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NEW YORK -- Historically, the disciplines of medicine and public health have maintained an icy relationship, but the market effects of managed care are beginning to force a thaw.

The New York Academy of Medicine hosted an April 9 symposium to explore how changes in today's turbulent health care environment are contributing to a new climate and creating a symbiosis between these two previously divergent sectors.

The meeting -- part of a medicine/public health initiative supported by the Robert Wood Johnson Foundation, the AMA and the American Public Health Assn. -- stems from the work of a multidisciplinary panel of practitioners and scholars, a series of focus groups and a nationwide survey of medicine and public health interactions. A monograph detailing the panel's work will be ready for distribution later this year.

"Why now, why are we here? That is an extremely important question," said Thomas R. Reardon, MD, vice chair of the AMA Board of Trustees.

The answer, he added, is that the time is right.

For medicine, managed care has raised new issues of competition and accountability, with the physician's focus moving from a one-on-one approach toward a more population-based way of thinking, Dr. Reardon said.

These forces also have triggered changes for public health, where market influences and dwindling government resources have led to a shift of preventive services and safety-net responsibilities to the private sector.

The result: a "continued blurring of the roles" between public health and medicine and a new co-existence that will become increasingly interdependent as both sectors are held more accountable for taking care of patients, he said.

Success hinges on flexibility

For success, both fields will have to be more flexible and, instead of worrying about who provides what services, work together to be sure that people receive the care they need, Dr. Reardon added.

Nowhere is the blurring of lines more apparent than in Medicaid managed care.

The transfer of patients, resources and services from public health agencies to private health plans is "a very big stimulus" for change in the way the two sectors interact, explained Roz Lasker, MD, director of the New York Academy of Medicine's Division of Public Health.

"Just think of what is required to provide effective medical care for Medicaid patients," said Dr. Lasker, who is overseeing the initiative's monograph project.

Services that in the past were linked to public health settings -- such as outreach, follow-up care and ancillary support -- now must be accessible through private medical practices.

And as health problems such as sexually transmitted diseases and lead poisoning are increasingly diagnosed and treated outside public health clinics, new mechanisms must be in place to assure that physicians' diagnoses are accompanied by community-protection responses -- whether it be contact tracing and partner notification to limit the spread of STDs or lead abatement to reduce the potential for exposure.

Other forms of collaboration stem from repercussions of market trends that Dr. Lasker described as "particularly disturbing."

Because a smaller pot of public health resources is left behind when private managed care plans tap into Medicaid revenues, public health agencies find it more difficult to finance essential services those dollars previously helped underwrite.

"This is creating a crisis not only for public health, but for the medical sector as well," Dr. Lasker said. Although funding may be scarce, the services -- ranging from other safety-net responsibilities to disease prevention and surveillance -- are central to public health's mission and vital to medicine's economic interests.

When those services fall through the cracks, hospitals and other providers may experience higher rates of uncompensated emergency care and medical systems face costly disease outbreaks.

Scarce resources force cooperation

These potential consequences make efficiencies of scale imperative.

"When neither sector has the resources to do everything by itself, the closer working relationships begin to make sense," Dr. Lasker said.

Under the old model, financial rewards came from doing more yourself, explained Sherry Glied, PhD, an assistant professor of health policy and management at the Columbia School of Public Health.

"But in the new paradigm, the incentive is to manage care in the most cost-effective way possible," she added.

For example, a Medicaid managed care plan would recognize that its physicians have the clinical expertise to do lead screening tests, while the community would rely on the local public health agency to do the lead abatement, based on the physicians' findings.

How vigorously managed care plans pursue these linkages, though, will in some cases depend on encouragement from the government.

So far, market forces have stimulated the development of closer working relationships without the reinforcement of public policy, explained Philip Lee, MD, a former assistant secretary for health in two presidential administrations and currently a senior adviser to the dean of the University of California/San Francisco School of Medicine.

In fact, current policies may create barriers instead of encouraging further collaboration, he said.

As examples, Dr. Lee cited Medicare's continued emphasis on fee-for-service medicine, biomedical research's interest in specific diseases and their biological triggers rather than health determinants, and the persistence of categorical public health programs.

To reverse this direction, Dr. Lee said, federal responses should be crafted to reinforce the market's interest in using population-based health strategies.

In Medicaid, for instance, eligibility laws often result in high turnover rates among low-income managed care enrollees. When patients move in and out of the plan on a monthly basis, the cost containment benefits of preventive strategies like immunization are lost, Dr. Lee said.

If adjustments were made to allow even a full year of Medicaid coverage once a family qualified, the potential for long-term savings would give managed care a stronger incentive to practice prevention.

Benefits for health plans

Forging partnerships with the public health sector can yield other benefits for managed care, Dr. Lasker said.

For example, information about a community's health status, health risks and the efficacy and costs of medical interventions has become increasingly valuable to managed care plans and physician networks as they take on financial risk.

This makes "certain perspectives and tools of public health à much more relevant in the medical sector," Dr. Lasker said.

"You need these to survive in a medical practice."

And future physicians in medical schools should learn how to use them, said Gail Warden, president and CEO of the Henry Ford Health System.

Public health is being incorporated actively into the curricula of some medical schools, he said, creating what are sometimes called "managed care colleges." These programs place considerable emphasis on the traditional public health tools and functions, such as epidemiology, vital statistics, health promotion and disease prevention.

On the flip side, the public health sector also has identified benefits from managed care. This delivery system makes it easier for public health agencies to locate medical partners for community-based campaigns -- providing an easier answer to what Dr. Glied said used to be public health's "ghostbuster's question: who to call."

Once a partnership is struck, the internal structure of a managed care organization can bolster the collaboration.

According to Dr. Glied, the fact that professionals in both fields are being held accountable for a growing set of variables -- based on both quality of care and financial costs -- also contributes to the evolving relationship and the potential for positive results.

Ensuring that the overall health system offers the best care to the most people based on measurable standards means combining these public health tools with the realities of medical practice and the expertise of its physicians, Dr. Glied said.

Joint initiative focuses on state, local activities

Now in its second year, the Medicine and Public Health Initiative sponsored by the AMA, the American Public Health Assn. and the Robert Wood Johnson Foundation is turning its attention to action at the state and local level.

"That is our best hope," said Mohammad Akhter, MD, MPH, executive director of the APHA.

Last year, the initiative, with funding from the RWJ Foundation, awarded grants to explore opportunities for collaboration between the public health and medical fields.

This process produced an important insight that the states offer the most potential as laboratories, explained Stanley Reiser, MD, PhD, a professor of Humanities in Health Care at the University of Texas, who also staffs the initiative.

During the April 9 New York Academy of Medicine symposium exploring the relationship between the two health sectors, Dr. Reiser announced that the project's next phase would be to convene public health and medicine congresses in every state.

But some locales are moving faster -- providing evidence of dialogues between state and local public health agencies, as well as organized medicine.

Late last year, New York State Health Commissioner Barbara DeBuono, MD, MPH, announced a set of 12 specific "public health opportunities" advanced as part of a coordinated, community-based plan to improve the state's overall health status in the next 10 years.

The list's broad objectives, which resulted from the work of a 19-member committee, include improving access to care, decreasing the incidence of low-birth-weight babies, reducing the prevalence of overweight people, increasing physical activity, and controlling substance abuse and tobacco use.

The Medical Society of the State of New York plans to incorporate the 12 objectives into its policy-making process -- using them as a "jumping-off point" for setting the society's priorities in the upcoming year, explained Sally Faith Dorfman, MD, director of the society's division of public health and education.

Meanwhile, the State Dept. of Health has begun using them to inform its policy pursuits.

"This document has become for us a benchmark and blueprint for everything that we do in health reform and health centers reform," Dr. DeBuono said during the symposium, citing ways in which they are being incorporated into Medicaid managed care contracts and quality standards for the general health care market.

"We are holding managed care plans accountable for improving health status in a way that that they have never been held accountable before," she said.

"While cost looms there as one of the factors we look at, the overarching concern we have à is whether we are improving the health status of the population served through this delivery and financing system," Dr. DeBuono said.

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The rise of managed care creates opportunities to narrow the gap between medicine and public health. Among the give-and-take factors:

• Public health disease prevention and health promotion strategies can reduce health care costs in the private sector.
• Managed care's measurement of outcomes and quality enhances community health assessment efforts and re-emphasizes the importance of traditional public health functions.
• Managed care provides a continuum of health care services emphasizing primary care and prevention.
• Proliferation of provider groups and networks allows public health to more easily identify partners for community-based disease prevention and health promotion campaigns.

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