Agenda - 03-09-1999 - III-B - Laserfiche WebLink

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18 0 HEALTHYCOMMUNITIES 0 Personal Health Services for Vulnerable Populations As managed care organizations enroll increasing numbers of people from disadvantaged groups, the biggest challenge for public health agencies is in the area of providing personal health services for poor and vulnerable populations. Public health agencies, primarily at the local level, have played an important role in providing health care services to both Medicaid - eligible and uninsured and underinsured population groups. For example, they provide maternal and child health services, sexually transmitted disease (STD) services, and tuberculosis services. For certain services, issues of expertise or confidentiality would suggest that public health agencies are the appropriate entities to continue to provide these services (Frieden et al., 1995; IOM 1996), so local public health agencies must maintain this capacity. As more states shift their Medicaid enrollees into managed care, public health agencies have the option of trying to obtain contracts with managed care organizations, but many are ill- equipped to compete for and negotiate with health plans (Lipson and Naierman, 1996). Many issues of language, culture, tradition, class, race, and ethnicity need to be taken into account when providing services to especially vulnerable populations. Perhaps the most serious aspect of this problem is providing services to those who are covered by neither insurance nor Medicaid and who are especially vulnerable. As many cities and counties move to privatize public hospitals, which have traditionally served vulnerable populations, they will have to consider whether and how managed care organizations fill this role and how the delivery of care to the underinsured and uninsured will continue. Individuals who are eligible for Medicaid but unfamiliar with managed care organizations may not understand how to access needed services. A strategy of partnering with both governmental, public health agencies and community-based organizations, which have the skills and experience needed to work effectively with these vulnerable populations, could strengthen the entire health system's response to the needs of these special populations. Many state Medicaid agencies do not have the management skills to monitor the performance of managed care organizations or to .write appropriate contracts with these organizations (Box 3). Competitive cost - cutting pressures coupled with vulnerable populations may result in opportunities for health care plans or providers to take advantage of poor patients. The problem of turnover of patient population as enrollees lose and regain their eligibility for Medicaid also contributes to serious problems of continuity of care. • PUBLIC HEALTHAND MANAGED CARE 19 BOX 3. Medicaid Managed Care The move toward managed care for Medicaid patients offers promise for improving health outcomes and solving potential problems. The promise is due to the shift inherent in managed care toward interest in the health of defined populations. This facilitates the use of public health assessment tools (e.g., epidemiology), strategic thinking about efficient ways to . improve the health of populations, and opportunities to undertake activities focused on disease prevention. Problems that may occur during this transition to Medicaid managed care include (1) personal health services traditionally carried out by public. health departments (i.e., prenatal care, immunization services, family planning and sexually transmitted disease [STD] clinics, and Early and Periodic Screening, Diagnosis, and Treatment [EPSDTI) will not be completely transferred to a managed care organization; (2) poor people who are eligible for Medicaid but are unfamiliar with managed care organizations may not understand how to access needed service, (3) many state Medicaid agencies do not have the management skills to monitorthe performance of managed care organizations or to write appropriate contracts with them; and (4) competitive cost- cutting pressures coupled with vulnerable populations and weak oversight may result in some unscrupulous health care providers taking advantage of poor patients. There is a growing realization that managed care organizations need the expertise and authority of public health agencies to undertake community -based interventions and perform outreach services that are necessary for maintaining the health of the populations for which they are responsible. Public health services are also necessary in cases in which confidentiality is an issue, such as at STD or family planning clinics. Many public health professionals now provide ,personal health services, often in community-based categorical public health clinics. Such services are the type that managed care organizations should be able to handle, and therefore, once they are trasferrred, there will be less of a need for health professionals with the same skills in public health departments. There will be an increased need in both public health departments and managed care organizations for people with public health assessment skills and health care management skills. L URCE: Presentations to the Institute of Medicine (IOM) Board on Health Promotion Disease Prevention and the National Research CounciUlOM Board on Children and ilies in joint session on June 15, 1995. DEFINING ROLES AND RESPONSIBILITIES Given the challenges involved in the transition to managed care, it will be important for each community to define the roles and responsibilities of governmental public health agencies and managed care organizations in improving health. Depending on local conditions, public health agencies can play a variety of roles, from serving in an advisory or regulatory capacity to obtaining contracts to OD V