Presented by Robert Rubin, M.D.
President and Chief Operating Officer, The Lewin Group
There may be a structural barrier between infectious disease surveillance and managed care organizations. In theory, private-sector laboratories report unusual infections and forward the isolates responsible for those infections to public health officials, who then verify the diagnosis and perform special studies of esoteric or low-volume infections. A study conducted by the Lewin Group, public health laboratories, and Health System Change on behalf of the U.S. Department of Health and Human Services evaluated public health laboratories in light of the changes in the health care system. Survey results from that study counter the commonly held belief that managed care has worsened the infrastructure of public health and microbiology laboratories. Only 43 percent of public health laboratory directors agreed with this widely held opinion, whereas 47 percent thought that managed care has no impact on public health efforts and 10 percent pointed to positive effects from managed care.
Under managed care, however, there is a tendency to treat patients empirically on the basis of symptoms rather than to perform laboratory tests and use the results of those tests as a basis for specific diagnoses. The emphasis on cost-efficiency may also be a disincentive to submission of reports and isolates. In addition, many HMOs have comprehensive contracts with large, national laboratories, with the Laboratory Corporation of America, Quest Diagnostics, and SmithKline Beecham Clinical Laboratories controlling 43 percent of the clinical testing in the United States (Sachs, 1997). Because of the interstate nature of their business, those laboratory personnel may not always be aware of state and local reporting requirements.
Several initiatives are under way to address these issues. The state of Washington's public health laboratory has entered into an agreement with Group Health Cooperative of Puget Sound to create the Clinical Laboratory Advisory Council to improve the laboratory delivery system and to open communications with all stakeholders. Representatives from public and private laboratories work through advisory groups that develop recommendations on a range of laboratory issues, from integration to practice guidelines to licensure. CDC has funded a few inventive pilot projects, including a study of the transmission of laboratory test results between managed care and the state public health laboratory in Washington State.
Public health laboratories, however, have not made the best use of the potential advantages of working with managed care. With limited resources being the obvious deterrent, many public health laboratories view managed care as a potential competitor. In addition, surveillance and monitoring issues, as well as the general topic of emerging infections, are seldom on the table when states seek to contract out services for their Medicaid populations. This may be shortsighted,