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OCR for page 1
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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Representative terms from entire chapter:
governmental public
