surveillance is based, better diagnostic information should also reduce the use of expensive treatments as well as allow the use of more focused and less expensive therapy. Such care management can maximize the efforts to provide the right treatment to the right people at the right time and lead the way for an effective disease management program.

Overcoming Structural Barriers

Workshop participants expressed concern that there is a fundamental structural barrier between surveillance and practice in managed care. They felt that managed care has negatively affected public health laboratories and the microbiology laboratory infrastructure for a number of reasons, some of which are listed here. First, because managed care focuses on efficiency, there is generally a disincentive for disease reporting and for submission of isolates recovered from patients with emerging diseases. Second, many managed care systems typically have comprehensive contracts with large national laboratories; for instance, three laboratories (Laboratory Corporation of America, Quest Diagnostics, and SmithKline Beecham Clinical Laboratories) control 43 percent of the clinical testing in the United States today. Because of the interstate nature of this type of business, laboratory personnel may not always be aware of the state and local reporting requirements, which may exacerbate the problems of identification and monitoring of diseases. Third, there is a tendency for managed care organizations to provide empirical treatment, which results in reporting problems. Fourth, public-sector laboratory information systems have lagged behind private-sector systems in leveraging potential advantages for managed care. Finally, as people are placed into Medicaid managed care environments, discussions and contract terms generally do not contain provider expectations about surveillance monitoring and their effects on emerging infections.

Workshop participants identified a number of initiatives that addressed the barriers between surveillance and managed care practices. These opportunities are identified below, but they are by no means all inclusive. With integrated patient databases, there is a potential for seamless communication between laboratories, managed care organizations, and public health officials. Such communication could help dissolve the structural barriers between surveillance and practice in managed care organizations and subsequently facilitate the exchange of information.

Additionally, the large national laboratories that are used extensively by managed care systems need to implement better internal guidance policies to help identify which states require the reporting of which infectious diseases. Workshop discussions suggested the need to establish incentives for disease reporting and for isolate submission within managed care organization's policies and regulations; the lack of such incentives jeopardizes surveillance and monitoring efforts. Treatment based on scientific observations rather than on empirical knowledge must also be emphasized as a rule of thumb, especially in ambu-



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