with local physicians and public health agencies in dealing with new or unforeseen problems. It is also anticipated that future increases in NIH's budget will provide additional funding for research on emerging infections.

MANAGED CARE SYSTEMS AND EMERGING INFECTIONS: EDUCATION AND OUTREACH

Presented by William B. Baine, M.D.

Senior Medical Advisor, Center for Outcomes and Effectiveness Research, Agency for Health Care Policy and Research

Although in everyday parlance ''costs" may be conceived of in terms of monetary payments, economic theory considers the costs of medical care to be the resources—physicians and nursing time, chemical and biological products, supplies and equipment, vehicles, and buildings—that are used for patient care instead of other purposes (Garber et al., 1996). Managed care has reduced the level of spending for medical care, but reduced spending is not synonymous with reductions in the underlying cost of that care (Chernew et al., 1997). It is left to the provider to cope with decreased payments for services (Kuttner, 1998). Essentially, providers achieve this by increasing efficiency (e.g., reducing costs themselves) or by reducing care per capita (e.g., abbreviated patient care encounters and the use of fewer diagnostic tests and referrals). In addition, providers attempt to minimize uncompensated care and forego the treatment of patients who have no coverage (insurance) for medical care. They also try to reassign the professional roles of physicians, nurses, and medical technicians, resulting in a broadening of responsibilities, cross-coverage, and decreased specialization. Medical practices and hospitals may also gravitate toward consolidation or even merge to achieve greater economies of scale and to enhance their advantage in contracting with managed care organizations.

These activities pose educational barriers to physicians and other clinical staff, which in turn could hinder the ability to respond to issues dealing with emerging infections. The clinician may have less exposure to patients with infectious diseases, which are more prevalent in uncovered (uninsured) populations; less interaction with subspecialists; less continuity of care and fewer follow-up visits; and less autonomy because of managed care protocols. In addition, interactions between the primary care physician and consultants, as well as continuing education, may be reduced because of the pressures of increased patient volumes. Managed care systems may also foster an atmosphere in which physicians have less time to educate trainees or patients as emphasis is placed on reducing the number of patient encounters and increasing the amount of time spent on documentation. Essentially, the outcome may result in increased dependence on protocols and transforming the functional role of the physician in terms of how much autonomy and judgment are practiced in patient care.



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