Joshua Lederberg, Ph.D.
A common theme that ran throughout the workshop was the heterogeneity and continuing rapid evolution of the managed care industry. Although a few large health maintenance organizations (HMOs) were highlighted as effective research and demonstration partners, it was recognized that others have very different capabilities and corporate cultures, leading to the repeated observation that HMOs, as well as public health agencies and microbiology laboratories, are extremely heterogeneous. As the dramatic restructuring of the nation's health care system evolves, forging better partnerships with managed care systems will likely have a strong positive effect not only on health care delivery but on many aspects of the public health enterprise as well.
Nonetheless, the incentive structure for managed care organizations provides few inducements for such organizations to take the broader and longer term public health-oriented view. Some of the incentives, even those concerning quality assurance for individual patients and for formulary restrictions, may be considered ambiguous and seem to intensify the problems facing public health. Beyond that, however, the evidence regarding managed care's actual performance and impact on emerging infections is at times confusing or missing. Because managed care is not monolithic, some plans have integrated services and sophisticated research capabilities, whereas others provide little more than cost reimbursement for conventional health care services.
Subsequently, it would be unrealistic to expect the managed care industry by itself to develop and implement solutions for the problems identified during the workshop. Yet, it is clear that the managed care industry could become a productive partner in this undertaking, particularly if it obtains financial support to cover the marginal costs of research and demonstration activities. Specific examples include the gathering of drug-dispensing data and crude surveillance of multi-drug-resistance among the organisms that cause tuberculosis and sexu
ally transmitted diseases. It is possible that some HMOs will garner a competitive advantage in being viewed as progressive, research-oriented organizations. Major purchasers of managed care will also have an important role alongside the managed care industry in developing and implementing solutions to confront emerging infections. Likewise, there are ample opportunities for academic health centers and government agencies to play the role of catalyst, as well as partner in research, for greater participation by managed care in addressing the public health threat of emerging infections.
A related common theme was the need for better information to support the provision of quality health care. For example, preliminary studies indicate that formulary practices may have an adverse impact on antibiotic resistance, prompting the need for additional comprehensive data on formulary practices and the impacts that drug formularies may have on infection control. The use of outcomes information was identified as one way of developing and implementing new clinical practice guidelines. One of the most promising fruits from the workshop discussion was the identification of the potential for integrated, computer-assisted medical information systems to assist physicians in diagnosing and treating infectious diseases; to assist managed care organizations in tracking antibiotic use, costs, and outcomes; and to assist public health agencies in monitoring and even preventing emerging infections and antibiotic resistance.
Many of the issues raised during the workshop, including both the use of drug formularies and surveillance, have international as well as domestic implications. In particular, it was explained that there are three health systems in Latin America—private, public, and employee systems—but that many of the providers in the region work with all three systems. As governments face increasing pressure to downsize, the impacts of that change on the vital public health functions of surveillance, control, and prevention of infectious diseases are a shared concern among all systems. In the United States, it is important to involve the National Institutes of Health, the Centers for Disease Control and Prevention, and private groups that are working on these issues in international deliberations. Unfortunately, it was noted that the subject of managed care was not part of the current White House foreign policy initiative in the area of infectious diseases. Nevertheless, the present discussion pointed to the need to bring the private sector into those deliberations in the future.