Prevention, public health, and managed care: obstacles and opportunities.

This conference was convened because managed care and public health have been pursuing quite different paths in terms of prevention, and there is more than a little tension and competition afoot, as there usually is when jobs, prestige, and money are on the line. This is complicated by the fact that neither side is exactly a monolith: in public health, there are contrasts between understaffed, underfunded county health departments nationwide and the wellfunded, renowned national infectious disease program at CDC. The managed care world is similarly characterized by lavishly capitalized health plans, led by multimillionaire chief executive officers, and thinly funded non-profit plans struggling to serve Medicaid, disabled, and other vulnerable patient populations. The lack of a binding sense of unity around prevention is therefore not surprising. Beyond that, there are at least three legitimate differences between public health and managed care that can impede collaboration on prevention. First, although both have responsibility for populations, managed care gets to choose its populations, whereas public health is responsible for everyone. For a long time, managed care’s main constituency was young, employed, reasonably healthy groups of people—not the most intractable population in terms of health. More recently, managed care has expanded into Medicaid and Medicare and is beginning to serve more difficult populations. In some cases, this change is proving to be a far superior way of organizing care for these vulnerable groups. In others, though, it has been a calamity characterized by brutal risk aversion by some managed care plans. The result has been lawsuits, injunctions, and, in many cases, lackadaisical regulatory response. Although Congress and state legislatures have been passing managed care legislation at a breakneck pace, too much of it has consisted of dictating how care is to be provided on a diagnosis-specific or procedure-specific basis, a terrible precedent in terms of clinical autonomy and quality of care. Meanwhile, at least 40 states plan to implement Medicaid managed care. This will increase the number of sicker people in managed care plans; a study by the Kaiser Family Foundation in 1996 found, for example, that 30% of all [welfare] families have at least one disabled member. Seeking to enroll these fragile patients in some managed care plans will not produce a good match in all cases, particularly if plans continue to skim on the basis of patient health status. In contrast, public health does not enjoy the luxury of selectivity; it has to protect everyone. Moreover, as the skimming goes on, public health is ending up with responsibility for more of the sickest and most difficult patients while the money goes elsewhere. Public health is also picking up persons technically enrolled in managed care who continue to seek public health services, as well as those who are being dropped from Medicaid—including the 180,000 persons dropped last year who had been deemed disabled by reason of substance abuse, and long-term [welfare] families and some immigrants who may be dropped soon. The effect, intentional or not, is that even the Medicaid population deemed eligible for managed care is being cleansed of bad risks and difficult populations. As for the uninsured, their numbers keep rising. According to the Census Bureau, 40 to 45 million people lack coverage most or all of the time. The private sector, though, is not hurrying to sign them up. Managed care can pick the populations for which it takes responsibility; public health cannot. This is a major source of tension between the two. A second difference is that public health’s mission is well defined, whereas managed care serves many masters. In managed care, which master you serve has everything to do with ownership and structure. I disagree with Dr. McGuire’s view that the issue is not for-profits versus non-profits or integrated versus non-integrated plans. These are precisely the issues. Most HMOs today are for-profit, and almost all of them are publicly held and are thus accountable to stockholders and to the Wall Street brokers who rate their stock. This is appropriate for a publicly held organization, but it raises questions about whether such accountability is appropriate for health care. In contrast, non-profits are first accountable to their boards, the Contributing Editor, Hospitals and Health Networks and Healthcare Forum Journal and Section Editor, Journal of the American Medical Association. Address correspondence to: Emily Friedmon, Unit G, 851 West Gummison Street, Chicago, Illinois 60640