 2014 and 2017 is the composition of our workforce. In three short years, we’re seeing changes in the average ages going down a little bit as we see more people retiring. But just to give you an example… public health is still a pretty aged workforce. The median age is 47, whereas in the US the median age is just 42. So it’s quite a bit older, and we have more people eligible to retire, planning to retire in the next few years, than the broader public. But it is bit less than 2014. What has increased, unfortunately, is the amount of folks who are thinking about leaving for reasons other than retirement. This is especially problematic for young and highly educated folks. If you think about PH WINS findings broadly, about 24% of folks are considering leaving for reasons other than retirement, but for these people who are 35 who have a master’s degree, that number is more like 39%. So it’s pretty substantial and it’s something that we need to watch pretty closely.  JPHMP Spotlight JP Leider

[bctt tweet=”I think we need to recognize that we do need to train the future public health workforce but that that workforce doesn’t just go into public health, that public health is affected from all sorts of angles.” username=”@JPHMPDirect @debeaumontfndtn”]

JPHMP Direct: Last month, I spoke with Dr. Peggy Honore, another JPHMP board member, a professor at Louisiana State University, and she pointed out the fact that the MPH has been seen as the entryway into public health when in fact, she said, half or more of the PH workforce doesn’t have a MPH degree. What will it take to align education with expected job outcomes in the coming years?

Dr. Leider: Dr. Honoré is absolutely right. The MPH isn’t the entryway to the workforce that we thought it was, if it ever was. So consider that 14% of governmental public health workforce has formal public health training of any kind — bachelor’s, master’s, doctoral. Far and away the MPH is the most common public health degree (about 8% of all staff have it). But the vast, vast, vast majority don’t. So we know that these folks aren’t going into governmental public health. At the same time, we now graduate something like 30,000 students a year across the bachelor’s/master’s/doctoral level. So if we know they aren’t going into government, where are they going? When we look at that for undergraduates versus master’s, let’s say, it looks a bit different. You have somewhere between 10-15% actually going into governmental public health in their early years. For the bachelor’s folks, we have a lot more going into the private sector, not in health. After that is folks going into the health sector, not-for-profit or for profit. And then you have people going on for more education and so on. For the master’s level, you have most folks going into not-for-profit in the health sector, so in that way they look similar, somewhat less going into for profits properly. But the fundamental idea here is that most aren’t going into government, even though that’s what we talk about what an MPH is or what it means. So to answer your question, I think we need to recognize that we do need to train the future public health workforce but that that workforce doesn’t just go into public health, that public health is affected from all sorts of angles and we need to keep that in mind. The other thing that I’ll mention is that we’re seeing a downturn in graduate level education, and that means that we need to be really careful aligning supply and demand and making sure that we are training folks for the jobs that they can get out of school, for what’s available, for what’s needed. And keep that in mind to make sure that we can equalize where we’re at in terms of graduate education as undergraduate education continues to climb. It shows no signs of slowing down just yet. 

JPHMP Direct: In 2017, you noted in an article published in the JPHMP, “Data, Staff, and Money: Leadership Reflections on the Future of Public Health Informatics,” that despite a potential substantial loss of the public health workforce as demographic shifts continue, there is an opportunity to innovate and train more information-savvy staff. Can you talk a little about that study and whether or not we’ve made any progress on public health informatics? JPHMP Spotlight JP Leider

Dr. Leider: Abosulety. So just a bit about the study… we conducted in 2016. It was a project in collaboration with Brian Castrucci at de Beaumont, Gulzar Shah and colleagues at Georgia Southern, where we looked across the country and interviewed 49 local health department leaders about where informatics was and where it’s going from a practice and local public health perspective. In this manuscript, we focus a lot on barriers, on funding, on staffing, being some of the primary barriers, which I don’t think to be very surprising. But what was interesting was the reliance on state systems and problems with HIPPA. So even though public health folks doing their public health jobs are largely exempt, there’s been a lot of data sharing problems coming from hospitals where leaders at health departments talk about trying to get data and being told there were HIPPA constraints, even though that’s subjectively not the case. So trying to get folks in the private sector to recognize that that’s not as much of an issue and to voluntarily turn over information to do things like chronic disease monitoring, which is somewhat new to folks reporting that in to health departments when they’ve been doing communicable disease for so long in terms of mandatory reporting. That was a challenge. The other surprise, I think, and something that seems to be a pretty practical policy recommendation, is that even in these centralized states where state health agencies and local health agencies are autonomous of each other and independent, locals really relied on the state systems that existed. And when you heard leadership talk about it, this was especially true in small and mid-sized health departments, whereas the big city health departments had a number of staff who had really good expertise, not just in epi but also in data analysis/claims analysis/access to electronic medical records, via folks at the mid-sized and small health departments might have AN epidemiologist or no epidemiologist. So trying to work with complicated data systems wasn’t very practical for them, so they relied on state systems even if they were independent of a state agency. So that’s something to really think about if you’re in a state with a lot of small or rural health departments, thinking about how can you create state infrastructure to support their work, especially if they don’t have the staff with that level of technical expertise. The other thing is keeping in mind that epidemiologist/data analyst positions are hard to recruit for and retain because of direct competition with health care. This is one of the areas people talk about the most, not just in informatics but across public health. When you’re talking about hard-to-hire positions, it’s nurses, epis, and data analysts are always at the top of the list.  JPHMP Spotlight JP Leider

JPHMP Direct: You are a co-author of a brand new article in the JPHMP that looks at State Laws and Nonprofit Hospital Community Benefit Spending. Do community benefit laws incentivize hospitals to redistribute their spending mix between purely charitable direct patient care services to more population health efforts? What should policy makers take into consideration when developing or refining laws?

Dr. Leider: Community benefit spending has been around, under different names, for decades. So when we got not-for-profit hospitals gaining that tax status, there was an idea federally that they needed to justify that status and how these hospitals need to justify not paying taxes. So the idea of charity care, of providing largely clinical services to folks who couldn’t afford it in your community, to filling in gaps in terms of access, was a primary way, was THE way, community benefit used to be talked about. The advent of the Affordable Care Act brought some changes in this space. The IRS introduced new ways of reporting, new kinds of categories, so not just talking about charity care or financial assistance or Medicare losses, but talking about health profession education, community health improvement, and some other broad, population-based lines that could be reported at. Our study engaged with the idea that on top of this federal requirement, some states have laws that relate to required reporting, whether that’s public reporting or not public reporting. There are also some threshold laws, which are much, much less common, but says that you have to spend X percent of operating on community benefit. Our study found that hospitals spend on the order of $50 billion+ a year on community benefits, and that in urban areas we saw that reporting laws, whether public or not public reporting, was associated with an increase in community benefit spending. But at rural hospitals, not so much. This is perhaps because rural hospitals do somewhat different things, different activities in their communities. They have less competition, but they may also have less financial flexibility than their urban counterparts. So impact on urban areas, yep. Impact on rural areas, not quite so much. I’d say this paper has two primary recommendations: One is that states without reporting laws could implement them and see hospitals spend more on community benefit in the spaces that these states might be interested in, which probably isn’t just charity care Medicaid losses. The second is that any law, especially a threshold law that says you’ve got to spend X amount, really needs to take into account the financial realities these hospitals face. So a lot rural hospitals have pressure. We hear a lot about rural hospitals closing. So just try to keep in mind, what are we trying to do from a public health perspective, how are we creating incentives to support that, how are we creating penalties to guide action, and what’s going to be the overall impact on the system. 

“I’ve been reading the Journal since my very first month in graduate school in 2008. Articles came up in class, right away, and then a couple practice-oriented faculty recommended we as students read it.”          JPHMP Spotlight JP Leider

JPHMP Direct: You also have a new case study in the July issue. Using the US Census Bureau’s Census of Governments data, you assessed the feasibility and implications of incorporating a local government health and social services spending measure into a rankings scheme such as the County Health Rankings. What did you find? JPHMP Spotlight JP Leider

Dr. Leider: This is a question I’ve wondered about for a few years. A colleague of mine, Mac McCullough at ASU, and I have looked at it for maybe four or five years. So for those playing at home, this closely relates to some of the finance work I’ve been with Mac and Beth Resnick and David Bishai at Johns Hopkins, thinking about how do we talk about and characterize and catalog spending in public health in a way that’s reliable, in a way that’s replicable, and in a way that can be measured over time. The real advantage to incorporating it into some kind of ranking scheme, like the County Health Ranking, is that you can make comparisons, county to county, year to year, and see what’s changing, how is investment relating to outcomes. But as we talk about in the article there are a couple of primary issues. Some of them are technical. Then some of them are really practical or prudential. So the first is the County Health Rankings are published every year and local finance data is not. So the best source of these data come from the Census of Government, and the full census is done only every five years. Every intervening year there’s a local sample that’s drawn. And for large counties, governments that are spending the most money are sampled essentially every year. But the really small rural governments may not, so much, so say every two years, three years, four years. So you would have to come up with a way to interpolate the missing data, which is somewhat problematic for a rankings. The other problem is that even if you can handle this annualization issue, the data just don’t come out that frequently. so the 2017 census was the last time they did it. Those data are going to come out later this year, we think. So that’s a pretty big lag that might be problematic incorporating into the rankings. And then the questions is also one of utility, so if your data are a little slow on the uptake, how can you show that changes made year to year are going to be associated with an impact or not? How do you evaluate that? If you had to use data from three, four, five years ago, that makes it a lot tougher to have something like the County Health Rankings, or really any rankings system, it could even be a state-based system… it’s still the same problem. So thinking about how to incorporate financials into a ranking is really important, really valuable if you can pull it off, but I think there are a lot of technical and practical questions that really make that challenging. JPHMP Spotlight JP Leider

“[N]ow is the time to read. I know this, since I assign plenty of reading to my students, that you have lots of reading to do. But one of the things I’ll say, having made that transition and going from doctoral student to junior to maybe now not quite so junior faculty, it gets harder to just read and keep up with all of the stuff going on with the scholarship.”

JPHMP Direct: This year marks the 25th anniversary of the JPHMP. Even though you’re just joining the editorial board, how long have you been aware of the Journal? Has it impacted your work in any way?

Dr. Leider: I’ve been reading the Journal since my very first month in graduate school in 2008. Articles came up in class, right away, and then a couple practice-oriented faculty recommended we as students read it. At the time, JPHMP was really the only journal that focused at all on public health finance. Some of Dr. Honore’s work, along with others, was really central to my dissertation, which came later. And my dissertation focused on public health finance, so it was very in line with what I was reading at the time with what I was working on. And I have to say, when I was a student and kind of moving out of that space, it was also really a professionally satisfying when I submitted some of my dissertation work to the Journal and had it accepted, after, of course, rigorous peer review and multiple revisions. Since then I think I’ve first-authored maybe a dozen articles in the Journal and then been a coauthor on many more. Parenthetically, a big part of the reason I do that is the readership. Essentially all of my scholarly work is around the public health system in the US, and JPHMP is oriented toward public health practitioners in a way that no other journal is. So it’s where I go first. I’m really excited to join the board and support its mission of practice-relative work, work that has high expectations of quality, work that has high expectations of scientific rigor, and good peer review. It’s really an exciting opportunity. 

JPHMP Direct: If my count is right, it’s been almost 7 years since you completed your doctoral work. Do you have any thoughts or recommendations for students listening to the podcast?

Dr. Leider: Yeah. I think now is the time to read. I know this, since I plenty of reading to my students, that you have lots of reading to do. But one of the things I’ll say, having made that transition and going from doctoral student to junior to maybe now not quite so junior faculty, it gets harder to just read and keep up with all of the stuff going on with the scholarship. You have other obligations in your day-to-day work. And so as a graduate student, this is your excuse, or even as an undergraduate that’s coming to learn about public health. The Journal is a great resource, there are other peer journals, and even things like the Kaiser Family Foundation, Commonwealth Fund, and media sites. So VOX does really great health work. Wall Street Journal does really great health work. Kaiser Health News does really great work. Just read consistently, maybe at least read the table of contents for four or five journals that come out every month. Find what you like keep reading to try and find out about something new. This has somewhat different implications for master’s and doctoral students. Doctoral students maybe don’t just read a couple tables of contents but read a bunch, really get to know the space, try and find web resources. There’s this great web resource called JANE that can help you track down similar topic ideas, find journals, find authors. It’s really useful. And then this might seem a bit strange to say, but you should feel free to contact the authors of these articles. People have invested a lot of time and energy into the work, and if have questions or ideas, please you can reach out. And then the other thing is don’t skip the methods section. If you’re a policy student but you’re running into some kind of technical question that leads you down this rabbit hole of a somewhat complicated methods section, those are really important. You need to be able to evaluate what are sound methods? What aren’t sound methods? If you don’t know, that’s where you ask faculty or peers or statistical consultants at your school. But you want to get to a place where you’re comfortable reading every single section so you can evaluate every single section of a paper. Really useful. JPHMP Spotlight JP Leider

JPHMP Direct: You are a public health systems researcher that publishes a lot on issues of practice, though you don’t work in a health department anymore. How can academics work with practitioners to do this type of research most effectively? JPHMP Spotlight JP Leider

Dr. Leider: Yeah, I’m a scholar that works a lot with public health practitioners, but I’m not a practitioner anymore. I’m not located in a health department. And if you want to do this kind of research, if you want to do it effectively, you have to meet practitioners where they are. So there’s definitely a lot of research questions that you might have that can indirectly benefit health department staff. This is kind of the nature of research, creating generalizable knowledge. But you have a responsibility to disseminate it in a way that’s open and accessible. So the minimum you can do is give results to participants. I usually do a lot more, and I’d say read Ross Brownson and Paul Erwin‘s work. But you can also design projects with practitioners for practitioners, and to me, those have been some of the most valuable things. So the last thing is public health is undergoing a lot of change right now. It’s a really interesting time. We’ve got big national initiatives. We’ve got state-based work going on. We’ve got a big federal investment that may or may not happen in public health infrastructure. We’ve got a lot of students that are going into various places. So I’ll be really interested to see what public health looks like in five years, and I expect to read it in the Journal of Public Health Management and Practice. 

Thank you, Dr. Leider. It’s been a pleasure. JPHMP Spotlight JP Leider

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Sheryl Monks
Sheryl Monks is the editorial associate of the Journal of Public Health Management and Practice. She manages JPHMP Direct.