The Changing Managed Care–Public Health Interface

MEDICAL PRACTICE and public health in the United States have remained functionally separate during most of the 20th century despite many similarities in mission and method.¹ The growth of managed health care has fueled a flurry of analysis and speculation about how managed care will affect the distinctions and the interactions between these 2 fields of practice. Some policy analysts and health plan executives argue that, because managed care plans assume clinical and financial responsibility for the health of defined populations, they have both opportunities and incentives for integrating aspects of medical care and public health practice.^{2 - 5} Collaborative relationships between managed care plans and public health agencies emerge as a mechanism for sharing the human, financial, and intellectual resources required to implement public health activities.⁶ Other observers warn that managed care plans may weaken the public health infrastructure, in part by siphoning off patients and Medicaid revenues that traditionally have supported public health agencies and related safety-net providers.^{7 - 8} Observers also suggest that health plans, which are mostly for-profit corporations, fail to engage in many public health activities because they are not profitable over relatively short time horizons or among enrollee populations that are constantly changing.⁹

Collaborative activities between public health agencies and medical practice are indeed occurring under managed care, but they remain relatively limited in scope and scale and fall short of the fully integrated community health systems envisioned by some proponents of these collaborations.⁴ Recent developments in managed health care delivery and in public health practice threaten some current forms of interaction but create new opportunities for future collaboration.

Much of the current interaction between managed care plans and public health agencies can be distilled into 1 of 3 basic types of activities: delivery of personal health services, exchange of health data and information, and development and implementation of community interventions and policies.

Joint activities involving personal health services delivery most often target Medicaid beneficiaries and other vulnerable populations.^{1 ,8 ,10} Some health plans and public health agencies develop formal referral networks and purchasing contracts for service delivery to specific Medicaid populations.^{5 ,10} Some coordinate the delivery of personal health services through mechanisms such as colocated clinics and staff. Most often, health plans contract with public health agencies to provide a set of specialized public health services to their Medicaid members, such as family planning and communicable disease services.¹¹ Occasionally, agencies provide a comprehensive range of primary care and case management services to Medicaid enrollees.^{12 (pp243-250)} Organizations participating in these arrangements report that they are generally successful in improving access to care and encouraging appropriate service utilization, but few empirical evaluations of these relationships have been conducted.^{1 ,10}

Collaborative activities involving health data and information range from the simple exchange of existing data to the joint collection and management of data through new surveillance strategies and information systems. Some plans and agencies establish data-sharing agreements that ensure that clinical information is reported back to the health plan whenever enrollees access services from public health agencies.¹¹ These mechanisms allow health plans to track the utilization of preventive health services such as immunizations or mammograms and to learn quickly about any new health conditions detected by public health clinics. Some organizations also collaborate in the development and management of childhood immunization registries that allow underimmunized children to be identified in health plans and in the community at large. Some organizations jointly sponsor population-based surveys of behavioral risk factors and access to care to obtain a better picture of health status and health risks within their service areas.^{12 (pp201-220)}

Collaborative activities involving community interventions and policies include a broad array of population-based initiatives, such as mass media educational campaigns, health fairs, community health clinics, and community planning projects.^{1 ,8 ,10} Some plans engage in these efforts primarily for the purposes of marketing and community relations. Nevertheless, these activities can achieve public health goals by raising awareness about health issues, risks, and community health resources. For example, some plans and agencies jointly sponsor mass media advertising campaigns aimed at increasing breast cancer awareness and mammography screening.¹⁰ Some collaborate to provide free primary care clinics, health assessment and screening fairs, and health education seminars.¹² Some plans work with public health agencies to develop local tobacco control proposals and advocate for their adoption.¹² Although these activities may produce tangible benefits for the populations they serve, these collaborative interventions generally occur as peripheral activities rather than as core operational processes for the participating health plans and public health agencies.

Recent marketplace and policy trends within the health system have important implications for the interface between public health and managed care. Changes in 4 general areas of the health system deserve special attention.

To survive economically, health plans must remain highly responsive to consumer and purchaser preferences as well as to the regulatory environments in which they operate. Consumer demand for greater choice in health care is fueling a dramatic growth in open-ended managed care products such as preferred provider organizations and point-of-service plans.¹³ This demand is also driving growth among plans that give patients direct access to certain types of specialists without referrals or other preapproval requirements. Regulatory proposals under consideration at both state and federal levels seek to expand consumer choice by requiring these open-ended offerings.¹⁴

As the dynamics among health plans, physicians, and patients change, so too must the roles that health plans play in public health initiatives. Open-ended plans do not have the same ability to monitor, inform, and educate providers as do more tightly managed health maintenance organizations (HMOs). As a result, changes in health plan operation may alter the types of relationships that develop between health plans and public health agencies. The emphasis in collaborative activity is likely to shift from informing clinical practice to informing consumer decision making and behavior.

Public health agencies have begun to reduce their involvement in personal health care delivery for vulnerable populations as other community providers and health plans develop these capacities.¹⁵ Greater emphasis is being given to population-based activities, such as assessing community health needs and risks, developing policies and plans to promote and protect health, and ensuring the availability and quality of health services provided in the community. To adequately perform these activities, many public health agencies are strengthening their capacities in areas such as outcomes measurement, continuous quality improvement, performance-based contracting, and decision analysis. Agencies may reduce their involvement as direct service providers for managed care plans, but they may need to increase involvement with these plans to adequately perform assessment and policy development activities.

Health plans and public health agencies face growing market and regulatory pressures to document their performance in addressing population health needs and demonstrate their accountability for public and private investments in health.¹⁶ These pressures encourage collaboration in developing population-based health information systems that can be used to monitor performance and demonstrate accountability. Moreover, as increasing numbers of health care consumers and purchasers receive access to this information, health plans and public health agencies face urgent needs to ensure that the public can use this information to improve health-related decision making. To be successful, these efforts must address limitations in the ability of individuals to understand health-related information because of educational, language, or cognitive barriers. Health plans and public health agencies are beginning to develop joint activities to disseminate community health information, including data about health plan performance, and assist consumers and purchasers in making effective use of this information. These activities also support informed consumer choices in the face of an increase in the number of open-ended managed care plans.

Additionally, health plans and public health agencies face a common need to address privacy and confidentiality concerns regarding health data and information. Both types of organizations depend on a free flow of information to support population-based health assessment and health management activities. Joint efforts to address these issues through smart technology and appropriate policy will become increasingly pressing.

Recent evidence suggests that, nationally, growing numbers of large commercial managed care plans are reducing or discontinuing their participation in Medicaid programs as they face the difficult realities of serving hard-to-reach population groups with very low Medicaid payment rates.^{17 - 18} At least 12 state Medicaid programs have experienced discontinuations in commercial health plan participation during 1997 and 1998, with Utah losing all its commercial plans.¹⁷ Plans that continue to serve vulnerable and underserved populations often appear very different in structure and function from the traditional commercial managed care plans.¹⁹ Many are provider-sponsored organizations that specialize in serving Medicaid beneficiaries, and many do not meet the regulatory requirements and accreditation standards for HMOs and other types of health insurance plans. Public health relationships with these plans are likely to be substantially different from relationships with large commercial health plans. These smaller Medicaid plans often cannot offer access to large clinical information systems or to broad networks of enrollees and providers. Because of resource limitations, these plans may need more assistance from public health agencies with basic public health activities such as health education and outreach to vulnerable populations.

Changes in health care markets and regulatory environments threaten some managed care–public health collaborations, such as those involving the delivery of personal health services and the management of clinical practice. These changes are creating a need for new relationships to support population-based, patient-focused health interventions that provide health education, information dissemination, and outreach. To be successful, these activities will need to move from the periphery to the core of managed care operations and public health practice, a move that will require much larger investments of human, financial, and intellectual resources from both participants. The difficulties that face these collaborative relationships should not be understated, but neither should the enthusiasm that continues to build in the marketplace, the medical community, and the field of public health.