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Prevention, Public Health, and Managed Care:
<br />Obstacles and Opportunities
<br />Emily Friedman
<br />his conference was convened because managed
<br />care and public health have been pursuing quite
<br />different paths in terms of prevention, and
<br />there is more than a little tension and competition
<br />afoot, as there usually is when jobs, prestige, and money
<br />are on the line. This is complicated by the fact that
<br />neither side is exactly a monolith: in public health,
<br />there are contrasts between understaffed, underfunded
<br />county health departments nationwide and the well-
<br />funded, renowned national infectious disease program
<br />at CDC. The managed care world is similarly character-
<br />ized by lavishly capitalized health plans, led by multi-
<br />millionaire chief executive officers, and thinly funded
<br />non -profit plans struggling to serve Medicaid, disabled,
<br />and other vulnerable patient populations. The lack of a
<br />binding sense of unity around prevention is therefore
<br />not surprising.
<br />Beyond that, there are at least three legitimate dif-
<br />ferences between public health and managed care that
<br />can impede collaboration on prevention. First, al-
<br />bough both have responsibility for populations, man-
<br />aged care gets to choose its populations, whereas public
<br />health is responsible for everyone. For a long time,
<br />managed care's main constituency was young, em-
<br />ployed, reasonably healthy groups of people --not the
<br />most intractable population in terms of health. More
<br />recently, managed care has expanded into Medicaid
<br />and Medicare and is beginning to serve more difficult
<br />populations. In some cases, this change is proving to be
<br />a far superior way of organizing care for these vulner-
<br />able groups. In others, though, it has been a calamity
<br />characterized by brutal risk aversion by some managed
<br />care plans.
<br />The result has been lawsuits, injunctions, and, in
<br />many cases, lackadaisical regulatory response. Although
<br />Congress and state legislatures have been passing man-
<br />aged care legislation at a breakneck pace, too much of
<br />it has consisted of dictating how care is to be provided
<br />on a diagnosis- specific or procedure - specific basis, a
<br />terrible precedent in terms of clinical autonomy and
<br />quality of care.
<br />Contributing Editor, Hospitals and Health Networks and Healthcare
<br />Forum Journal and Section Editor, Journal of the American Medical
<br />Association.
<br />Address correspondence to: Emily Friedmon, Unit G, 851 West
<br />Ommison Street, Chicago, Illinois 60640
<br />102 Am J Prey Med 1998;14(35)
<br />® 1998 American journal of Preventive Medicine
<br />Meanwhile, at least 40 states plan to implement
<br />Medicaid managed care. This will increase the number
<br />of sicker people in managed care plans; a study by the
<br />Kaiser Family Foundation in 1996 found, for example,
<br />that 30% of all [welfare] families have at least one
<br />disabled member. Seeking to enroll these fragile pa-
<br />tients in some managed care plans will not produce a
<br />good match in all cases, particularly if plans continue to
<br />skim on the basis of patient health status.
<br />In contrast, public health does not enjoy the luxury
<br />of selectivity; it has to protect everyone. Moreover, as
<br />the skimming goes on, public health is ending up with
<br />responsibility for more of the sickest and most difficult
<br />patients while the money goes elsewhere.
<br />Public health is also picking up persons technically
<br />enrolled in managed care who continue to seek public
<br />health services, as well as those who are being dropped
<br />from - Medicaid — including the 180,000 persons
<br />dropped last year who had been deemed disabled by
<br />reason of substance abuse, and long -term [welfare]
<br />families and some immigrants who may be dropped
<br />soon. The effect, intentional or not, is that even the
<br />Medicaid population deemed eligible for managed care
<br />is being cleansed of bad risks and difficult populations.
<br />As for the uninsured, their numbers keep rising.
<br />According to the Census Bureau, 40 to 45 million
<br />people lack coverage most or all of the time. The
<br />private sector, though, is not hurrying to sign them up.
<br />Managed care can pick the populations for which it
<br />takes responsibility; public health cannot. This is a
<br />major source of tension between the two.
<br />A second difference is that public health's mission is
<br />well defined, whereas managed care serves many mas-
<br />ters. In managed care, which master you serve has
<br />everything to do with ownership and structure.
<br />I disagree with Dr. McGuire's view that the issue is
<br />not for - profits versus non profits or integrated versus
<br />non - integrated plans. These are precisely the issues.
<br />Most HMOs today are for -profit, and almost all of them
<br />are publicly held and are thus accountable to stock-
<br />holders and to the Wall Street brokers who rate their
<br />stock. This is appropriate for a publicly held organizes
<br />tion, but it raises questions about whether such ac-
<br />countability is appropriate for health care. In contrast,
<br />non - profits are first accountable to their boards, the
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