latory-care settings. Furthermore, because public health laboratories have not leveraged the potential advantages of working with managed care organizations, states need to increase the available resources in their respective public health laboratories to maximize the potential advantages for managed care systems. Finally, when states seek to contract out services for their Medicaid populations, such contracts must incorporate terminology that will take into account the need for surveillance and monitoring as well as emerging infection issues.
There is concern that managed care may have a negative effect on infectious disease surveillance and monitoring. For example, a feature of managed care is to shift patient care from inpatient to outpatient settings, where there are reduced diagnostic and patient management capabilities. Another concern is that managed care relies heavily on empirical diagnoses rather than laboratory data, which may further reduce disease reporting as well as the forwarding of pathogens for detailed analysis and epidemiological investigation. Consequently, public health laboratory practices may have to adjust their role in the overall health care system because fewer tests are available to identify new pathogens and their susceptibilities to therapeutic agents. This is coupled with fact that testing is being conducted primarily by three large commercial laboratories that frequently are not in the same state as the contracting HMO. Thus, it seems unlikely that the next outbreak will be detected through a single HMO, making the outbreak more difficult to track.
Given that the current system of managed care is evolving rapidly and that the level of heterogeneity is increasing among HMOs, there is concern that the extensive patient databases maintained by HMOs may remain uncoordinated and poorly networked. Such an outlook may complicate the present tasks of infectious disease surveillance and monitoring and may make it difficult to plan for future surveillance systems. Models of sophisticated, integrated data systems at the local level and of coordinated action to standardize databases and reporting at the regional level may be extended to other levels and specific diseases. Action at the state level may also be needed to improve the ability of the public health system to handle the information and samples provided by HMOs. There appears to be no legal impediment to privatizing or contracting out at least some of the functions of this public health surveillance system. These issues could be examined in a future workshop to examine the capacities of public health systems to respond to emerging infections.