Question

What changes in professional practice do you foresee occurring as a result of increased governmental influences in health care delivery?

Answer 1

For Americans to enjoy optimal health—as individuals and as a population—they must have the benefit of high-quality health care services that are effectively coordinated within a strong public health system. In considering the role of the health care sector in assuring the nation's health, the committee took as its starting point one of the recommendations of the Institute of Medicine (IOM) report Crossing the Quality Chasm (2001b: 6): “All health care organizations, professional groups, and private and public purchasers should adopt as their explicit purpose to continually reduce the burden of illness, injury, and disability, and to improve the health and functioning of the people of the United States.”

the issues of access, managing chronic disease, neglected health care services (i.e., clinical preventive services, oral, and mental health care and substance abuse services), and the capacity of the health care delivery system to better serve the population in terms of cultural competence, quality, the workforce, financing, information technology, and emergency preparedness. In addition, the chapter discusses the responsibility of the health care system to recognize and play its appropriate role within the intersectoral public health system, particularly as it collaborates with the governmental public health agencies.

The health care sector in the United States consists of an array of clinicians, hospitals and other health care facilities, insurance plans, and purchasers of health care services, all operating in various configurations of groups, networks, and independent practices. Some are based in the public sector; others operate in the private sector as either for-profit or not-for-profit entities. The health care sector also includes regulators, some voluntary and others governmental. Although these various individuals and organizations are generally referred to collectively as “the health care delivery system,” the phrase suggests an order, integration, and accountability that do not exist. Communication, collaboration, or systems planning among these various entities is limited and is almost incidental to their operations. For convenience, however, the committee uses the common terminology of health care delivery system.

Because of its history, structure, and particularly the highly competitive market in health services that has evolved since the collapse of health care reform efforts in the early 1990s, the health care delivery system often does not interact effectively with other components of the public health system described in this report, in particular, the governmental public health agencies. Health care's structure and incentives are technology and procedure driven and do not support time for the inquiry and reflection, communication, and external relationship building typically needed for effective disease prevention and health promotion. State health departments often have legal authority to regulate the entry of providers and purchasers of health care into the market and to set insurance reimbursement rates for public and, less often, private providers and purchasers. They may control the ability of providers to acquire desired technology and perform complex, costly procedures that are important to the hospital but increase demands on state revenues. Finally, virtually all states have the legal responsibility to monitor the quality of health services provided in the public and private sectors. Many health care providers argue that such regulation adds to their costs, and high-profile problems can create additional tensions that impede collaboration between the state public health agency and the health care delivery system.

Furthermore, when the delivery of health care through the private sector falters, the responsibility for providing some level of basic health care services to the poor and other special populations falls to governmental public health agencies as one of their essential public health servicesl

Health care is not the only, or even the strongest, determinant of health, but it is very important. For most Americans, having health insurance— under a private plan or through a publicly financed program—is a threshold requirement for routine access to health care. “Health insurance coverage is associated with better health outcomes for adults. It is also associated with having a regular source of care and with greater and more appropriate use of health services. These factors, in turn, improve the likelihood of disease screening and early detection, the management of chronic illness, and the effective treatment of acute conditions,” I

Medicare provides coverage to 13.5 percent of the population, whereas Medicaid covers 11.2 percent of the population (Mills, 2002). Additionally, public funding supports directly delivered health care (through community health centers and other health centers qualified for Medicaid reimbursement) accessed by 11 percent of the nation's uninsured, who constitute 41 percent of patients at such health centers (Markus et al., 2002). Because the largest public programs are directed to the aged, disabled, and low-income populations, they cover a disproportionate share of the chronically ill and disabled. However, they are also enormously important for children. In early 2001, Medicaid and the State Children's Health Insurance Program (SCHIP) provided health care coverage to 23.1 percent of the children in the United States, and this figure had risen to 27.7 percent according to data from the first-quarter estimates in the National Health Interview Survey

The committee is concerned that the specific types of care that are important for population health—clinical preventive services, mental health care, treatment for substance abuse, and oral health care—are less available because of the current organization and financing of health care services. Many forms of publicly or privately purchased health insurance provide limited coverage, and sometimes no coverage, for these services.

Clinical Preventive Services

The evidence that insurance makes a difference in health outcomes is well documented for preventive, screening, and chronic disease care (IOM, 2002b). Clinical preventive services are the “medical procedures, tests or counseling that health professionals deliver in a clinical setting to prevent disease and promote health, as opposed to interventions that respond to patient symptoms or complaints” (Partnership for Prevention, 1999: 3). Such services include immunizations and screening tests, as well as counseling aimed at changing the personal health behaviors of patients long before clinical disease develops. The importance of counseling and behavioral interventions is evident, given the influence on health of factors such as tobacco, alcohol, and illicit drug use; unsafe sexual behavior; and lack of exercise and poor diets. These risk behaviors are estimated to account for more than half of all premature deaths; smoking alone contributes to one out of five deaths (McGinnis and Foege, 1993).

Coverage of clinical preventive services has increased steadily over the past decade. In 1988, about three-quarters of adults with employment-based health insurance had a benefit package that included adult physical examinations. Two years later, the proportion had risen to 90 percent (Rice et al., 1998; Kaiser Family Foundation and Health Research and Educational Trust, 2000). The type of health plan is the most important predictor of coverage (RWJF, 2001). The use of financial incentives and data-driven performance measurement strategies to improve physicians' delivery of services such as immunizations (IOM, 2002c) may account for the fact that managed care plans tend to offer the most comprehensive coverage of clinical preventive services and traditional indemnity plans tend to offer the least comprehensive coverage.

Although the trend toward inclusion of clinical preventive services is positive, such benefits are still limited in scope and are not well correlated with evidence regarding the effectiveness of individual services. The U.S. Preventive Services Task Force (USPSTF), a panel of experts convened by the U.S. Public Health Service, has endorsed a core set of clinical preventive services for asymptomatic individuals with no known risk factors

Public health departments have always differed greatly in regard to the delivery of health care services, based on the availability of such services in the community and other reasons (Moos and Miller, 1981). Some provide no personal health care services at all, whereas others provide some assortment of primary health care and safety-net services. In general, however, there has been a decrease in the number of local governmental public health agencies involved in direct service provision. In a recent survey of public health agencies, primary care or direct medical care services were the least common services provided (NACCHO, 2001). Despite this, 28 percent of local public health departments report that they are the sole safety-net providers in their communities (Keane et al., 2001).

During the 1990s, Medicaid shifted from a fee-for-service program to a managed care model. This change has been a challenge to the multiple roles of public health departments as community-based primary health care providers, safety-net providers, and providers of population-based or traditional public health services. The challenge has been both financial and organizational. First, managed care plans reimburse safety-net providers less generously than fee-for-service Medicaid providers do (under Medicaid, federally qualified health centers benefited from a federal requirement for full-cost reimbursement), and they impose administrative and service restrictions that result in reduced overall rates of compensation (IOM, 2000a). In many states and localities, these changes have decreased the revenue available to public health departments and public clinics and hospitals. In many cases, funds were no longer available for population-based essential public health services or had to be diverted to the more visibly urgent need of keeping clinics and hospitals open (CDC, 1997). The result of this interplay is that many governmental public health agencies have found themselves in a strained relationship with managed care organizations: on the one hand, encouraging their active partnership in an intersectoral public health system and, on the other, competing with them for revenues (Lumpkin et al., 1998). Second, the shift of Medicaid services to a managed care environment led some public health departments to scale down or dismantle their infrastructure for the delivery of direct medical care. The recent trend of the exit of managed care from the Medicaid market has left some people without a medical home and, in cases of changes in eligibility, has left some people uninsured. This problem may be most acute in rural areas, where public health departments are often the sole safety-net providers (Johnson and Morris, 1998).

One strategy to help lessen the negative impacts of changes in health care financing undertaken by some public health departments has been the development of formal relationships (e.g., negotiating and implementing memoranda of agreement) with local managed care organizations that provide Medicaid and, in some cases, safety-net services. Such arrangements have made possible some level of integration of health care and public health services, enhanced information exchange and continuity of care, and allowed public health departments to be reimbursed for the provision of some of the services that are covered by the benefits packages of managed care plans (Martinez and Closter, 1998). At this time, governmental public health agencies are still called on to play a role in assurance broader than that which may be compatible with their other responsibilities to population health. However, closer integration between these governmental public health agencies and the health care delivery system can help address the needs of the uninsured and underinsured. Denver Health, in Colorado, provides an intriguing example of a hybrid, integrated public–private health system (Mays et al., 2000). Denver Health is the local (county and city) public health authority, as well as a managed care organization and hospital service. Although changes in the Medicaid program continue to challenge Denver Health, it continues to balance its broad responsibilities to the public's health with its role and capacity as a large health care provider.