Summary

Joshua Lederberg, Ph.D.

Over the past 20 years, managed care has risen to dominate health care delivery in the United States. In a managed care system, health plans attempt to coordinate and control the use of medical health care-related services by limiting reimbursement. Purchasers of health plans (employers) contract with managed care organizations, which then select providers or groups of providers (primary care physicians) to care for an enrolled patient population. After a patient either selects or is assigned a provider, these primary care physicians generally act as gatekeepers for access to specialty or emergency services, with the goal of reducing the level of unnecessary health care services provided, thereby promoting reductions in overall costs. Generally, managed care is considered more cost-effective than the third-party fee-for-service system because of the potential for more stringent control over expenditures and use of services (Kizer, 1999).

The development of managed care systems for the financing and delivery of health care in the United States has created both opportunities and challenges for both providers and patients. As dramatic restructuring of the nation's health care system evolves, managed care will likely have a major effect not only on health care delivery but on many aspects of the public health enterprise as well. The fight against infectious diseases—through prevention, surveillance, treatment, and research—represents one of many areas in which managed care organizations have the potential to make marked improvements in a community's health. To make such a contribution, however, controls on reimbursements for health care expenditures must be reevaluated, as they can pose an impediment to effective collaboration among managed care organizations and the public health community.

Trends indicate that some managed care organizations are making progress in the fight against infectious diseases, but they also indicate potential problems. The emphasis on controlling costs, the move toward management of infectious



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Managed Care Systems and Emerging Infections: Challenges and Opportunities for Strengthening Surveillance, Research, and Prevention, Workshop Summary Summary Joshua Lederberg, Ph.D. Over the past 20 years, managed care has risen to dominate health care delivery in the United States. In a managed care system, health plans attempt to coordinate and control the use of medical health care-related services by limiting reimbursement. Purchasers of health plans (employers) contract with managed care organizations, which then select providers or groups of providers (primary care physicians) to care for an enrolled patient population. After a patient either selects or is assigned a provider, these primary care physicians generally act as gatekeepers for access to specialty or emergency services, with the goal of reducing the level of unnecessary health care services provided, thereby promoting reductions in overall costs. Generally, managed care is considered more cost-effective than the third-party fee-for-service system because of the potential for more stringent control over expenditures and use of services (Kizer, 1999). The development of managed care systems for the financing and delivery of health care in the United States has created both opportunities and challenges for both providers and patients. As dramatic restructuring of the nation's health care system evolves, managed care will likely have a major effect not only on health care delivery but on many aspects of the public health enterprise as well. The fight against infectious diseases—through prevention, surveillance, treatment, and research—represents one of many areas in which managed care organizations have the potential to make marked improvements in a community's health. To make such a contribution, however, controls on reimbursements for health care expenditures must be reevaluated, as they can pose an impediment to effective collaboration among managed care organizations and the public health community. Trends indicate that some managed care organizations are making progress in the fight against infectious diseases, but they also indicate potential problems. The emphasis on controlling costs, the move toward management of infectious

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Managed Care Systems and Emerging Infections: Challenges and Opportunities for Strengthening Surveillance, Research, and Prevention, Workshop Summary diseases by nonspecialists, and the shift from inpatient to outpatient treatment all raise concerns in terms of infectious disease prevention, control, and reporting. Additionally, managed care practices may increase the complexity of an infectious disease outbreak investigation and subsequent public health response. If such trends continue, the result may be lost opportunities to mitigate the impacts of infectious diseases. However, collaborations between the public health community and managed care industry can ensure that the public's health is protected and that the health care environment is increasingly managed with cost containment as a goal. To help inform the debate about the consequences of health care restructuring on infectious disease control and to identify model systems that illustrate best practices, the Forum on Emerging Infections convened a workshop—the subject of this workshop summary—to identify, clarify, and solidify some of the current and potential best practices in managed care with respect to identifying and treating emerging infections. The workshop focused on five major areas of importance to infectious disease control that both shape and are shaped by the changing health care environment: (1) basic and clinical research, (2) clinical practice guidelines, (3) surveillance and monitoring, (4) education and outreach, and (5) drug formularies. Workshop participants outlined many of the challenges to be overcome and identified possible opportunities for addressing obstacles. A summary of these challenges and opportunities listed in the following sections were addressed and discussed by workshop participants. These challenges and opportunities, however, do not necessarily represent the views of either the Forum on Emerging infections or the Institute of Medicine. BASIC AND CLINICAL RESEARCH Health care reform has changed the financial base upon which the modern academic medical center is structured. The cost-containment efforts of managed care organizations have reduced the institutions' net revenues from the provision of clinical care that have traditionally been used to support research and training. Concomitantly, the amount of time that faculty can spend conducting research and training future scientists and physicians has also been reduced, as the managed care system encourages physicians to treat more patients on a daily basis. Yet, in light of these changes, managed care can work with academic health centers to strengthen the foundation on which they conduct clinical investigations. Armed with large patient populations and centralized information systems, managed care organizations are uniquely positioned to partner their resources with the research infrastructure and culture offered by academic health centers. The following objectives related to conducting basic and clinical research in a managed care setting emerged during the workshop presentations and discussions and are described in greater detail in the workshop summary: supporting the functions of academic health centers,

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Managed Care Systems and Emerging Infections: Challenges and Opportunities for Strengthening Surveillance, Research, and Prevention, Workshop Summary ensuring adequate databases for clinical research, exploiting the unique advantages of managed care for surveillance and research, and promoting collaboration. CLINICAL PRACTICE GUIDELINES One hallmark of successful clinical practice is the adherence to preestablished guidelines. However, the adoption of standard guidelines among managed care organizations has been slow, as competing managed care organizations are often unwilling to share the data necessary to construct the guidelines. Even when the data are available, moreover, standardized clinical practice guidelines often have not been validated under sustained use in clinical settings. Furnishing managed care organizations with opportunities to implement and evaluate clinical practice guidelines will entail the involvement of providers and purchasers of health care to overcome both organizational and psychosocial barriers. The following challenges to and opportunities for the development of clinical practice guidelines in managed care organizations emerged during the presentations and discussions and are discussed in greater detail in this workshop summary: developing clinical practice guidelines, promoting adoption and use of guidelines in managed care organizations, and involving clinicians in guideline development and implementation. SURVEILLANCE AND MONITORING The surveillance and monitoring of emerging infections, including microbial resistance, in the managed care environment demand an effective partnership among health care providers, academic health centers, commercial laboratories, and the traditional public health system. Professional roles and responsibilities across the spectrum of infectious disease surveillance activities must be clearly understood and supported by all parties involved. The capabilities of public and private microbiology laboratories cannot be overlooked (and therein may lie a role for the Centers for Disease Control and Prevention in providing training for state laboratory personnel in the use of new molecular tests). Sharing data on rapid and accurate diagnosis and disease reporting will be at the heart of an effective partnership with managed care and public health systems to combat emerging infections. The following challenges and opportunities to disease surveillance and monitoring in the managed care setting are discussed in the text of this workshop summary:

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Managed Care Systems and Emerging Infections: Challenges and Opportunities for Strengthening Surveillance, Research, and Prevention, Workshop Summary understanding professional roles in surveillance and monitoring, ensuring availability of data, promoting sharing of data, tracking nosocomial infections, accurate reporting of encounter-level data, and overcoming structural barriers. EDUCATION AND OUTREACH Managed care organizations are interested in improving the health of the entire community, not just their own members. However, infectious diseases may not be as high a priority as other diseases to health maintenance organizations, and consequently fewer resources are committed to any systematic, large-scale education or outreach initiatives. Although this direction may not seem beneficial to patients, it is driven by the purchasers of managed care who give a lesser priority to infectious diseases. Opportunities do exist, however, for educational institutions or pharmaceutical manufacturers to play a larger role in health education, both to providers and to purchasers of health care. The hope is that such efforts will then spread throughout the managed care industry. The following challenges to and opportunities for the development of education and outreach programs in the managed care setting are discussed in this workshop summary: promote professional education efforts, encourage judicious antibiotic use, and invest in educational programs. DRUG FORMULARIES Drug formularies were originally intended to help reduce prescription drug costs while maintaining good health care. Recent evidence suggests that formulary policies concerning antibiotics may have contributed to the rise in the rate of antibiotic resistance by microorganisms even while the expected goals of cost containment have not been realized. To examine these concerns, this session was organized around three basic issues: (1) how managed care makes formulary decisions, (2) the relationship between pharmaceutical companies (manufacturers and distributors) and managed care, and (3) the impacts of these formulary decisions on the discovery and development of new antimicrobial agents. Although further studies are needed to address the increasing costs associated with formularies, some practices that could provide quality health care without adverse repercussions were identified. The following challenges and opportunities to the development of drug formularies in managed care organizations are discussed in this workshop summary:

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Managed Care Systems and Emerging Infections: Challenges and Opportunities for Strengthening Surveillance, Research, and Prevention, Workshop Summary ensuring availability of current information on new drugs, managing antibiotic selective pressure, need for new management strategies for cost reduction, and achieving quality care and cost containment.