Department of Health and Human Services 
OFFICE OF 
INSPECTOR GENERAL 
PUBLIC HEALTH AND 
MANAGED CARE 
OPPORTUNITIES FOR COLLABORATION 
JUNE GIBBS BROWN 
Inspector General 
JULY 1999 
OEI-01-98-00170  OFFICE OF INSPECTOR GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, is to 
protect the integrity of the Department of Health and Human Services programs as well as the 
health and welfare of beneficiaries served by them.  This statutory mission is carried out through a 
nationwide program of audits, investigations, inspections, sanctions, and fraud alerts.  The 
Inspector General informs the Secretary of program and management problems and recommends 
legislative, regulatory, and operational approaches to correct them. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) is one of several components of the Office of 
Inspector General.  It conducts short-term management and program evaluations (called 
inspections) that focus on issues of concern to the Department, the Congress, and the public.  The 
inspection reports provide findings and recommendations on the efficiency, vulnerability, and 
effectiveness of departmental programs. 
OEI's Boston Office prepared this report under the direction of Mark R. Yessian, Ph.D., Regional 
Inspector General.  Principal OEI staff included: 
REGION  HEADQUARTERS 
Russell W. Hereford, Ph.D., Project Leader  Elise Stein, Program Specialist 
Nicola Y. Pinson 
To obtain copies of this report, please call the Boston Regional Office at (617) 565-1050 
Reports are also available on the World Wide Web at our home page address: 
http://www.dhhs.gov/progorg/oei  E X E C U T I V E  S U M M A R Y  
PURPOSE 
To assess how State public health agencies are taking advantage of opportunities for 
collaboration with managed care plans to further population-based health activities. 
BACKGROUND 
State and local public health agencies carry out a fundamental government responsibility 
to protect the health of the population.  They track disease, intervene in communities to 
control exposures that threaten the population, and respond to changes in communities 
health needs. 
Increasing portions of privately and publicly insured populations are enrolled in managed 
care plans.  As organized systems of care that are increasingly data-driven, managed care 
plans offer public health agencies opportunities to track disease and health trends and to 
mount effective interventions. 
The Department of Health and Human Services has recognized the important influence of 
managed care across many operating divisions.  Within the Department, the Centers for 
Disease Control and Prevention, the Health Resources and Services Administration, and 
the Health Care Financing Administration have initiatives that directly address the impact 
of managed care on public health programs within their purview. 
This inspection utilizes the results of a national survey of State health officers and 
intensive interviews with State and local public health officials to obtain an overview of 
activities that are taking place in this field. 
FINDINGS 
States are giving increased attention to fostering collaborations between public 
health departments and managed care organizations. 
Public health officials in 16 of 47 States responding to our survey reported that their State 
requires managed care organizations to collaborate with public health departments. 
Because collaborations are very recent, measurable accomplishments to date are limited. 
Yet, all 16 of these State officials indicated that they plan to continue the collaborations. 
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Public Health and Managed Care  OEI-01-98-00170  Despite the absence of State law or regulations, another 27 States reported that some 
collaborations are taking place between managed care plans and public health 
departments. 
Collaborations focus predominantly on delivering services, rather than on 
population-based public health activities. 
The majority of States reported that collaborations focus on delivering direct personal and 
medical services to Medicaid eligible individuals enrolled in managed care plans. 
Very few States reported collaborations that link clinical activities of managed care 
organizations with population-based functions that are the responsibility of public health 
departments. 
We identified three major areas of challenge that confront collaborations to 
further public health population-based functions. 
Although there is a conceptual alignment between managed care and public health 
concepts of prevention-oriented health services, managed care goals do not translate easily 
into public health goals. 
Managed care operational decisions and activities are affected by multiple stakeholders, 
such as medical providers and private health care purchasers.  Yet, these groups are 
largely absent in planning and implementing the collaborations. 
Despite the potential role that clinical data from managed care plans could play to enhance 
public health activities, States reported extensive obstacles that hinder data sharing. 
CONCLUSION 
Based on the findings of our study, we come to one central conclusion:  Collaborations 
that address public health population-based strategies have barely begun.  In fact, the 
current environment may mean that opportunities for realizing the potential of 
collaboration are fading. 
We draw this conclusion from elements we identified in our findings, including the 
traditional isolation between the medical and public health sectors; limited participation 
among key stakeholders; and the resources needed to coordinate data systems and 
collection.  In addition, the situation looks even less promising when one considers 
constraints such as the highly competitive market among managed care organizations and 
their increasing reliance on decentralized network models to deliver services. 
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Public Health and Managed Care  OEI-01-98-00170  OPPORTUNITIES FOR IMPROVEMENT 
Given these constraints, constructive movement toward collaborations to further essential 
public health population-based activities is hard pressed based on good will efforts alone. 
Because regulation of managed care plans occurs for the most part at the State level, the 
Federal role in encouraging MCOs to invest in broad population-based activities is limited. 
But the Department of Health and Human Services can exert an important leadership role 
by encouraging collaboration under its existing authorities. 
To be sure, components within the Department have begun to coordinate their managed 
care and public health activities.  For example, HCFA, HRSA, and CDC have recently 
signed a formal interagency agreement to support data sharing between State Medicaid 
and public health agencies.  These agencies also have supported the development of 
contract specifications that provide guidance on purchasing services such as 
immunizations, tuberculosis, lead paint poisoning, and HIV/AIDS. 
Toward this goal, and with this progress in mind, we offer some options for consideration. 
<	 The Centers for Disease Control and Prevention could incorporate into its program 
announcements and guidance specific language pertaining to coordination of public 
health and managed care activities, including data sharing, where appropriate. 
<	 The Health Care Financing Administration could encourage States to require that 
managed care plans contracting with Medicaid specify how they will work with State 
and local health agencies to identify and achieve public health goals; encourage State 
Medicaid programs to examine sample purchasing specifications as they prepare 
contracts with managed care providers; and encourage managed care plans to share 
HEDIS or other appropriate data with State public health departments in order to 
enhance their surveillance function. 
<	 The Health Resources and Services Administration could work with organizations, 
such as community health centers and Ryan White CARE Act-funded providers, that 
participate in managed care networks to help these providers exchange data with the 
State public health departments. The agency also could foster collaborations by 
encouraging its field units in the Departments Regional Offices to work proactively 
with the States to initiate collaborative activity with managed care organizations. 
COMMENTS ON THE DRAFT REPORT 
Within the Department, we received written comments on the draft report from CDC, 
HCFA, and HRSA.  We also received comments from the Association of State and 
Territorial Health Officials.  Here, we summarize these comments and our response.  We 
have also made a number of editorial and technical changes in the report. 
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Public Health and Managed Care  OEI-01-98-00170  Centers for Disease Control and Prevention (CDC) 
The CDC generally agrees with our report, but asks that we clarify wording regarding the 
emphasis it might place upon activities it funds.  We have adopted, with minor 
modification, the CDCs recommended language because it provides additional specificity 
to further the intent of actions we suggested. 
The CDC also raises concerns that our conclusion is too negative.  We based this 
conclusion on evidence we found   the limited extent and scope of collaborative efforts, 
and the formidable constraints that confront them. 
Health Care Financing Administration (HCFA) 
The HCFA concurs with the opportunities for improvement we identified.  The HCFA 
questions whether it should require Medicaid plans to share HEDIS data with public 
health agencies.  We believe that HCFA could exert leverage for further collaboration by 
requiring the sharing of such data.  We modified language to address HCFAs concern. 
The HCFA also asks us to seek input of State Medicaid directors.  We carefully weighed 
such a survey, but opted to focus on public health departments in order to find 
collaboration occurring among private sector, as well as in Medicaid managed care plans. 
Health Resources and Services Administration (HRSA) 
The HRSA asks that we replace our suggestion that HRSA require States to provide 
information on linkages with language to encourage the development of voluntary 
reporting measures on such linkages.  In response, we modified the report to address 
HRSAs concern.  Such information would provide HRSA with a baseline from which the 
agency could develop technical assistance, training, information dissemination, and 
evaluation efforts through its Center for Managed Care. 
Association of State and Territorial Health Officials (ASTHO) 
The ASTHO raises concerns that our report does not adequately reflect the work 
regarding collaborations that focus on service delivery.  We do not diminish the 
importance of these services.  Rather, this report focuses on population-based activities. 
The ASTHO indicates that, while it may be true that State and local public health officials 
are missing out on opportunities, our report seems to indicate that the problem lies solely 
with health departments.  We do not ascribe blame to any sector.  Our text indicates the 
challenges that confront both the public health and managed care sectors. 
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Public Health and Managed Care  OEI-01-98-00170  T A B L E   O F   C O N T E N T S  
PAGE 
EXECUTIVE SUMMARY  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1

INTRODUCTION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  6

FINDINGS

Collaborations Increasing  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  9

Few Population-Based Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  11

Obstacles to Collaboration  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  14

CONCLUSION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  17

OPPORTUNITIES FOR IMPROVEMENT  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  18

COMMENTS ON THE DRAFT REPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  21

APPENDICES

A:  Text of Comments on the Draft Report  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  24

B:  Frequency Responses to Mail Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  36

C:  Endnotes  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  45

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Public Health and Managed Care  OEI-01-98-00170  I N T R O D U C T I O N  
PURPOSE 
To assess how State public health agencies are taking advantage of opportunities for 
collaboration with managed care plans to further population-based health activities. 
BACKGROUND 
Public Health Population-Based Functions 
State and local public health agencies carry out a fundamental government responsibility 
to protect the health of the population at large.  This public health responsibility relies on 
population-wide surveillance systems that provide basic information for public health 
officials to track and trace disease within communities, intervene in communities and 
control exposures that are threats to the population, and develop appropriate policies and 
programs that respond to the changes in health status and health needs of communities. 
Over the past several decades, public health departments have also taken on a role in 
providing medical care to low-income and uninsured populations.  As States shift 
increasing portions of Medicaid and low-income populations into private managed care 
plans, the role of public health agencies is also changing.  In many States, public health 
agencies are lessening their role in the provision of clinical services, and turning increased 
focus toward population-wide strategies that make communities a healthier place to live. 
Opportunities for Collaboration with Managed Care Organizations 
Public health agencies and managed care organizations (MCOs) have the potential to 
combine efforts to pursue activities that neither system can do alone.  With timely and 
accurate data from managed care organizations, public health agencies can identify 
changes and trends in key health indicators, and mount effective interventions.  In turn, 
managed care organizations can benefit from effective public health population-based 
practices that prevent medical problems. The Institute of Medicine recently reported, If 
the proper kind of partnerships between managed care organizations and government 
public health departments are developed, managed care can indeed make an important 
contribution to improving the health of the public.1 
We identified five key characteristics of managed care plans that present a unique 
opportunity for public health agencies in pursuing population-based strategies: 
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Public Health and Managed Care  OEI-01-98-00170  1.  Managed care organizations are responsible for providing health care services 
to increasing numbers of both privately and publicly insured populations.  State 
governments are using managed care for most or all of their Medicaid programs. 
2.  Managed care organizations and public health departments share interests in 
prevention-oriented activities.  Under a capitated system, MCOs have financial 
incentive to support public health prevention activities in order to reduce cost of 
expensive medical interventions. 
3. Managed care organizations represent organized care systems that focus on 
defined populations.  In contrast to loosely integrated individual providers and 
patients in the fee-for-service system, managed care systems offer a more 
consolidated potential for communication with the public health system. 
4.  Health care services and quality in managed care plans are increasingly data 
driven, offering public health opportunities to track disease and health trends 
among communities.  Managed care plans maintain and continue to develop data 
systems to measure performance and improve quality of services; States are also 
employing external systems of measurement (e.g., HEDIS 3.0).  These systems 
could provide timely and accurate data that are necessary for public health to 
mount effective interventions. 
5.  Managed care organizes individual physicians into larger networks and may 
sponsor continuing education, practice guidelines, and other influences over 
physician practices. 
The Federal Interest in Fostering Collaboration 
The Department has recognized the important influence of managed care across many 
operating divisions.  The Centers for Disease Control and Prevention, the Health 
Resources and Services Administration, and the Health Care Financing Administration all 
have initiatives that directly address the impact of managed care on public health programs 
within their purview. 
The new Strategic Plan for the Department notes that the shift to managed care heralds a 
changing role for health agencies, especially the opportunity to concentrate on providing a 
full range of essential public health services.2 
The Centers for Disease Control and Prevention (CDC) maintains a particular interest in 
ensuring that data collection and disease surveillance systems are operating effectively to 
ensure the health of the public.  The CDC has supported several grants to strengthen State 
public health infrastructures and improve the integration of information systems.  These 
include, for example, the CDC Assessment Initiative and the CDC Information Network 
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Public Health and Managed Care  OEI-01-98-00170  for Public Health Officials (INPHO) grant. 
The Health Resources and Services Administration (HRSA) established a Center for 
Managed Care in 1996 to provide technical assistance, training, information dissemination, 
and evaluation on managed care issues that cross all of HRSAs programs.  The Center is 
responsible for assuring that HRSA's programs and the underserved and vulnerable 
populations they serve are active and knowledgeable participants in managed care 
systems.3 
The Health Care Financing Administration (HCFA) has supported the development of 
managed care for beneficiaries in both the Medicaid and Medicare programs.  The 
intersection between Medicaid managed care and public health agencies is of particular 
note in specifying coordination of essential public health services that occur outside the 
clinical environment.  In addition, public health agencies can play a role in developing 
quality indicators to monitor the performance of plans. 
METHODOLOGY AND SCOPE 
The intent of this inquiry is to provide a national overview of the extent to which State 
public health departments are pursuing collaborative opportunities with managed care 
organizations. We focus on an assessment of the extent and overall nature of these 
relationships, excluding attention to specific details of individual case studies. 
Data collection for this inspection comprises three parts: 1.)  A national mail survey of 
State Health Officers conducted in June 1998.  We focused on State Health Officers 
because we determined that the State Health Department would be in the best position to 
know about population-based public health activities; 2.)  Structured follow-up telephone 
interviews with State and local public health officials to obtain a more in-depth 
understanding of the activities that are taking place in this field.  We also conducted 
structured interviews with several representatives of the managed care sector; 3.)  An 
intensive site visit to Minnesota, a State with legislatively mandated collaboration between 
managed care plans and the public health community. 
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Public Health and Managed Care  OEI-01-98-00170  F I N D I N G S  
States are giving increased attention to fostering collaborations 
between public health departments and managed care 
organizations. 
Public health departments in 16 of 47 States responding to our survey reported 
that their State requires managed care organizations to collaborate in some way 
with public health departments. 
Within the last several years, States have established a range of requirements that 
encourage collaborative activities between public health departments and managed care 
organizations.  Six of the 16 States require all managed care organizations to collaborate 
with local or State public health departments.  Twelve States require collaboration in their 
Medicaid managed care contracts.  Two States require collaboration in both the Medicaid 
contract, as well as more broadly among all MCOs. 
Minnesota and New York, for example, require all State-regulated MCOs to collaborate 
with local health departments.  In Minnesota, State law requires MCOs to develop 
collaboration plans in conjunction with local health departments.  Each MCO must submit 
collaboration plan documents biennially to the Minnesota Department of Health.  These 
documents describe how the MCO will work with local or State public health departments 
toward achieving public health goals.  In New York, the Department of Health requires 
MCOs to coordinate specific public health related services, such as communicable disease 
control, with local public health departments. 
The majority of the 16 States require collaboration in the Medicaid contract with MCOs. 
We identified two ways that States require collaboration in Medicaid contracts.  First, 
most contracts require MCOs to reimburse public health departments for delivering 
specific services to enrollees.  These include services that public health department 
traditionally provided for Medicaid clients, such as immunizations, family planning, 
prenatal and postnatal care, and STD services.  Second, some contracts require 
coordination between clinical services and population-based public health services.  For 
example, the Michigan Medicaid contract developed a detailed matrix that specifies 
essential roles for the State health department, local health departments, and MCOs 
regarding eight services provided by MCOs, such as services for communicable disease 
and lead poisoning. 
In addition to the 16 States with formal requirements, another 9 States indicated that they 
are very likely to establish collaborations in the next 2 years.  Texas, for example, will 
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Public Health and Managed Care  OEI-01-98-00170  implement requirements for formal agreements between local health departments and 
MCOs in two regions of the State by 1999. 
Because collaborations are very recent, measurable accomplishments to date are 
limited.  Yet, all 16 of these State officials indicated that they plan to continue the 
collaborations. 
Very few States employ specific performance measures to evaluate their collaborative 
activity or progress.  Some States reported plans to gauge their collaborative impact 
through HEDIS or other MCO quality performance measures.  Yet overall, States 
reported, as one State health department summarized, future goals to explore more 
specific data and measurement issues, including building a set of common indicators or 
standards to evaluate the effectiveness of collaborative efforts.  Most of these 16 States 
reported progress in developing relationships between MCOs and public health 
departments as their most significant accomplishments to date. 
States described future expectations to strengthen linkages between the clinical activities 
of managed care organizations and population-based functions of public health 
departments. These expectations include collaborations that would strengthen public 
health surveillance systems to track and trace disease in communities, conduct appropriate 
environmental interventions, identify community health needs and gaps in services, and use 
data in planning and policy development. 
Despite the absence of State law or regulations, another 27 States reported that 
some collaborations are taking place between managed care plans and public 
health departments. 
Several voluntary initiatives underway reflect a growing awareness on the part of both the 
public health and the managed care sectors of mutual benefits to be gained from working 
with each other.  Many communities are getting together without auspices of formal 
requirements. 
As an example of an innovative collaborative initiative, the HHS Regional Directors 
Office in New England has initiated a Public Health/ Managed Care Collaborative 
Initiative.  Public health officials and managed care representatives in the six New England 
states (Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, and Connecticut) 
are discussing collaborative opportunities in areas of asthma detection and prevention, 
tobacco control, and improving childhood immunization rates. 
- 10 -
Public Health and Managed Care  OEI-01-98-00170  Collaborations focus predominantly on delivering personal 
health and medical care services.  Collaborations that address 
population-based public health activities are much less 
common. 

The majority of States reported that collaborations focus on delivering direct

personal and medical services to Medicaid eligible individuals enrolled in

managed care plans. 

Twelve of the 16 States reported that collaborations focus activity on direct-care services. 
The Medicaid managed care contract serves as the primary vehicle for most of these 
collaborations.  Some States encourage health departments to become a part of the 
managed care plans network of providers.  Other States require health plans to reimburse 
local health departments for delivering certain services. 
We identified two primary activities that comprise the direct-care services that 
collaborations address.  First, States reported collaborations that focus on direct medical 
services that local health departments have traditionally provided to Medicaid clients. 
These include services for communicable diseases, clinical preventive services, and 
primary care services.  For example, Colorado law requires Medicaid MCOs to contract 
with local health departments for direct care services.  Oregon requires contracts between 
Medicaid managed care plans and local health departments in order to specify how 
reimbursement will occur for STDs, TB, and family planning services. 
Second, State health departments reported significant activity in providing direct care 
services that complement medical services delivered to Medicaid populations.  For 
example, New Mexicos three Medicaid MCOs contract with the Department of Health 
for the Department to offer and provide prenatal and infant/child case management 
services to eligible pregnant women.  In Tennessee, local health departments provide 
outreach, education, and case management services to Medicaid clients enrolled in 
managed care plans. 
We heard three primary reasons that States give priority to arrangements around the 
delivery of direct-care services.  First, the public health system has built considerable 
expertise over the past several decades in addressing obstacles that Medicaid populations 
face in accessing medical services.  Twelve States reported significant concern within the 
public health community about losing their role in service delivery to managed care 
organizations.  Repeatedly, public health officials expressed concern over the ability of 
managed care organizations to meet the diverse set of needs of Medicaid clients, that are 
often not apparent in delivering services to their commercial populations. 
Second, reimbursements from managed care organizations for direct care services allow 
public health departments to continue their clinical and direct care programs.  Over the 
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Public Health and Managed Care  OEI-01-98-00170  past several decades, Medicaid reimbursements for direct care services have been 
significant sources of revenue supporting several types public health programs and 
functions.  With major shifts of Medicaid populations into managed care plans, these 
funding streams have also shifted, confronting the public health system with significant 
losses in revenue.  Health departments also expressed concern that the complete absence 
of clinical services from their programs will not allow them resources to provide services 
to the uninsured or homeless, functions which the public health community views as a 
fundamental responsibility. 
Third, health departments reported concern over health services delivered through 
managed care organizations that are especially dependent upon coordination between 
clinical and population-based activities.  For example, if a managed care organization 
identifies and treats an enrollee with a sexually transmitted disease, how should the MCO 
coordinate follow-up STD contact tracing?  Who is responsible for treating partner-
contacts who are not a part of the MCO enrolled population? 
Very few States reported collaborative activities that link the clinical activities of 
managed care organizations with population-based functions that are the unique 
responsibility and authority of public health departments. 
Because MCOs are organized systems of medical care for defined populations, the medical 
information and data that they maintain could greatly strengthen public health department 
surveillance systems to facilitate activities that protect the health of the population at-
large.  These activities include tracking and tracing disease in communities, identifying 
community health needs, identifying emerging public health issues, and activating 
appropriate community interventions. 
However, based on our survey, States reported few collaborative activities that are taking 
routine advantage of clinical information from MCOs to perform essential public health 
population-based functions.  Only four States reported that their collaborations involve 
sharing disease incidence data; six States reported sharing reportable disease data; and 
only two States reported sharing environmental exposure data.  None of the States 
indicated collaborative activity that facilitates public health environmental interventions 
based on managed care clinical information. 
States reported slightly more collaborative activity that increases managed care 
involvement in communities beyond their enrolled populations.  For example, six States 
reported collaborative activity in health education campaigns; and eight States indicated 
activity in planning and policy development.  Overall, however, these activities are not 
based on data that systematically identify community health needs.  One managed care 
representative summarized these activities as the philanthropic side of managed care that 
fits into their community benefit activities, but does not affect their core business 
operations, such as medical practices and medical data. 
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Public Health and Managed Care  OEI-01-98-00170  The potential of linkages between managed care clinical activities and essential public 
health functions can be seen in efforts underway in a few States.  For example, New York 
and Michigan use guidelines to facilitate coordination between managed care clinical 
activities and public health population-based functions.  The guidelines specify essential 
responsibilities of managed care organizations and public health departments for specific 
issues of public health importance.  These essential activities include, for example, 
delivering medical services, conducting appropriate follow-up or environmental 
interventions, reporting disease incidence, conducting disease surveillance, coordinating 
community resources, and developing educational materials.  Public health issues 
addressed include communicable disease control, STDs, HIV/AIDS, TB, cancer, diabetes, 
lead poisoning, rabies, and immunizations. 
Oregon also reported collaborative activity intersecting managed care clinical and public 
health population-based functions.  The Department of Health has initiated a Managed 
Care/ Public Health Assessment Initiative, which requires managed care organizations to 
share encounter data on their Medicaid populations.  Data from this initiative are being 
analyzed to pinpoint incidence and prevalence of diabetes and breast cancer among 
Medicaid beneficiaries. 
Five States also indicated collaborative activity to develop population-based data 
registries.  Generally, these registries involve the centralized collection of immunization 
data.  As an example of a promising activity in this regard, Missouri has developed a state-
wide central immunization registry that is planned as part of a larger integrated 
information system of all public health functions.  The project has attracted active 
managed care participation and interest.  One public health department official explained, 
because populations are constantly moving in and out of MCOs, they see a particular 
advantage to accessing immunization histories for current and new enrollees. 
Both the Oregon and Missouri projects are supported in part through a CDC grant to 
facilitate development of integrated State information systems. 
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Public Health and Managed Care  OEI-01-98-00170  We identified three major areas of challenge that confront 
collaborations to support public health population-based 
functions. 
Although there is a conceptual alignment between managed care and public 
health concepts of prevention-oriented health services for defined populations, 
the managed care goals do not easily translate into public health goals. 
We heard three fundamental differences that it make it difficult to establish managed care-
public health relationships. 
First, the two sectors have traditionally operated in isolation from each other; they often 
have minimal understanding of what the other does and how these activities might 
intersect in collaborative work that truly benefits both partners.  Thirteen States indicated 
a lack of awareness within the managed care community of public health activities as a 
significant obstacle hindering collaboration.  Nine States indicated in our survey that lack 
of knowledge about managed care posed significant obstacle to collaboration. 
We heard several examples that demonstrate the isolation of both sectors.  First, managed 
care organizations commonly do not understand the population-based functions conducted 
by public health departments.  One expert identified common managed care perceptions of 
public health departments as synonymous with the Medicaid agency, or public providers 
of health care services.  In addition, managed care representatives often understand public 
health activities as preventive clinical services for populations of people. In sum, MCOs do 
not recognize how they can contribute to a unique role for public health departments that 
extends beyond the MCOs own capacity and authority. 
We also heard repeated comments that public health is not abreast of managed care 
market environment, which inhibits efforts to coordinate and communicate effectively. 
One expert told us that, Public health likes to think of managed care organizations as the 
old staff-model HMO.  In reality, managed care organizations represent a variety of 
rapidly evolving prepaid health care systems, ranging from non-profit to for-profit entities, 
and from tightly managed staff model systems, to relatively loose configurations of 
provider networks. 
Second, there are very different financial incentives between the two cultures.  Eleven 
States reported a general distrust of managed care plans as a significant obstacle; managed 
care expressed frustration with lack of public health appreciation for managed care cost 
considerations.  MCOs are operating in a competitive business environment, where short-
term cost savings are paramount.  Operational activities and decisions are based on a 
narrow analysis of the cost and benefits of health care services provided to their enrolled 
populations.  Any expansion of benefits means an increased premium that must be paid by 
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Public Health and Managed Care  OEI-01-98-00170  enrollees and affects their financial bottom line.  Public health departments, on the other 
hand, are carrying out broad-based social responsibility to ensure the health of the public 
at-large.  It is often difficult to measure the significance of these activities in a narrow 
cost-benefit analysis.  In addition, because public health activities are paid for through 
governmental revenues, the actual costs are much more diffuse. One managed care 
representative summarized differences, Public health has a fundamental charge to reduce 
human suffering and disease for the population at-large.  Health plans are charged with 
how to pay for specific health care services for their enrolled populations. 
Third, States reported obstacles to communication between the two sectors.  For example, 
organizational vocabularies demonstrate fundamental differences.  We heard one example 
in the way public health and managed care communities understand the term risk.  In the 
public health world, the term risk refers to health conditions that people might suffer 
from (i.e. risk of cancer).  In the managed care world, the term risk translates into the 
financial burden resulting from utilization of medical services.  Another example is the 
reference to the term population.  Public health officials are thinking in terms of entire 
community or state populations.  Managed care organizations focus on their enrolled 
populations.  Finally, collaborative members reported confusion over the term provider. 
Public health officials commonly referred to the MCOs as providers; while MCOs referred 
to networks of medical practitioners as providers.  This confusion reflected common MCO 
frustration with lack of public health awareness of limitations of MCO influence over 
provider practices. 
Managed care operational decisions and activities are affected by multiple 
stakeholders in the health care environment, such as medical providers and 
health care purchasers.  Yet, these groups are largely absent in planning and 
implementing the collaborations. 
State survey responses indicated that the groups planning and implementing the 
collaborations are overwhelmingly composed of health departments, the Medicaid 
agencies, and managed care representatives.  We identified three key groups that are 
largely absent from the collaborative planning and implementation process. 
First, members of collaborative groups reported repeatedly the importance of input and 
involvement from medical providers.  Yet, only three States reported involvement of 
medical providers in planning the collaborations.  Ten States indicated the lack of priority 
of this activity among providers as a significant obstacle hindering collaborations.  One 
member of a collaborative group summarized the absence of providers as, There is a lot 
of dialogue between MCOs and public health departments.  But when the rubber hits the 
road, its at the provider level.  Managed care increasingly is evolving away from tightly 
integrated staff-model HMOs, yet plan representatives told us they found public health 
misperceptions of MCOs ability to direct and influence provider behavior. 
- 15 -
Public Health and Managed Care  OEI-01-98-00170  Second, fourteen out of the 16 States reported no or limited roles of purchasers in 
planning or implementing the collaborations.  Yet, twelve States reported a lack of 
purchaser interest in supporting managed care collaborative activities with public health 
departments as a significant obstacle hindering collaboration.  Managed care 
representatives repeatedly reported that the influence that purchasers exert over MCO 
activities is poorly understood.  Repeatedly, members of collaborative groups reported the 
need to increase purchaser interest in the potential business benefits of public health 
population-based preventive functions. 
Third, States reported little to no involvement of other community health-related 
organizations.  Attention to these organizations is important to integrate the collaborative 
activities with existing community efforts and resources.  Despite the potential role these 
groups might play, much of the collaborative activity has focused on managed care and 
public health relationships, and has not yet filtered out into broader community groups. 
Despite opportunities for managed clinical data to further public health 
population-based activities, States reported extensive obstacles hindering 
activities to share data. 
States identified major obstacles for sharing data that fall into three major categories. 
First, eleven States indicated technical difficulties in matching data systems are an obstacle 
hindering collaboration.  Collaborations must address the differences between public 
health and managed care data elements in order to use managed care data in a public 
health context.  For example, public health collects data based on conditions, such as 
cancer; managed care data rest on medical services that are delivered and paid for by the 
MCOs, such as chemotherapy or surgeries rendered for patients with cancer. 
Second, we heard about proprietary concerns for releasing data.  For example, ten States 
indicated that managed care organizations fear that data will be used for regulatory 
purposes.  Eleven States indicated competition among health plans hinders data sharing. 
One managed care representative summarized, Even if the MCO is not against releasing 
the data, it needs a good reason to let data leave the plan.  Otherwise releasing the data 
presents a potential vulnerability for competitors to use data in some competitive manner 
they are not yet aware of. 
Third, there are privacy issues around patient confidentiality and sharing personal medical 
information.  Whenever personal information is released, there is a vulnerability for 
misuse.  In some cases privacy issues present significant barriers.  For example, Minnesota 
was unable to pass legislation for a statewide immunization registry because of an existing 
law barring the release of personal immunization information. 
- 16 -
Public Health and Managed Care  OEI-01-98-00170  C O N C L U S I O N  
Significant attention has focused recently on opportunities for collaboration between 
managed care organizations and public health departments:  potential for comprehensive 
approaches that intersect the patient-oriented practice of medicine and the population-
based strategies of public health.  As organized, data-driven systems of medical care 
delivery, MCOs could facilitate health departments ability to track disease, identify 
outbreaks, and implement effective interventions that meet communities needs. 
Based on the findings of our study, however, we come to one central conclusion: 
Collaborations that address public health population-based strategies have barely begun. 
When we began this study we expected to find numerous examples of how health 
departments are working with MCOs to obtain information that assists them in carrying 
out their responsibility for the health of the population at large.  To date, however, most 
collaborations have focused on arrangements for delivering services to individuals, not on 
population-based public health.  We recognize the vital public health importance of 
medical care services, but we focus our attention here toward population-based activities.4 
Despite conceptual links between the two sectors activities, our report identifies 
significant constraints that inhibit these types of collaborations. 
<	 Isolation.  Traditional isolation between the medical and public health sectors 
compounds the odds against productive areas of collaboration that recognize the 
essential and unique roles of each sector. 
<	 Limited stakeholder participation.  Limited involvement of health care providers 
and purchasers narrows the base of support needed for MCOs partnership in public 
health population-based practices. 
<	 Data challenges.  Demands for time, money, and other resources challenge the ability 
to coordinate data systems and collection. 
In fact, the current environment may mean that opportunities for collaboration are fading. 
<	 Competition.  The MCO market is highly competitive.  Performing a broad-based 
community function reaching beyond the enrolled population is unlikely where the 
short-term bottom line is paramount, unless all plans make the same contribution. 
<	 Growth of networks.  The evolution of managed care toward decentralized network 
models further erodes the potential for collaboration with organized systems of care. 
- 17 -
Public Health and Managed Care  OEI-01-98-00170  O P P O R T U N I T I E S   F O R  
I M P R O V E M E N T  
Given these constraints, constructive movement toward collaborations to further essential 
public health population-based activities is hard pressed based on good will efforts alone. 
Because regulation of managed care plans occurs for the most part at the State level, the 
Federal role in encouraging MCOs to invest in broad population-based activities is limited. 
The Department of Health and Human Services can exert an important leadership role by 
encouraging collaboration under its existing authorities.  Because many Departmental 
activities cut across individual agency lines, fostering interagency coordination and 
collaboration will be critical.  To be sure, components within the Department have begun 
to coordinate their managed care and public health activities.  For example, HCFA, 
HRSA, and CDC have recently signed a formal interagency agreement to support data 
sharing between State Medicaid and public health agencies. 
Another important step toward collaboration is the development of sample purchasing 
specification language for use by State Medicaid offices when they contract with managed 
care plans.  These purchasing specifications were developed by the George Washington 
University Center for Health Policy Research, under contract with HRSA and CDC and 
with input from HCFA.  The specifications provide a base structure to establish and 
negotiate collaboration among public health agencies, purchasers of publicly-funded health 
services, and managed care plans.  Additionally, the specifications address public health 
issues, quality assurance, data collection and sharing, memoranda of understanding, 
surveillance, and information systems. 
Toward this goal, and with this progress in mind, we offer some options for consideration. 
Agencies within the Department could adapt these to further enhance the coordination and 
collaboration between managed care and public health. 
<	 The Centers for Disease Control and Prevention could place emphasis in the 
appropriate activities it funds on projects that focus on integrating the data and 
communications infrastructure and improving data sharing between public health 
departments, Medicaid agencies, and managed care organizations.  The CDC already 
supports some collaborative activities.  Among the State collaborations we examined, 
Minnesota, Oregon, and Missouri identified support from CDCs Assessment 
Initiative, a cooperative agreement program intended to help States improve data 
coordination and integration as a way of developing information for improved policy 
making.  Missouri noted that it also is receiving CDC support under the Information 
Network for Public Health Officials (INPHO) project, designed to assist States to 
develop the infrastructure and support needed for effective information and 
- 18 -
Public Health and Managed Care  OEI-01-98-00170  surveillance systems.  As it awards future funding under these authorities, the CDC 
might wish to pay particular attention to projects that help State public health 
departments determine how they can work with organized delivery systems to design 
information systems that enhance their capacity and ability to share surveillance data. 
The CDC also could require States to submit information on the extent to which the 
programs the agency funds work with managed care organizations.  For example, the 
CDC might require States to document the extent of MCO reporting to 
communicable disease or cancer registries. 
<	 The Health Care Financing Administration could encourage collaboration by 
developing guidance for States on the kinds of public health activities that might be 
included in Medicaid managed care contracts.  For example, the HCFA might 
encourage States to require that managed care plans contracting with Medicaid 
specify how they will work with State and local health agencies to identify public 
health goals, and how they will work with the agencies to achieve these goals. 
The HCFA also might provide specific guidance to States on guidelines that could be 
communicated to health plans.  For example, the sample purchasing specifications 
noted previously could be used by State Medicaid programs as a tool to help identify 
key issues and decision points as they prepare their purchasing agreements for 
services such as immunization and lead poisoning screening, prevention, and 
treatment.  The HCFA could encourage States to review and consider the 
appropriateness of these specifications, and how they could be adapted to the unique 
needs of each States Medicaid program.  The sample purchasing specifications may 
be found at http://www.gwumc.edu/chpr. 
The HCFA could also encourage managed care plans, both Medicaid and or 
Medicare, to share HEDIS or other appropriate data with State public health 
departments in order to enhance their public health surveillance function.  One way in 
which HCFA could encourage managed care plans to provide such information is 
through the QISMC (Quality Improvement System for Managed Care) that Medicare 
managed care plans and many State Medicaid plans are using.  The QISMC uses 
HEDIS as a major data collection instrument.  Consequently, QISMC provides one 
opportunity through which health plan contracts for both Medicare and Medicaid 
might place emphasis on incentives to share information with public health agencies. 
. 
<  The Health Resources and Services Administration could work with organizations 
it funds, such as community health centers, that participate in managed care networks. 
The HRSA could help these providers determine how they might enhance data 
exchange with the State public health departments.  As the agency funds grant 
programs to the States, such as Title V Maternal and Child Health State Block 
Grants, HRSA could encourage States to provide information on the extent to which 
- 19 -
Public Health and Managed Care  OEI-01-98-00170  these programs are linking with managed care organizations to obtain data to further 
the health departments capacity to conduct disease surveillance activities. 
The HRSA also could foster collaborations by encouraging its field units in the 
Departments Regional Offices to work proactively with the States to initiate 
collaborative activity with managed care organizations.  The Regional Offices, in fact, 
may be the best positioned of any Department component to initiate these types of 
activities.  The Regional Health Administrators work with State and local officials on 
multiple health programs funded by the Department.  Consequently, they know and 
are sensitive to the local health care environment and market.  Much could be learned 
from the Region 1 initiative that brings together public health officials and managed 
care executives from the six New England States to develop collaborative strategies. 
These officials and plans are working together to develop guidelines for treating 
asthma, reducing tobacco use, and improving immunization levels, according to 
locally identified needs. 
The HRSA also is sponsoring a series of meetings in conjunction with the American 
Public Human Services Association, which represents State Medicaid directors.  The 
goal is to bring together State public health providers (such as Maternal and Child 
Health program directors, Primary Care Association leadership, and Ryan White Act 
providers) with State Medicaid directors to address issues of mutual concern and to 
create strong working relationships between Medicaid offices and public health at the 
State-level.  The agency could use these, or similar, meetings as a way to encourage 
and involve MCOs, as well as local health departments, in collaborative activities. 
- 20 -
Public Health and Managed Care  OEI-01-98-00170  C O M M E N T S   O N   T H E  
D R A F T   R E P O R T  
We received written comments on the draft report from the Centers for Disease Control 
and Prevention (CDC), the Health Care Financing Administration (HCFA), the Health 
Resources and Services Administration (HRSA), and the Association of State and 
Territorial Health Officials (ASTHO).  In addition, we received verbal comments from 
staff in the Office of the Assistant Secretary for Planning and Evaluation. 
In response to the comments, we have made a number of editorial and technical changes in 
the text.  As suggested by those who commented, we also have included a copy of the 
mail survey, with frequency distribution of responses, as Appendix B of this report. 
Here, we summarize comments from each of the respondents and present our response to 
the salient points that they raised.  The full text of each set of comments is included in 
Appendix A. 
Centers for Disease Control and Prevention 
The CDC generally agrees with our report.  The agency asks that we clarify wording in 
the Executive Summary, regarding our characterization of the emphasis it might place 
upon activities it funds.  We have adopted, with minor modification, the CDCs 
recommended language regarding specific ways of encouraging public health and managed 
care linkage.  We believe that the agencys suggested language provides additional 
specificity regarding actions that it could take to further the intent of actions we 
suggested. 
The CDC asks us to amplify the importance of the contract purchasing specifications 
that we reference.  We recognize these specifications as an important example of 
interagency cooperation among CDC, HCFA, and HRSA, and we have included CDCs 
suggested language in the appropriate section of the report. 
The CDC also raises concerns that our conclusion is too negative.  We based this 
conclusion on evidence that we found while doing our research  the limited extent and 
scope of collaborative efforts, and the formidable constraints that confront such 
collaboration.  We continue to believe that constructive movement toward collaboration 
will not occur naturally; therefore, we encourage the appropriate Federal agencies, 
including CDC, HCFA, and HRSA, to build upon and enhance the leadership efforts that 
they have begun to exert. 
- 21 -
Public Health and Managed Care  OEI-01-98-00170  Health Care Financing Administration 
The HCFA concurs with the opportunities for improvement we identified in our report, 
but the agency raises a number of issues to which we wish to respond. 
We are encouraged by the agencys interagency agreement with HRSA and CDC to 
support data sharing between Medicaid and public health agencies.  We view this as an 
important step.  We agree with HCFA that all three agencies should exchange ideas and 
analysis, as well as data, as a way of furthering collaboration. 
The HCFA questions whether it should require Medicaid plans to share HEDIS data with 
State public health agencies.  We believe that HCFA could exert leverage for further 
collaboration between State Medicaid programs and managed care plans by requiring the 
sharing of such data.  Efforts that encourage Medicaid agencies to coordinate sharing of 
information and data with public health agencies are an important step in this direction. 
The HCFA also asks us to seek the input of State Medicaid directors.  In the course of 
research for this inspection, we carefully considered surveying all Medicaid directors, but 
opted to focus our survey on public health departments for two reasons.  First, we 
intentionally wished to examine the topic of collaboration from the public health agency 
perspective, rather than the perspective of contract purchasing arrangements under 
Medicaid.  Second, we had hoped to find collaborations occurring in the private managed 
care sector (as we found in a few States), as well as Medicaid managed care plans. 
Health Resources and Services Administration 
The HRSA asks that we replace our suggestion that the agency require States to provide 
information on linkages with language to encourage the development of voluntary 
reporting measures, which the agency has developed in negotiations with the States.  In 
response, we modified our language.  We encourage the agency to work with States and 
organizations through grant-funded programs to enhance information exchange on the 
extent of linkages between States and managed care plans.  We believe that having such 
information available would provide HRSA with a baseline from which the agency could 
develop further efforts in this area.  We believe that having such information is critical for 
HRSA as it develops the capacity of its Center for Managed Care to provide technical 
assistance, training, information dissemination, and evaluation on managed care issues that 
cross all of HRSAs programs as noted in its comments. 
The HRSA also notes that a major focus of its efforts is on quality of care and service 
delivery, while obtaining data on disease surveillance is a major focus of the CDC.  The 
reasoning underlying this report and other efforts associated with encouraging 
collaboration, is that such linkages are vital for effective public health intervention in both 
population-based health surveillance and service delivery strategies. 
- 22 -
Public Health and Managed Care  OEI-01-98-00170  Finally, we note HRSAs statement, many States are not experienced in delivering 
population-based health services.  We believe that although public health has increasingly 
focused on the delivery of personal care services over the past several decades, an 
important segment of the public health community continues to carry out essential 
population based functions.  It is toward this segment of the public health community that 
we encourage enhancement and growth through relationships with managed care plans. 
Association of State and Territorial Health Officials 
The ASTHO raises concerns that our report does not adequately reflect the work being 
done in many States, particularly the vital public health importance of collaborations that 
focus on delivery of services, as opposed to population-based activities.  We do not in any 
way wish to diminish the importance of these services.  Rather our intent was to focus on 
population-based activities.  We have added language to the report the reflects the vital 
public health role that delivery of specific public health services plays. 
The ASTHO indicates that, while it may be true that State and local public health officials 
are missing out on opportunities, our report seems to indicate that the problem lies solely 
with health departments.  We do not mean to imply that this situation is solely the fault of 
public health departments.  We do not ascribe blame to either sector.  Our text indicates 
clearly responsibilities and challenges that confront both the public health and the managed 
care communities.  We address, for example, the lack of financial incentives for 
collaboration among both the public health and managed care sectors, and we noted the 
increasingly competitive market environment in which managed care plans operate.  We 
certainly agree that it would behoove both the public health and managed care 
communities to carry out additional research on the costs and benefits of collaboration. 
The ASTHO questions why we focus our suggestions for improving collaboration only 
toward Federal agencies, rather than toward the States, as well.  Our jurisdiction is with 
Federal agencies only, and we do not direct suggestions and recommendations at State 
and local governments regarding their operations.  Instead, in this report we call on our 
Federal colleagues to exert leadership to encourage collaborations among their partners at 
the State and local levels.  We recognize that moving forward in the endeavors we 
describe here will take concerted effort and cooperation at all levels. 
The ASTHO also urges us to acknowledge current literature that is addressing 
collaboration such as we describe here.  As part of our research for this report, we 
examined that work, particularly the work cited in the ASTHO comments.  This literature 
is a new and important contribution to the increasing attention being paid to collaboration 
between managed care and public health.  The recent attention being paid to this field 
reflects, we believe, the types of issues and steps we identify in our analysis. 
- 23 -
Public Health and Managed Care  OEI-01-98-00170  APPENDIX A

FULL  TEXT  OF  COMMENTS 
ON DRAFT REPORT 
PAGE 
Centers for Disease Control and Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  25

Health Care Financing Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Health Resources and Services Administration  . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Association of State and Territorial Health Officials  . . . . . . . . . . . . . . . . . . . . . . 34

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Public Health and Managed Care  OEI-01-98-00170  - 31 -
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Public Health and Managed Care  OEI-01-98-00170  - 34 -
Public Health and Managed Care  OEI-01-98-00170  - 35 -
Public Health and Managed Care  OEI-01-98-00170  APPENDIX B

FREQUENCY DISTRIBUTION OF MAIL SURVEY 
U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES

OFFICE OF INSPECTOR GENERAL

OFFICE OF EVALUATION & INSPECTIONS

Survey of State Health Officers 
This survey is part of a study being conducted by the Office of Inspector General, U.S.

Department of Health and Human Services.  The purpose of the study is to assess the extent to

which State and Local public health departments are collaborating with managed care plans to

further public health activities. 

This survey seeks basic information about collaborations between health departments and

managed care plans.  For the purposes of this survey, our concern is with managed care plans,

such as health maintenance organizations and similar entities, that are licensed or regulated by

your State.

Information that you provide in this survey will help us to develop a comprehensive national

picture of collaborations between public health departments and managed care plans.  We are also

interested to learn details about any innovative activities taking place in your State.

Please identify your State and the name of the person completing the survey in case we need

additional information or clarification:

State:  Frequency Distribution of 47 Survey Responses

Name of person completing survey:______________________________________________

Title and Department:_________________________________________________________

Phone number and email:______________________________________________________

_ 
Please return your completed survey by Friday, June 19. 
Return the survey either by Fax to (617) 565-3751, 
or in the enclosed business reply envelope to: 
OIG-OEI Room 2475, JFK Federal Building, Boston, MA 02203 
If you have any questions about the survey, please contact: 
Russell Hereford (617-565-1054, email: rherefor@os.dhhs.gov) 
Nikki Pinson (617-565-1056, email npinson@os.dhhs.gov) 
-36-
Public Health and Managed Care  OEI-01-98-00170  MECHANISMS FOR COLLABORATION: This section seeks information about any 
formal mechanisms that require collaborations between managed care plans and public health 
departments in your State. 
1.  Does your State require managed care plans to formally identify how they will collaborate with 
State or Local health departments to further public health activities? 
 YES  If Yes," please check any of the following formal mechanisms that apply. 
Please send us a copy of the relevant regulations or statutes governing these 
provisions; please provide references to published materials, web sites, and any 
citations that we might look up ourselves.  N =16 
1a.   Collaboration required by State law.  N =9 
1b.   Collaboration required by State Health Department regulations.  N =6 
1c.    Collaboration required by other State agency regulations (please 
specify agency):  N =2 
d.    Other:  Collaboration required by other formal mechanism (please 
specify mechanism):  N =7 
 NO  If managed care plans are not required to identify how they will collaborate 
with public health departments in your State, please skip to the last page of the survey 
(page 9).  N =31 
If you answered Yes, please continue to next page     
-37-
Public Health and Managed Care  OEI-01-98-00170  TYPES OF COLLABORATIVE ACTIVITIES:  This section seeks information about 
the types of public health functions that the collaborations are pursuing.  Please include any 
functions that are not listed.  We are also interested in examples of particularly significant 
collaborations in your State. 
2.  Please estimate the level of activity that the collaborations devote to the following 
public health functions. 
Function  No  Limited  Moderate  Extensive 
activity  activity  activity  activity 
Surveillance functions 
2a.  Environmental exposure data  2  2  2  0 
2b.  Disease incidence data  2  10  2  2 
2c.  Reportable disease data  4  6  2  4 
2d.  Laboratory data  8  5  1  2 
2e.  Population-based data registries  7  4  2  3 
2f.  Other:  13  0  1  1 
Population-focused functions 
2g.  Planning and policy development  6  2  7  1 
2h.  Health education campaigns  2  8  6  0 
2i.  Provider education  4  5  6  1 
2j.  Environmental interventions  9  7  0  0 
2k.  Other:  15  0  0  0 
Functions focused on individuals 
2l.  Delivery of services  2  2  9  3 
2m. Operation of school-based  5  7  3  1 
programs 
2n.  Case management/ Enabling  3  4  7  2 
services 
2o.  Other:  14  0  1  0 
3.  Please provide examples of particularly significant collaborative activities; please include the 
names, affiliation, and phone numbers/e-mail of people we might contact for more information. 
-38-
Public Health and Managed Care  OEI-01-98-00170  COLLABORATIVE PLANNING:  This section seeks information about the 
collaborative planning process.  Please provide information about the groups involved in 
planning the collaborations and the information sources used to identify areas on which to 
collaborate. 
4.  To what extent do the following groups play roles in planning the collaborations? 
Group  No  Limited  Moderate  Extensive 
role  role  role  role 
4a.  State Health Department  2  1  4  9 
4b.  Medicaid agency  1  2  4  9 
4c.  Local health agencies  3  6  3  4 
4d.  State Legislature  4  9  1  2 
4e.  Managed care plans  1  1  8  6 
4f.  Practitioners affiliated with managed  4  9  1  2 
care plans 
4g.Hospitals affiliated with managed care  4  7  4  1 
plans 
4h. Purchasers/ Business  8  6  1  1 
4i.  Community organizations  5  6  3  2 
4j.  Voluntary health organizations  7  5  2  2 
4k.  Other groups:  12  2  1  1 
5.  What role do the following sources play in identifying health issues for collaboration 
between managed care plans and public health agencies? 
Sources  No role  Limited  Moderate  Extensive 
role  role  role 
Published sources 
5a.  Healthy People 2000 goals  1  6  8  1 
5b.  State public health goals  0  4  7  5 
Population-based data 
5c.  State Health Department data  0  3  7  6 
5d.  Medicaid data  2  2  5  7 
5e.  Local health agency data  5  6  2  3 
Health plan data 
5f.  HEDIS indicators  3  2  6  5 
5g.  Plan encounter data  3  5  3  5 
5h.  Other sources:  13  0  1  1 
-39-
Public Health and Managed Care  OEI-01-98-00170  IMPLEMENTATION: This section seeks information about the implementation of the 
collaborations.  We are interested in 1.) if the implementation is required or voluntary and 2.) 
which groups are involved in implementing the collaborations. 
6.  Are managed care plans required to implement collaborative activities that have been identified 
or planned? 
 REQUIRED. Managed care plans are required to implement collaborative activities that 
have been planned or identified.  N =9 
 NOT REQUIRED.  Implementation of collaborations is voluntary. N =9 
  OTHER. (Please explain):  N =1 
7.  To what extent do the following groups play roles in implementing the collaborations? 
Group  No  Limited  Moderate  Extensive 
role  role  role  role 
7a.  State Health Department  1  0  9  6 
7b.  Medicaid agency  2  4  2  8 
7c.  Local health agencies  3  4  5  4 
7d.  State Legislature  9  5  1  1 
7e.  Managed care plans  0  3  7  6 
7f.  Practitioners affiliated with managed  3  8  2  3 
care plans 
7g.  Hospitals affiliated with managed  4  9  2  1 
care plans 
7h.  Purchasers/ Business  9  5  1  1 
7i.  Community organizations  4  7  3  2 
7j.  Voluntary health organizations  9  4  1  2 
7k.  Other Groups:  13  0  2  1 
-40-
Public Health and Managed Care  OEI-01-98-00170  OUTCOMES ASSESSMENT: This section seeks information about measuring the 
outcomes of the collaborations. 
8.  Does your State assess the outcomes of the collaborations? 
N =9  YES, our State assesses the outcomes of collaborations. 
N =7  NO, our State does not assess the outcomes of collaborations. 
(Please skip to Question 10). 
8a.  How does your State assess the outcomes of the collaborations?  (Please send us copies of 
any formal outcomes measures used or reports prepared.) 
9.  To what extent do the following groups play roles in assessing the outcomes of the 
collaborations? 
Group  No  Limited  Moderate  Extensive 
role  role  role  role 
9a.  State Health Department  7  3  1  5 
9b.  Medicaid agency  8  2  1  5 
9c.  Local health agencies  9  5  1  1 
9d.  State Legislature  11  3  0  2 
9e.  Managed care plans  8  2  1  5 
9f.  Practitioners affiliated with managed  8  4  1  3 
care plans 
9g.  Hospitals affiliated with managed care  9  4  1  2 
plans 
9h.  Purchasers/ Business  12  3  0  1 
9i.  Community organizations  11  3  0  2 
9j.  Voluntary health organizations  11  2  1  2 
9k.  Other Groups:  15  0  0  1 
-41-
Public Health and Managed Care  OEI-01-98-00170  OBSTACLES TO COLLABORATION: This section seeks information about obstacles 
that make collaborations in your State difficult.  Please describe any obstacles that are not 
listed. 
10.  In your opinion, to what extent do the following obstacles hinder successful collaboration 
between public health departments and managed care plans? 
No  Minor  Moderate  Major 
obstacle  obstacle  obstacle  obstacle 
Within the public health community: 
10a.  Lack of knowledge about managed care.  4  3  5  4 
10b.  Lack of clearly defined public health goals.  7  4  4  1 
10c.  Fragmentation of public health authority and  4  8  3  1 
responsibility across multiple State agencies. 
10d.  General distrust of managed care plans.  3  2  7  4 
10e. Concern about losing service delivery role to  3  1  8  4 
managed care plans. 
Within the managed care community: 
10f. Lack of awareness of public health agencies and  1  2  6  7 
activities in the community. 
10g. Public health goals not integrated into core  0  1  5  10 
business strategies of managed care plans. 
10h.  Medical providers do not view collaboration  0  5  5  6 
with public health departments as a priority. 
10i. Purchasers do not view collaboration with public  1  3  4  8 
health departments as a priority. 
Data concerns: 
10j.  Technical difficulties in matching data systems.  2  3  5  6 
10k.  Regulatory barriers to accessing Medicaid data.  5  6  4  1 
10l.  Privacy/ confidentiality concerns.  3  5  7  1 
10m. Competition among health plans/ concern about  2  3  8  3 
releasing proprietary information. 
10n. Fear that data will be used for regulatory  3  3  7  3 
purposes. 
11.  Please tell us about any other major obstacles to collaboration that you have encountered 
(please use back of page if needed) 
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Public Health and Managed Care  OEI-01-98-00170  ACCOMPLISHMENTS: This section seeks information about what the collaborations have 
achieved and what you hope to see in their future. 
12.  Accomplishments: What have been the most significant accomplishments to date of the 
collaborations between managed care plans and public health departments? 
13.  Do you expect your State to continue the collaborative activity? 
 YES (please answer question 14).  N=16

 NO (you have completed the survey, please see instructions below).  N=0

14.  What opportunities do you hope to realize through collaborations in the future? 
Thank you for completing the survey. 
Please return your completed survey by Friday, June 19. 
Return the survey either by Fax to 617- 565-3751, or in the enclosed business reply envelope to: 
OIG-OEI, Room 2475, JFK Federal Building, Boston, MA 02203 
If you have any questions about the survey, please contact: 
Russell Hereford (617-565-1054, email: rherefor@os.dhhs.gov) 
Nikki Pinson (617-565-1056, email: npinson@os.dhhs.gov) 
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Public Health and Managed Care  OEI-01-98-00170  Please answer the following  questions if your State is not involved in 
collaborative activities: 
Unlikely  Possible  Likely  Very 
likely 
15.  How likely is it that your State will develop  4  11  7  9 
collaborations between public health agencies and 
managed care plans in the next two years? 
16.  Are there significant voluntary collaborations between managed care plans and your States 
public health community that are seeking to further public health activities at the State and Local 
levels? 
 YES, there are voluntary collaborations between managed care plans and public 
health departments in our State.  (please answer questions 17 and 18).  N =27 
 NO, there are no voluntary collaborations between managed care plans and public 
health departments in our State.  (please skip to question 18). N =4 
17.  Please estimate the number of voluntary collaborations that are occurring in your State at the 
State and Local levels: 
17a.  State-level (please estimate number):  0-8 
17b.  Local-level (please estimate number):  0-96 
18.  To what extent do the following prevent your State from establishing collaborations between 
public health and managed care? 
Obstacles preventing collaboration  No  Minor  Moderate  Major 
obstacle  obstacle  obstacle  obstacle 
18a.  Lack of knowledge about managed care.  9  13  9  0 
18b.  General distrust of managed care plans.  10  8  11  2 
18c.  Concerns about public health departments  10  5  12  4 
losing their service delivery role to managed care 
plans. 
18d.  Managed cares lack of awareness of public  4  4  12  11 
health agency activities. 
18e.  Managed care plans are not a significant  13  4  8  6 
service delivery system in your State. 
18f.  Other obstacles:  0  0  3  3 
Thank you for completing the survey.  Please return by Friday, June 19 
following instructions on cover page. 
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Public Health and Managed Care  OEI-01-98-00170  APPENDIX C

E N D N O T E S  
1.  Institute of Medicine, Healthy Communities: New Partnerships for the Future of Public 
Health, (Washington, DC:  National Academy Press, 1996), 15. 
2.  U.S. Department of Health and Human Services, Strategic Plan, September 30, 1997, p. 5-1. 
3.  U.S. Department of Health and Human Services, Health Resources and Services 
Administration, Meeting the Challenge: HRSA and Managed Care.  November, 1997, p. 1. 
4.  We recognize that the survey and data collection for this report are one year old, and it is 
plausible that changes may have taken place over time.  However, considering the continued 
competition and changes in the managed care market place, and the formidable constraints our 
findings identify, it seems unlikely that significant developments have occurred. 
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Public Health and Managed Care  OEI-01-98-00170