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Executive Summary The Future of Public Health, issued in 1988, set forth a vision of public heals and a specific role for the governmental public health agency within Mat vision, including the mission and content of public health, and an organizational framework. In the eight years since the report was released, there has been a significant strengthening of practice in governmental public health agencies and other settings. Substantial social, demographic, and technological changes in recent years, however, have made it necessary to reexamine governmental public health agencies' efforts to improve the public's health. Drawing on the activities and discussions initiated by the Institute of Medicine (IOM) Committee on Public Health, the current report addresses two critical public health issues that can greatly influence the opportunity for our public to be healthy as the United States enters a new cenblry~l) the relationship between public health agencies and managed care organizations, and (2) the role of the public health agency in the community and their implications for the broader issues raised in The Future of Public Health. The committee's analysis, presented In this report, reaffirmed Me understanding of public health professionals and health scientists that the public's health depends on the interaction of many factors; thus, the health of a community is a shared responsibility of many entities, organizations, and interests in the community, including health service delivery organizations, public health agencies, other public and private entities, and the people of a community. Within this context of shared responsibility, specific entities should identify, and be held accountable for, the actions they can take to contribute toward the community's health. As a result of this understanding,

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2 HEALTHY COMMUNITIES the committee focused its report on how governmental public health agencies, especially at the state and local level, can develop partnerships with managed care organizations for the delivery of personal and population-based health services and with public and private community organizations to deal with broader concerns to advance the health of the community. Developing these partnerships, the committee believes, will be critical for advancing the health of the public and of communities in the future. PUBLIC HEALTH AND MANAGED CARE There has been substantial growth in organized health care delivery systems (which include managed care organizations) in recent years, and these developments have important implications for the health of the public. Managed care organizations are systems that are under the management of a single entity that (a) insures members, (b) furnishes covered benefits through a defined network of participating providers, and (c) manages the health care practices of participating providers. In the discussions initiated by the Public Health Committee, proponents of managed care have argued that its goals and tools are consistent with public health. Many public health professionals, on the other hand, have also expressed concerns about managed care organizations' motives and ability to deliver on their promises. The committee's view, as developed in this section, is that if the proper kinds of partnerships between managed care organizations and governmental public health departments are developed, managed care can indeed malce an important contribution to improving He health of the public. The proliferation of organized health care delivery systems, which continue to provide care for an increasing number of Americans, has made it possible in some locales for governmental public health agencies to assure the provision of personal health services (which involve a one-to-one interaction between patient and provider) entirely within the private sector. How many elements of public health services private organizations can or should subsume remains unclear, but the number could be considerable. Providing care for the uninsured, however, remains a challenge; governmental public heals departments will be ill prepared and inadequately funded to do so if no other personal services are being provided. In order to ensure that partnerships between governmental public health agencies and managed care organizations work effectively toward improving the health of the public, the committee reiterates The Future of Public Health recommendation that the function of local public health agencies should include an "assurance that high-quality services, including personal health services, needed for the protection of public health in the community are available and

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EXECUTIVE SUMMARY 3 accessible to all persons...." This assurance function can be carried out "by encouraging other entities (private or public sector), by requiring such actions through regulation, or by providing services directly." Public health agencies can only exercise this responsibility if they are adequately staffed, equipped, and funded for this complex and demanding task and have appropriate relationships with health service providers. These activities should not be undertaken at the expense of existing essential public health services. Particular concerns arise when health departments have a dual role: direct provision of personal health services to some people and regulating private entities providing similar services to others. To improve the efficiency of all health systems, health agencies and organized health delivery systems, in conjunction with other community stakeholders, must reach agreement on their proper roles and responsibilities, which will vary by locale. Successful models of the integration of public health and managed care and of joint approaches to policy development do exist and need to be studied and tested more broadly. Most public health agencies do not currently have the full statutory and regulatory authority to ensure the accountability of the organized health delivery systems to the public. In the current regulatory structure, health care delivery systems are often regulated by insurance commissions that focus on fiscal integrity rather than on health. State Medicaid agencies, usually separate from public health departments, also typically focus on fiscal rather than medical accountability dimensions, except in states that have a quality initiative. Recognizing the clear need for financial oversight, governmental public health agencies should increase their ability to oversee health care providers, with the goal of becoming coequal partners with insurance regulators and state Medicaid agencies, to ensure that the public's health is addressed in the regulation of public and private health care delivery systems. In many states, additional legislative authority will be needed before public health agencies can take on this role. This approach requires population-based health outcome and performance standards that can be monitored, and public health agencies should be a major contributor to the development and monitoring of these standards. The fimctions described in this report cannot be undertaken without properly trained professionals available to all communities. Thus, public health professionals should be trained to work with health services organizations to ensure quality personal health services in a community, as an essential element in providing for the health of the public. In addition, public health agencies should actively participate with organizations such as state health professions boards, medical schools, and accrediting bodies in planning and policy development.

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4 HEALTHY COMMUNITIES PUBLIC HEALTH AND THE COMMUNITY In its discussions with community group representatives and public health officials, the committee heard of many innovative and effective approaches to community partnerships and collaboration that are consistent with widespread themes regarding community development and "reinventing government." Broader application and further development of these new approaches to collaboration within government (with legislators, boards of health, and nonhealth agencies) and with community partners to achieve public health goals should be encouraged. Shared responsibility, however, requires careful management. The governmental public health agency in each community needs to be capable of identifying and working with all of the entities that influence a community's health, especially those that are not directly health related. This function must be undertaken by public health agencies that understand the interactions of the full range of factors that influence the community's health. To address this, a companion IOM report proposes a "community health improvement process" that draws on performance monitoring concepts, an understanding of community development, and the role of public health consistent with the Committee on Public Health's discussions (IOM, in press). Public health professionals who must work with a community to improve its own health need to be trained and their roles need to be upgraded or enhanced. The committee's discussions showed that many functions essential to the public's health, such as immunizations and health education, can and are being performed by either public or private entities, depending on the historical context, community resources, and political dynamics of a particular area. Some functions, however, such as environmental regulation and enforcement of public health laws, must remain the responsibility of governmental public health agencies. There also needs to be a resource in each community to ensure that the health impact of multiple interventions in the community are understood and addressed. This remains an ideal fimction for governmental public health agencies and should not be delegated. Thus, the committee reasserts the critical findings of The Future of Public Health that governmental public health agencies have a unique function in the community: "to see to it that vital elements are in place and that the [public health] mission is adequately addressed." These elements include assessment, policy development, and assurance. For a governmental agency to execute this responsibility effectively, there must be explicit legal authority, as well as heal goals and functions, that the public understands and demands. A fundamental building block for this new approach to governance is public trust. With trust in public institutions at risk or at low levels in many communities, governmental

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EXECUTIVE SUM~4RY s public health agencies must find ways to improve their openness and their communication with the public to maintain and increase their trustworthiness. REVISITING THE FUTURE OF PUBLIC HEALTH Through its analysis of the interactions between managed care organizations and governmental public health agencies and the role of public health agencies to enhance the health of the community, and through its discussions about the many responses to The Future of Public Health, the committee found that the constructs of the mission and substance for public health agencies envisioned in that report have been extraordinarily useful in revitalizing the infrastructure and rebuilding the system of public health at all levels of government in the United States and continue to be viewed as the fundamental building blocks for the future. However, although clear progress has been made, some of the recommendations of that report have not yet been implemented. In light of this, the committee's analysis shows that the concepts in The Future of Public Health remain vital and essential to current and future efforts to energize and focus the efforts of public health. These concepts need to be advanced, applied, and taught to all health professionals. The committee also found that the concepts of assessment, policy development, and assurance, while useful in the public health community itself, have been difficult to translate into effective messages for key stakeholders, including elected officials and community groups. These concepts need to be translated into a vernacular that these groups can understand. In conclusion, the committee found that the public health enterprise in the United States, as embodied in governmental public health agencies, is necessarily diverse in organization and function, but operates within the common framework set out in The Future of Public Health. The committee's discussions, however, revealed continuing evidence of inadequate support for governmental public health agencies in many communities. Now, as nearly a decade before, society must reinvest in governmental public health agencies, with resources, commitments, and contributions from government, private and non-profit sectors, and substantial legal authorities, if the public's health is to improve. The partnerships that are the focus of this report between governmental public health agencies and managed care organizations, and between public health and the community-can provide both political support and a vehicle for this reinvestment.

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