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<br />14 HEALTHY COMMUNITIES
<br />achieve a public health objective in a community (Box 1). Private health service
<br />organizations sometimes sponsor outreach activities such as mass screening and
<br />health fairs (at times with commercial interests), with and without a public health
<br />agency's involvement.
<br />BOX 1. Overcoming Barriers to Immunization: An Example for Public Health
<br />In 1992 the 16,000 members of the Florida District of Kiwanis International formed
<br />a partnership with the Department of Health and Rehabilitative Services' (HRS's) State
<br />Health Office Immunization Program to help increase immunization levels in the
<br />preschool population. As part of their "Young Children: Priority One" major initiative,
<br />the Florida District Kiwanis made an eight -year commitment to be lead volunteer agency
<br />assisting in implementing Florida's Immunization Action Plan. This plan provides
<br />objectives to raise the immunization rates of Florida's two-year -olds to 900/* by the year
<br />2000. At the time of the formation of the partnership, only 63% of Florida's two-year -
<br />olds were up to date with their immunizations. Since the HRS- Kiwanis partnership was
<br />formed four years ago, the immunization levels have increased by 2wo.
<br />The Kiwanis have donated many thousands of volunteer hours in immunization
<br />clinics and have organized coalitions, recruited other community groups, and purchased
<br />computer equipment, vans, and educational materials. With the Kiwanis's help, Florida's
<br />67 county public health units have increased their clinic hours, opened new clinic sites,
<br />extended service times and added locat ions, arranged transportation services for low -
<br />income clients, and coordinated services with other agencies to reach more children.
<br />Because of this partnership, more of Florida's young children are protected against
<br />vaccine - preventable diseases now than at any other time in the state's history. The 1995
<br />Survey of Immunization Levels in the two-year -old population indicated that an
<br />unprecedented 80% of Florida's two-year -olds are immunized. Much of the increase can
<br />be attributed to the Kiwanis's leadership in volunteer efforts.
<br />This partnership has helped reduce the dangers that exist when society fails to
<br />immunize its children. For example, the number of measles cases in Florida. had nearly
<br />doubled, from 322 cases in 1989 to 603 cases in 1990. Two of the cases occurred among
<br />unvaccinated preschool children. In 1995, there were 14 confirmed measles cases in
<br />Florida. Through this partnership, the Kiwanis, the county public health units, and the
<br />immunization program office have set an example that demonstrates the positive benefits
<br />that result when a community-based partnership works together to donate time, energy,
<br />and resources to improve the health of Florida's children.
<br />SOURCE: Based on information provided by Charles Mahan, Dean of the University of
<br />South Florida College of Public Health (former director, Florida State Department of
<br />Health and Rehabilitative Services). 1996.
<br />PUBLIC HEALTH AND MANAGED CARE
<br />15
<br />An estimated 90 million insured Americans are enrolled in managed care
<br />plans, including more than 25% of Medicaid beneficiaries and 10• /a of Medicare
<br />beneficiaries (Rosenbaum and Richards, 1996). Most of the growth in enrollment
<br />has occurred in recent years. Between 1988 and 1993, the percentage of
<br />employees enrolled in a managed care plan increased from 290/a to 51% (Gabel et
<br />al., 1994). In the Medicaid program, the growth has been even more dramatic as
<br />states have requested waivers from the Health Care Financing Administration
<br />(HCFA) to shift their Medicaid populations into managed care arrangements.
<br />Between 1993 and 1994, the number of Medicaid beneficiaries in managed care
<br />increased by 63 0/e, from 4.8 million to 7.8 million (Kaiser Commission, 1995). The
<br />factors contributing to the growth in managed care are the rising costs of personal
<br />health care and an interest among employers to find ways to control providers and,
<br />therefore, to control costs (Rosenbaum and Richards, 1996). States have also used
<br />managed care arrangements as a way of containing spiraling costs in the Medicaid
<br />program and of trying to improve access to care (Kaiser Commission, 1995).
<br />STRENGTHS AND WEAKNESSES OF
<br />MANAGED CARE FOR PUBLIC HEALTH
<br />Managed care offers opportunities for public health (CDC and GHAA, n.d.;
<br />Baker et al., 1994; HRSA, n.d.) but it also poses challenges. In the discussions
<br />initiated by the Public Health Committee, proponents of managed care have
<br />argued that its goals and tools are consistent with public health. Many public
<br />health professionals, on the other hand, have also indicated concern about
<br />managed care organizations' motives and ability to deliver on their promises. The
<br />committee's view, as developed in this section, is that .if the proper kinds of
<br />partnerships between managed care organizations and governmental public health
<br />departments are developed, managed care can indeed make an important
<br />contribution to improving the health of the public.
<br />Accountability, Responsibility, and Quality
<br />Because it is responsible for delivering care to a defined group of enrollees,
<br />managed care makes possible, for the first time, accountability in terms of quality
<br />of care for populations, including access to care and health outcomes. This is
<br />possible because managed care organizations can monitor the health outcomes of
<br />enrollees and examine their use of services. However, this is not regularly done.
<br />Some managed care organizations, especially large staff -model managed care
<br />organizations, are using their data systems to track the health of their enrollees, but
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