of health care (Joint Council Committee on Quality in Public Health, 1996).

Community-oriented primary care (COPC), which gained increased attention in the 1970s and 1980s, starts from a health care provider perspective to bring together care for individuals with attention to the health of the community in which they live (Kark and Abramson, 1982; IOM, 1984). Although performance monitoring is not an explicit focus of COPC, this approach to health care emphasizes the importance of community-based data for understanding the origins of health problems.

The emergence of managed care and various forms of integrated health systems has been another factor that is broadening the health care focus from individual patient encounters to the health needs of a population. Enrolled members are generally the population of primary interest, but many of these organizations participate in activities serving the larger community such as violence prevention, immunization, AIDS prevention, and school-based health clinics. Some have formalized their commitment to community-wide efforts through mechanisms such as the Community Service Principles adopted by Group Health Cooperative of Puget Sound (1996). Nationally, organizations such as the Catholic Health Association (CHA, 1995) and the Voluntary Hospitals of America (VHA, 1992) have adopted community benefit standards that call for accountable participation in meeting the needs of the community. The attributes of a "socially responsible managed care system," proposed by Showstack and colleagues (1996), also support involvement in community-wide health improvement efforts.

More generally, financial incentives are encouraging health care organizations to consider community-wide health needs. Nonprofit hospitals and health plans, plus the foundations established by provider organizations and insurers, are responding to the "community benefit" requirements needed to preserve their tax status. In addition, managed care plans are serving an increasing proportion of Medicare and Medicaid beneficiaries (Armstead et al., 1995), whose health may be adversely affected by problems not easily resolved in the health care setting (e.g., violence, poverty, social isolation). Because limited periods of eligibility for Medicaid benefits mean frequent enrollment and disenrollment, health plans may increasing see value in services that improve the health of nonmembers who might be part of their enrolled population in the future.



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