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Internal Revenue Service, the state government, and, in
<br />many cases, their members and communities.
<br />Furthermore, most HMOs are not integrated. An
<br />integrated plan employs or exclusively contracts with
<br />physicians in group practices, likely owns some or most
<br />of the hospitals that serve its members, and provides
<br />most services in a reasonable continuum of care. An
<br />IPA or broker -type plan simply makes a deal between
<br />payers and providers, transfers much or even all the risk
<br />to the providers, and'takes as much as a third of the
<br />premium money as its-payment.
<br />An integrated plan actually provides services as well
<br />as collecting premiums, and it bears the risk. It makes a
<br />difference, in terms of a commitment to prevention,
<br />whether you are required by law to provide community
<br />benefits or are required by law to maximize profit for
<br />stockholders. It makes a difference in terms of access,
<br />in terms of quality of care, and in terms of which master
<br />you serve.
<br />This is not a dilemma faced by public health.
<br />Whether its structure facilitates it or not—and often it
<br />does not, whether the funding is there or not—and
<br />often it is not, public health is supposed to protect the
<br />public —all of the public. Some health plans do serve
<br />the public and serve it brilliantly. Others do not It
<br />makes a difference.
<br />A third area of difference is turf and money. The
<br />positions of the combatants appear to be that managed
<br />care is attacking and winning public health territory,
<br />with public health on the defensive and being beaten
<br />back. The question is what managed care will do with
<br />the territory it wins if it is able to hang on to it. Fears on
<br />the part of the public health community that some
<br />plans will just take the money and run are thoroughly
<br />justified.
<br />Concerns also center on the many faces of preven-
<br />tion. Some consultants and managed care advocates are
<br />now suggesting that all prevention and public health
<br />activities can be taken over by managed care plans.
<br />Well, perhaps in a perfect world; but I cannot see
<br />health plans figuring out which part of the water supply
<br />to protect because they are only responsible for their
<br />own members, or surveying their members about the
<br />restaurants they eat in so that they only have to worry
<br />about salmonella in those restaurants. This may seem
<br />far- fetched, but as competition for patients, turf, and
<br />funds increase, many health care entities will be actively
<br />seeking new worlds to conquer.
<br />On a larger scale, if we decide that the CDC is,
<br />superfluous, who will do the epidemiology in the face
<br />of new disease agents attacking us from all sides?
<br />On the other hand, the managed care community's
<br />frustration with the parochialism, paranoia, and arro-
<br />gance of public health people is also sometimes justi-
<br />fied. If public health is so wonderful at prevention, why
<br />are so many of our 2-year-olds not immunized? Why are
<br />100
<br />we struggling with antibiodc- resistant tuberculosis and
<br />pneumococci? Why did dozens of American children
<br />die of measles in 1991? This is hardly an advertisement
<br />for the achievements of public health. Maybe Aak
<br />could learn something from truly integrated, commi
<br />red health plans.
<br />The most remarkable thing about this conference,
<br />then, is that so many participants were willing to put
<br />aside their differences and start talking to each other. It
<br />has not been without suspicion and tension, of course,
<br />but, for the most part, this has been a good start.
<br />If the overcoming of these differences or at least
<br />the opening of negotiations —has been the most visible
<br />accomplishment of this conference, the most impor-
<br />tant responsibility of the people here is to accept that
<br />managed care and public health share an enormous
<br />amount when it comes to preventive health. Not all of
<br />what they share is positive, but much of it is.
<br />First, you share three obstacles to improving both the
<br />theory and practice of prevention in this country. As
<br />Dr. Smith said, this is not a country or culture that
<br />exactly worships at the altar of prevention. We talk a
<br />good game, but the fact is that we glorify anorexia; we
<br />price health clubs and equipment out of the reach of
<br />the persons who could benefit from them the most; we
<br />preach fresh fish and vegetables to people who are
<br />trying to raise a family on $13,000 a year and whose
<br />supermarkets are in 7- Elevens; and we market a healthy
<br />lifestyle characterized by grueling exercise, nothing fun
<br />to eat, no cigarettes, no alcohol, no drugs, and exho0
<br />tations to watch the stress levels. And then we wonder
<br />why people don't flock to our banner.
<br />At the same time, when people do not live up to our
<br />expectations, we scorn them. As Dr. Roger Evans of the
<br />Mayo Clinic has written: "As we pursue the ideology of
<br />preventive health, those persons who have inherited or
<br />acquired health deficiencies for which they are consid-
<br />ered responsible will necessarily be viewed. as pariahs
<br />who place excessive demands on society."' He argues
<br />that we view these people as failures —and that our
<br />sociopolitical system does not like to reward failure.
<br />Public health has been able to slip prevention (in
<br />small doses) into schools, onto radio and television,
<br />and in some cases into the popular culture. On the
<br />other hand, managed care has included preventive
<br />services in the regular regimen of care, something that
<br />the fee - for - service system and the insurers who paid for
<br />it not only did not do regularly, but excluded from
<br />most policies. So managed care is doing something
<br />right in that regard. The fact remains, though, that all
<br />of us must work harder to make prevention easier,
<br />more accessible, and more attractive in a country that
<br />essentially still refuses to take it seriously.
<br />Another obstacle is that Americans are distrustful of
<br />public functions, whether they are provided in the
<br />public or the private sector. This country was settled by
<br />Am J Prev Med 1998;14(35) 103
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