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

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anti- government radicals whose philosophy still holds sway. Moreover, the average American's fear of bureau- crats is so pervasive that we seem to be expecting less and less of the public sector. Therefore, even a private HMO trying to encourage smoking cessation and weight control must contend with patient distrust and apprehension about "Big Brother " –like behavior. Man- aged care and public health both have to do a better job in dealing with paranoia about our intruding too deeply into people's private lives, asking too many questions, and being careless with data and information that can ruin someone's life. Also, we must become much more serious about evaluation, outcomes, and implementation. Prevention theory needs to become prevention practice, and guideline theory needs to become protocols that peo- ple pay attention to. As for evaluation and outcomes, we see too much anecdotal data being presented as gospel, shady statistics whose origin is always proprietary so that their legitimacy cannot be assessed, public opinion surveys that have been manipulated into meaningless- ness, and scare tactics that result in a rush to judgment. Like the'rest of health care, prevention has become an industry, and it, too, wants to justify its existence. At these prices, however, maybe we should cast a colder eye on what we are doing and find out what really makes a difference. One clue could come from the great economist Eli +� Ginzberg, who conducted an exhaustive study of the impact of the health care system on poor people in the United States. In his book, Tomorrow's Ho*itaf, he concluded that the health care system's greatest contri- bution to the health of the poor is to employ them and thereby get them out of poverty --the single most important determinant of a person's health.' Thus, there are undoubtedly some problems we should throw money at, but they may not be clinical in nature. These are obstacles faced by anyone and any organization, public or private, that really wants to do prevention. Fortunately, there are three shared opportunities as well. First, although it has been obscured by time, politics, and distractions, managed care and public health started out with a shared vision. The first health plans, which were non - profit, community - oriented, and highly integrated as service providers as well as insurers, put a high premium on keeping people healthy. The almost limitless opportunity to spend money on the front end has always been available to both health plans and the public health community. In the end, the goals are the same, even if they were derived from strikingly different organizations and traditions. The recent emergence of managed care as an investment opportu- nity and an avoider of risk has obscured that shared 0 ision, but if we clear away the smoke, it is still there. Second, the good guys are in it for the long term. Despite the rumors of its demise, public health isn't going anywhere. Neither are the oldest integrated health plans. Both plan to stick around, and that means being able to reap the rewards of prevention, i.e., seeing children grow up having never smoked a cigar rette, snacked on lead paint, or been struck by a parent in anger. Third, both public health and good managed care can redistribute any savings achieved through success- ful prevention activities. There are many opportunities to do enormous good with the money saved by organ nizing care better and practicing meaningful preven- tion: extension of coverage to the uninsured, environ- mental health initiatives, real violence prevention on the streets and in our homes, facing up to hunger and homelessness. Of course, any savings achieved by prevention activ- ities can be stolen or squandered, and there is still debate as to whether prevention does, in fact, save money — although I, at least, believe it does. But on the assumption that at least some savings will be achieved, there is a world of opportunity for those organizations, public and private, that can capture the savings and reinvest them in their communities. What a chancel This is what you share. This is what we all share. This is a rich enough possibility that it is worth giving each other the benefit of the doubt. I will close with three suggestions to you as organiza- tions and three to you as individuals. As organizations; first, pick your fights about content and turf. We need to focus more on what matters. My discussions with health plan representatives about what we really know about prevention have yielded three thoughts: (1) tobacco is really bad for you; (2) some exercise —which can be no more complicated than taking a walk —is really good for you; and (3) depres- sion, even mild depression, makes almost all other threats to good health worse. Similarly, in terms of turf, protect what must be protected, and give' way when you should. Public health's turf clearly includes restaurant inspections, food and water safety, epidemiology, and other things that public health has always done and that must be done for everyone. Managed care's turf centers on more circumscribed populations and goals. Give way when you should. No one will win them all, but know which ones you can win —and what is worth fighting for in the first place. 1. Second, find out who does what best, and support them. That could mean having health plans fund public agencies, public agencies fund health plans, or both fund a third party, e.g., an AIDS hospice, a feeding program, or a summer camp for lour- income children. Do not reinvent the wheel. Do not duplicate existing excellence. Do not compete for the sake of comped- 104 American Journal of Preventive Medicine, Volume 14, Number 3S 101 I 1 i i I