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GOVERNMENT, POLITICS, AND LAW |
Erica I. Lubetkin and Marthe R. Gold are with the Department of Community Health and Social Medicine, City University of New York Medical School, New York, NY. Shoshanna Sofaer is with the School of Public Affairs, Baruch College, City University of New York, NY. Marc L. Berger and Steven M. Teutsch are with Outcomes Research and Management, Merck & Co Inc, West Point, Pa. James F. Murray is with Health Benefits Management, Human Resources Decision Support, Merck & Co Inc, Whitehouse Station, NJ.
Correspondence: Requests for reprints should be sent to Erica Ilene Lubetkin, MD, MPH, Department of Community Health and Social Medicine, CUNY Medical School, 138th St and Convent Ave, New York, NY 10031 (e-mail: lubetkin{at}med.cuny.edu).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONTHE BIFURCATED...THE BIFURCATED...A MODEST PROPOSALReferences |
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Both the medical care and public health systems have invested considerable resources to define, measure, and improve quality and health outcomes. A movement toward accountability has generated performance indicators from the medical arena and "leading health indicators" from the public health arena.
The focus on specific conditions by the medical care system has been at odds with public health’s emphasis on improving population health and has perpetuated a bifurcated system.
Aligning the goals of medical care with those of public health will require reformulation of performance measurement and accountability into a common language that is valued by both systems. Such a creation would amount to a whole that is stronger than the sum of the component parts.
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INTRODUCTION |
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"Would you tell me, please, which way I ought to go from here?" "That depends a good deal on where you want to get to," said the Cat. "I don’t much care where . . ." said Alice. "Then it doesn’t matter which way you go," said the Cat.
Lewis Carroll, Alice in Wonderland
FOURTEEN PERCENT OF Americans are uninsured.1 White Americans live, on average, 7 years longer than African Americans, and analogous disparities in life expectancy exist between persons of higher and lower income.2 The average American lives 4 years less than the average Japanese does. Yet the hottest topic in medical care policy circles these days is not about achieving universal coverage or eliminating disparities but rather about reducing medical errors. Analogously, the primary rationale disseminated for rebuilding a creaky public health infrastructure is the threat of bioterrorism.
Can attention to issues of safety and security take us down the right path to more effective health care and a healthier nation? We argue that we need to (1) refocus our attention on a broader definition of performance that integrates the perspectives, goals, and strengths of medical care and public health and (2) acknowledge and find ways to implement shared accountability for improvements in health.
A decade ago, an Institute of Medicine (IOM) panel defined quality of care as "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge."3 The panel’s focus, legitimately, was on the ability of the health care system to improve health both at the individual and community levels. With a sharpened interest in accountability, the medical care and public health systems have moved to develop and refine systemspecific quality and performance indicators to help monitor progress and improve the effectiveness of interventions.
The medical care system has gravitated toward process indicators that assess performance primarily in terms of delivery of clinical preventive services (e.g., mammograms, immunizations) or management of chronic conditions (betablockers after heart attacks, comprehensive care for diabetics) for individual patients.4 By contrast, on the public health side, the Department of Health and Human Services has developed process- and outcome-oriented objectives targeting the nation2 while public health officials have focused on the influence of physical and social environment, public policies and regulations, and individual behaviors on health and functioning. Neither approach is wrong—the existing evidence suggests that high-quality performance is important in all of these areas. Indeed, increases in life expectancy and declines in disability over the 20th century5,6 have been attributed to both the public health and medical care systems.7 In understanding the determinants of health,8 we increasingly recognize that although medical care and medical innovations have made significant contributions, almost half of our deaths are attributed to lifestyle and environmental factors,9 socioeconomic conditions,10,11 and physical location.12
However, the real message of recent research on the determinants of health is that the health of the public depends on a multitude of factors13 and that no single point of intervention is sufficient to maximize health. We appear to forget that in the lives of individuals, families, and communities, these multiple determinants interact. Effective interventions, therefore, require aligning the medical care and public health systems to maximize potential synergies and breakthroughs.14
Integration of performance measurement and improvement activities provides an important mechanism for uniting these 2 essential arms of health interventions. Formal linkage of measures of medical care system performance to key population health indicators would create a data-driven method to integrate individual- and population-based strategies to accomplish jointly articulated objectives. In the process, each system would learn from the methods and experiences of the other, and different and combined approaches to improving outcomes and increasing efficiency could be evaluated side by side.
In the remainder of this article, we describe key factors that reflect, and often support, the continuing bifurcation of medical care and population health. We then describe some of the problems created by our current approach as well as possible benefits associated with meaningful collaboration in performance review. We conclude with ideas for next steps.
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THE BIFURCATED SYSTEM—OPPORTUNITIES LOST |
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One dimension on which public health and medical care differ (but not to the extent often believed) is their "auspices" or ownership. Public health is perceived as a governmental function while medical care is viewed as a private enterprise. However, this perception is blurred by the focus of traditional public health departments on providing personal health services to individuals. In reality, the "safety net" systems of state and local public hospitals and health departments provide essential medical services while a wide range of private sector and community-based organizations provide essential public health services.
The public visibility of the 2 systems varies. Because the institutions of clinical medicine are more readily identifiable and their roles more often are experienced directly, the public has a clearer understanding of their mission and role. In contrast, public health functions, such as sanitation inspections, facility accreditation, traffic safety, tobacco legislation, fluoridation, and even community health education, are far less visible or understood. Perhaps for this reason, the resources available to these 2 systems differ dramatically. For many years, approximately 96% of expenditures on health in the United States were for medical care rather than public health.15
Classically, the 2 systems intervene at different levels and focus on different manifestations of "ill health." Medical care helps persons who are ill while public health, through the provision of both personal preventive and population-based services, helps persons who are well from becoming ill. Clinical medicine addresses the problems at the individual level by delivering services on a case-by-case basis while public health works to improve the health of populations. Clinical medicine prioritizes disease and injury, particularly managing acute events and preventing sequelae of chronic conditions. Public health implements policies and programs to prevent disease and injury in communities and high-risk groups. Medical care tends to deliver increasingly specialized, sophisticated, and targeted technologies to ameliorate the downstream consequences of illness and injury, while public health looks toward more upstream solutions. Dentists fill caries while public health agencies fluoridate water. Oncologists struggle to cure lung cancer while tobacco control coalitions seek to raise the price of cigarettes.
Accountability and Performance Measurement
Accountability also varies in this bifurcated system. In medical care, the underlying model of accountability is that individual clinicians or institutions can and should be held accountable for care provided to patients. Since the spread of managed care, performance measurement has focused on health plans, where a definable "denominator" of members presumably enables plans to be held accountable for the health of their enrollees. In the public health system, a different model of accountability operates. First, since most public health dollars are public, and much, though not all, public health activity is undertaken by public employees working for elected officials and their appointees, a more political view of accountability is presumed to exist—accountability through the democratic process. In addition, as funds cascade from federal to state to county/city to neighborhood, oversight is supposed to come from officials with responsibility for program management.
Performance measurement is in part a response to increasing demands (primarily from those who pay the bills) that the health care system be held publicly accountable. Furthermore, since the pervasive approach to resource allocation in medical care has entailed using a competitive market, public disclosure is intended to drive the decisions of individual and group purchasers. The medical care model of accountability may be overly specific while the public health model may be too vague. Indeed, the bifurcation between public health and medical care means that we have no consensus on who is, or should be, held accountable for real improvements in individual and population health status.
Within the medical care system, specific clinicians, institutions, or health plans often resist being held accountable, especially for outcomes, because they realize they do not have total control over these outcomes. This model of accountability does not recognize that many parties can contribute to an outcome even if they cannot control it. In the public health system, even though "Healthy People" objectives are generated and tracked at multiple levels, persons or organizations responsible for achieving those objectives rarely are specified.
In reality, the achievement of improvements in both individual and population health almost always will require actions by multiple actors. Our current bifurcated systems of performance objectives and indicators, however, have no way to respond explicitly to the realities of multiple determinants, multiple contributions, and shared accountability. Most tragically, in addition, many in society not only lack access to adequate health care but are ignored by most performance measurement systems. Thus, we know little, if anything, about the quality of health care received by the uninsured or by those who, though nominally insured, have compromised access to services.
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THE BIFURCATED SYSTEM—OPPORTUNITIES FOUND |
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Medical care leaders can support efforts to adopt public policies (seat belt laws, driving limits, greater enforcement of laws prohibiting the sale of tobacco products to minors) that promote the health of their patients. The clinical management of chronic conditions such as asthma is enhanced by efforts to improve the environment: reducing air pollutants at the macrolevel and reducing dust, dander, smoke, and other "triggers" at the microlevel of the home. If effective, these efforts could reduce the pressure on the medical care system of avoidable emergency room visits and hospitalizations.
Joint Ownership of Performance Measurement
Public health and medical care can teach and learn from one another in the area of performance measurement. For example, as noted, although public health agencies set population-level objectives, they rarely conduct systematic assessments of the performance of specific programs and even more rarely provide that information to the public. Public health agencies, therefore, need more measurement at the level of processes and intermediate outcomes that are linked to specific programs or sets of programs.
While great progress has been made in assessing the experience of users of medical services by means of surveys such as the Consumer Assessment of Health Plans (CAHPS)16 instruments, such user surveys are far rarer and less rigorous in population health. Although many services are relatively invisible, others are not, and the public’s level of satisfaction with, for example, air quality or restaurant cleanliness rarely is assessed as an indicator of performance. Improved measures of the performance of public health programs and policies might increase the awareness of public health efforts among both policymakers and the public, thereby enhancing the sense that these tax-supported efforts are accountable as opposed to self-perpetuating.
On the other side, the public health sector has been significantly more attentive and successful than has the medical care system in tracking health status disparities associated with sociodemographic characteristics (race, ethnicity, age, income, education, health insurance, and place of residence). For insured persons, meaningful performance variations in subpopulations covered within a medical care delivery system are masked when measures of quality focus on the entire population, rather than sharpening the focus on the experience of populations at higher risk. For example, insured minority populations experience decreased service delivery compared with others.17,18 By modeling on the public health sector’s emphasis on examining subgroups, the medical care system could improve its scrutiny of delivery-related issues that contribute to health status differences.
Measuring performance for those who have health care coverage lets us look only "under the lamppost" at the performance of the medical care system. There is ample evidence that the uninsured suffer from disparities in both the intensity and type of health care services they receive. Public health brings with it a long-standing focus on disparities. The performance of the medical care system also needs to be assessed by how well it succeeds in caring for those at highest risk by reason of their socioeconomic and insurance status.
As epidemiologists and health services researchers continue to demonstrate the impact of behavioral and cultural factors, medical care indicators also need to become more comprehensive. For example, an important dimension of quality for a diabetic is not just whether he or she receives timely eye and foot examinations but also whether clinicians assess the family, cultural, and home environment to identify barriers and facilitators to adherence to medication and diet regimens.
Both medical care and public health have begun to place greater attention on process-based, outcome-oriented performance measures. Within medical care, well-validated measures of health and functional status, such as the SF-36,19 have become standard both for assessing morbidity and for risk-adjusting other measures. The primary performance measures, however, tend to be disease-specific process measures, as assessed by HEDIS4 or the Joint Commission on Accreditation of Healthcare Organizations’ ORYX initiative,20 since processes occur with sufficient frequency to be assessed accurately within an individual plan or institution. By contrast, public health uses a panoply of indicators, including global health measures (life expectancy, infant mortality), disease-specific measures (emergency room visits for asthma), lifestyle measures (physical activity, smoking), system function (adequacy of the public health system), and environmental measures (safe waterways).
These differences in outcome measures mean that no widely accepted common units exist around which to conduct assessments, compare results, and develop improvement strategies. Yet, as we move toward more outcome-oriented evaluations, the 2 systems must collaborate to identify how to implement performance measures in a context of shared, rather than exclusive, accountability. Although the leading health indicators for Healthy People 2010 were developed for this purpose,2 these indicators would need to undergo significant further development in order to serve in this role.
An integrated approach to performance measurement would reflect what we already know about how medical care can support both individual and population health improvement by adopting a more biopsychosocial model of intervention.21 This approach also could provide greater visibility to the less evident but critical "health protection" aspects of public health work. An integrated model would raise public awareness that receipt of services is not the only way that health problems can be addressed, and that more high-technology care is not always the answer. Indeed, many issues can be addressed only through a combination of policy redefinition, system redesign, social marketing, and the delivery of services. Examples include issues as varied as sexual health (sexually transmitted diseases and unintended pregnancy) and violence (child abuse, domestic violence), which require both population-based approaches (healthy social environment, education, access to support services, alignment of incentives) as well as clinical approaches (treatment, identification, and management of individuals at risk).
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A MODEST PROPOSAL |
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To begin, we must create a national forum to facilitate progress in the dialogue between public health and medical care delivery experts in order to overcome the pervasive separation of their infrastructures and cultures. Cooperation between the 2 sectors was initiated in 1994 when the American Medical Association and the American Public Health Association began a working alliance to enhance collaborative efforts at the local, state, and national levels.22 The ongoing and structured dialogue would build upon this work. In addition, the dialogue would seek to enhance recognition of potential synergies through establishing joint performance metrics and identifying specific circumstances (perhaps in terms of specific conditions, as suggested by the IOM’s recent Quality Chasm report23) for which synergies can be identified in evidence-based public health and medicine. The dialogue could be convened under the aegis of a single federal agency, such as the Public Health Service, but it might reflect the necessity of involvement from multiple stakeholders more effectively if convened through the joint action of multiple public and private agencies (e.g., the Public Health Service, the Centers for Medicare and Medicaid Services, the IOM, a major foundation, the National Governors Association, etc.).
This first step requires not only political will but also technical and political skill. The second step—delineation of the roles and responsibilities of various stakeholders, both in building an integrated performance measurement system and in health improvement—will be more problematic. Overcoming the fractured nature of the cultures, organizations, accountability, and financing for public health and medical care will represent a significant challenge.
Each stakeholder will play a critical role.24 The federal government will need to provide an umbrella for these initiatives, as well as facilitate the appropriate regulatory and legal environment. Public health agencies can assist in the measurement of population outcomes through national surveys that already exist (e.g., the National Health and Nutrition Examination Survey) and that could be developed (e.g., a community-level version of CAHPS to assess the public’s experience of both public health and medical services and achievements). Payers (both private and governmental) will need to champion rigorous evidence-based performance metrics for both systems and shift to a shared accountability for improvements in individual, community, and national health. Medical care and public health workers should recognize what they can contribute to a joint effort and be willing to be publicly accountable for their results. Both payers of health care, who have led the charge for data collection and reporting on the medical side, and decisionmakers, who monitor and fund programs in public health, must provide input to any final products of performance measurement that emerge from these joint ventures.
Because the construction of a framework for performance measurement will require a tremendous investment, the information collected should demonstrate value for all stakeholders. In particular, the data must be valued not only for payers and decisionmakers who will be interpreting the data but also for health care providers and public health workers who may be providing the data. Efforts to collect or report data that are isolated from key stakeholders will have far less impact on improving health and will not be sustainable.
We do not expect that a single integrated system will emerge. Rather, a number of implementation models are likely to be proposed and should be given the opportunity for testing. Room for experimentation was viewed as critical in efforts to reform important government programs such as welfare and Medicaid, and it will similarly be important in reengineering the country’s efforts to improve population health. Therefore, we envision that demonstration projects would be implemented, and rigorously evaluated, at a state or local level. A state-level approach is consistent with the precedent for social program reform as well as the constitutional responsibilities of the states. However, experimentation at local levels (i.e., metropolitan area, county) might be feasible. Given both the high stakes and high risks in participating in such experiments, there must be meaningful incentives available to encourage engagement, innovation, and objectivity about results. Resources are always an incentive, but the freedom to innovate and tailor strategies to local circumstances also is critical.
The success of demonstration projects ought to be measured according to standards negotiated and set forth in advance. The principles must emphasize the necessity of measuring success on a population level and, where appropriate, on vulnerable subgroups. In order for purchasers to be engaged, costeffectiveness should be a focus. The time frame for assessment needs to be commensurate with the evidence regarding the ability to measure changes in both process and outcomes measures; process measures can be evaluated over the short term, whereas outcomes measures generally require longer evaluation periods. In addition, these demonstration projects should include public education about the benefits and limitations of medical services and the responsibility and impact that individual behaviors and public policies can have on health outcomes.
If we are to achieve quality as defined by the IOM, we must not only identify national health priorities across the systems of medical care and public health but also identify effective, efficient, integrated strategies for pursuing these priorities. In particular, we should capitalize on the approaches of all sectors and the use of sets of performance measurement that reflect multiple contributions. Ultimately, successful application of the "best practices" from the demonstration projects we foresee will depend on the emergence of a social and political consensus regarding our separate and collective responsibility for the health of all Americans.
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Acknowledgments |
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The authors wish to thank Carolyn M. Clancy, MD, of the Agency for Healthcare Research and Quality for her helpful comments.
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Footnotes |
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Accepted for publication November 15, 2002.
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References |
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24. Stoto MA. Sharing responsibility for the public’s health: a new perspective from the Institute of Medicine. J Public Health Manag Pract. 1997;3:22–34.
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
