Primary Care America's Health in a New Era (1996) / Chapter Skim
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F Integrating Our Primary Care and Public Health Systems: A Formula for Improving Community and Population Health
F Integrating Our Primary Care and Public Health Systems: A Formula for Improving Community and Population Health
Pages 341-373
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From page 341... ...
The significance is even further emphasized as government-sponsored health programs at the federal, state, and local levels (e.g., Medicare, Medicaid, Federal Employees Health Benefits Program, CHAMPUS, as well as numerous state and local employee health benefit and worker's compensation programs) move just as aggressively to adopt managed care concepts.
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From page 342... ...
This paper identifies current issues and offers suggestions for integrating concepts to support functional and practical improvement while ensuring population health maintenance and improvement and reasonable access to services in a context of controlled long-term per capita cost. To ensure these desired outcomes, we must expand our vision to encompass both population-based and primary medicine and health care services as a single integrated system; we must work to remove barriers to its formation; we must develop new operating paradigms to ensure its high-quality performance; and we must develop programs to focus its objectives and ameliorate its excesses.
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From page 343... ...
It may now be important to develop a more integrated view of the two, however, because these distinct cultures are increasingly being forced to operate together as a result of a series of broader market reforms. Increasingly, these market reforms emphasize the development of competitive managed care programs and strategies to organize and provide integrated health care and preventive services at controlled cost and quality to defined populations, including most of those formerly cared for directly by local and state health departments.
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From page 344... ...
as fud911ing society's intetast in assmimg cond hons in wb cb people can be bealdby" and i tbe cote funcdons of publio health agencies at all levels of govetnment are assessment, policy development, md assurance" (3, p.
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From page 345... ...
Such a public-private organization would be separate from the health department, would be based on collaborative and partnership principles within and across the community, and would assume significant responsibility for overseeing communitybased programs of health promotion and disease prevention and for providing appropriate linkages between the world of primary and preventive services and public health policy (6~. A more recent and somewhat more functionally oriented definition of public health is provided in the 1994 USPHS Report for a Healthy Nation: Returns on Investment in Public Health (7~.
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From page 346... ...
, and subsequent legislation defining physician payment in terms of the Resource-Based Relative Value Scale. These major legislative initiatives, occurring in combination with the increasingly aggressive adoption of managed care programs by large employers and governmental programs, have begun to force a practical integration of personal and preventive services and the development of population-based management and assurance systems to support this integration.
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From page 347... ...
Over the same period, the focus of the nation's major industries and employers has turned to issues of international competitiveness and cost control focusing on controlling the rapidly rising cost of health care. State and local governments are facing increasingly constrained resources to support rapidly rising health care costs and the competing needs of more effective social, educational, and crime prevention programs.
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From page 348... ...
(13) in their article "Primary and Secondary Prevention Services in Clinical Practice: Twenty Years' Experience in Development, Implementation, and Evaluation." In that article, the authors describe their own and their HMO's experience with primary and clinical preventive services and provide their recommendations for the effective implementation of an integrated population health and primary care model.
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From page 349... ...
(13) have used these concepts to develop an intervention model, summarized in Figure F-2, which specifies three groups of factors necessary to support behavioral change in health professionals and necessary to achieve effective integration of primary and preventive medical services when the professionals deliver those services from an integrated population and individual or personal health perspective.
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From page 350... ...
(131. Although the work makes a significant theoretical and practical contribution to our understanding of the integration and actual delivery of population health and primary care concepts and its application to an organized primary care prac
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From page 351... ...
At this point one could simply conclude that community-oriented primary care is an excellent idea if the population of interest is clearly defined, if the medical practice is organized appropriately, if the financial incentives are appropriately aligned, if the policy support and community service coordination exist, if the staffing is affordable, and if the professionals are appropriately trained. As noted earlier, the COPC model has not expanded its practice base substantially in this country beyond a relatively small number of academia-based urban practices and a number of staff-model HMOs (which place an increasing emphasis on the integration and delivery of clinical and preventive services at the primary care practice level)
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From page 352... ...
Unfortunately, these models are few and far between. MOVING TOWARD AN INTEGRATED COMMUNITY HEALTH SYSTEM: UNDERSTANDING PUBLIC HEALTH AND PRIMARY CARE INTERACTIONS In general, there does not appear to be an effective and integrated working partnership between public health practitioners and community-based primary care practitioners in the local community.
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From page 353... ...
Primary Care Practitioner Perspective: General Comments There is a conceptual gap between the primary care physician and the public health professional: · Primary care physicians are providing care to individual patients and families. · They do not routinely stay in touch with the local health department.
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From page 354... ...
Primary care physicians and public health professionals will need to understand that they often have much in common with each other as they develop the necessary systems solutions to difficult organization problems and as they provide the necessary leadership in these important areas to their communities and to their colleagues within the specialty medical community. Integration of Public Health and Medicine in Education and in Practice Integration of public health and primary care through a shared population perspective has been neither a primary focus nor an inherent value in either the primary care or public health educational and practice cultures.
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From page 355... ...
Many providers feel that the state and local health departments or affiliated and newly formed nonprofit organizations chartered and operating in the public interest should be playing a community-wide role in leading this development. There are related roles in standardizing information systems across health plans and integrated health delivery systems and in supporting patients and families over time as they change health plans and
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From page 356... ...
In short, a kinship and potential for shared perspective and values exist between public health in this context and primary care practitioners. Information to Ensure Market Function and Health Plan Accountability Just as broad-based population health information is essential for ensuring the quality of care currently and longitudinally to populations and communities, it is also essential to improve market function and the public accountability of health plans offered in the market.
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From page 357... ...
At the same time the local health department is often not structured to meet the public health needs of the primary care physician. As noted earlier, this leads to lack of meaningful and/or timely communication between the two groups.
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From page 358... ...
One of the most important functions to be accomplished in this regard will be to ensure the standardization and availability of information to health providers and managed care organizations and to consumers individuals, employers, and government program sponsors. To accomplish this critical function it will be particularly important for public health departments or other designated community health agencies to establish strong operational relationships with managed care organizations and with emerging integrated delivery systems, many of which are combining hospitals and primary care physicians in the same organizational structures.
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From page 359... ...
Finally, significant opportunities exist for health departments, schools of public health, and schools of medicine to collaborate with each other and with these emerging systems of care sharing in research and in training for the future. These partnerships, and those with managed care organizations and emerging integrated health delivery systems, will be critical to ensure the future health of populations and communities.
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From page 360... ...
_ _, 1 ~ ~ ~ = 1 (Health Plans &~` I Learn ~ _ I roams I ~ J Organization, Deliverer & ~ _ Financing of Health Senrices I/ ~ ~ systems J ~ ~ ~~ Primary Care) A_ _ System J— ~ tudividu~s Families Health Status ~ _ , J _ _ ~ r Health Delivery System ~ FIGURE F-3 General community health systems model.
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From page 361... ...
Some of the training will occur within the system through the ongoing performance improvement process. Ultimately, these integrated community health systems must depend on the educational establishment to train a broad range of health professionals (not only primary care physicians)
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From page 362... ...
When the two are combined with each P&PC and the community health agency focuses on monitoring and supporting the health improvement of the same specific populations in an information environment defined and supported through an integrated community health information network and in a context within which the health status impacts of improvements in environmental and occupational health policy and programs are understood and integrated (even if these policies and programs are not, as is most often the case, under the control of the health department) a model for an integrated community health system emerges, as outlined in Figure F-4.
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From page 363... ...
Iurance Fin ~ _~ ~ J ;~ z_ /( antedated P&cPC~ ~ 1, ,] r I ldlleBrated P ~ #2 1~ rim 4 Population # 1 - Elealth Plan # 1 Healtl~ Plan #2 ~ _ ~ ~ FIGURE F-4 The integrated community health system.
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From page 364... ...
diminishing value per dollar spent on health care or on taxes required to support publicly sponsored health care programs increase, changes of this kind are more likely to occur. This will be exacerbated by an increasing public recognition and understanding of the importance of environmental and occupational health programs on personal, family, and community health status.
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From page 365... ...
4. Health departments working collaboratively with providers and health plans should make greater efforts to coordinate community services affecting community health status (e.g., health aspects of social and educational services)
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From page 366... ...
Aligning the statistical perspective of markets and service areas, disease prevention and control, and primary care will ultimately realign the perspectives and ongoing communications patterns of population health and primary care professionals. Noted, at this point, is the fact that multiple health plans and primary care systems will likely serve each primary care market area.
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From page 367... ...
, working in partnership with interested private foundations and with public health leaders, should develop recommendations for a standardized model for training primary care physicians (including training in population health concepts and skills) and for encouraging schools of public health to train population health professionals in the skills and methods previously outlined to support the community practices of primary care physicians.
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From page 368... ...
il Most of the suggestions presented above call for fundamental change at the ndividual program or health department level. This arises from the dramatic changes in the markets for health services and in the significant restructuring, already under way, of our primary care provider, health plan and integrated community health delivery systems.
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From page 369... ...
Mutual changes to a population perspective, service orientation, organizational structure, communications skills and patterns, and rapid movement to a modern information technology base to support population health improvement will lead us where we need to go. Several of these issues were addressed by Joyce Lashof in her 1991 Plenary Address to the AHCPR Conference on Primary Care Research: spectrum of community health problems is more difficult initially but in the long run far simpler than developing separate programs for each risk factor and disease....
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From page 370... ...
Having said this, however, we must acknowledge both the degree and completeness of the change required for state and local public health departments to support our evolving market-oriented structure, particularly in the case of those populations categorically supported for the past 50 years and for those populations for which public health has been the "provider of last resort." Ultimately such a vision and the required reorientation of existing large bureaucratic structures, a task analogous to turning a huge, lumbering oil tanker in a very short distance, is unachievable without four vital resources: political vision combined with appropriate amounts of courage, and willing and appropriately trained personnel and committed leadership supported by adequate resources. To this end the challenges for the nation's schools of public health, medicine, nursing, and allied health professions have never been greater.
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From page 371... ...
We suspect that the perspectives of population health professionals and personal health professionals will continue to exhibit tensions vis a vis priorities and resource allocation. To a large degree this is healthy.
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From page 372... ...
IOM. Community Oriented Primary Care: A Practical Assessment, Vol.
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From page 373... ...
H Health Promotion and Disease Prevention in Health Care Reform.
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