The Uninsured and the Underinsured

The persistently large proportion of the American population that is uninsured—about one in five working-age adults and one in seven children— is the most visible and troubling sign of the nation's failure to assure access to health care. Yet the public and many elected officials seem almost willfully ignorant of the magnitude, persistence, and implications of this problem. Surveys conducted over the past two decades show a consistent underestimation of the number of uninsured and of trends in insurance coverage over time (Blendon et al., 2001). The facts about uninsurance in America are sobering (see Box 5–1). By almost any metric, uninsured adults suffer worse health status and live shorter lives than insured adults (IOM, 2002a).

BOX 5–1

Findings from Coverage Matters. In its report Coverage Matters, the IOM Committee on the Consequences of Uninsurance (IOM, 2001a) found the following: Forty-two million people in the United States lacked health insurance coverage in 1999 (Mills, 2000). (more...)

Because insurance status affects access to secure and continuous care, it also affects health, leading to an estimated 18,000 premature deaths annually (IOM, 2002a). Having a regular source of care improves chances of receiving personal preventive care and screening services and improves the management of chronic disease. When risk factors, such as high blood pressure, can be identified and treated, the chances of developing conditions such as heart disease can be reduced. Similarly, if diseases can be detected and treated when they are still in their early stages, subsequent rates of morbidity and mortality can often be reduced. Without insurance, the chances of early detection and treatment of risk factors or disease are low.

However, even when the uninsured receive care, they fare less well than the insured. The IOM Committee on the Consequences of Uninsurance found that “[u]ninsured adults receive health services that are less adequate and appropriate than those received by patients who have either public or private health insurance, and they have poorer clinical outcomes and poorer overall health than do adults with private health insurance” (IOM, 2002a: 87). For example, Hadley and colleagues (1991) found that uninsured adult hospital inpatients had a significantly higher risk of dying in the hospital than their privately insured counterparts. Emergency and trauma care were also found to vary for insured and uninsured patients. Uninsured persons with traumatic injuries were less likely to be admitted to the hospital, received fewer services when admitted, and were more likely to die than insured trauma victims (Hadley et al., 1991).

For children, too, being uninsured tends to reduce access to health care and is associated with poorer health. The 1998 IOM report America's Children: Health Insurance and Access to Care found that uninsured children “are more likely to be sick as newborns, less likely to be immunized as preschoolers, less likely to receive medical treatment when they are injured, and less likely to receive treatment for illness such as acute or recurrent ear infections, asthma and tooth decay” (IOM, 1998: 3). That report emphasized that untreated health problems can affect children's physical and emotional growth, development, and overall health and well-being. Untreated ear infections, for example, can have permanent consequences of hearing loss or deafness.

Even when insured, limitations on coverage may still impede people's access to care. Many people who are counted as insured have very limited benefits and are exposed to high out-of-pocket expenses or service restrictions. Three areas in which benefits are frequently circumscribed under both public and private insurance plans are preventive services, behavioral health care (treatment of mental illness and addictive disorders), and oral health care. When offered, coverage for these services often carries limits that are unrelated to treatment needs and are stricter than those for other types of care (King, 2000). Cost-sharing requirements for these services may also be higher than those for other commonly covered services. (Additional discussion of these and other “neglected” forms of care appears later in this chapter.)

Access to care for the insured can also be affected by requirements for cost sharing and copayments. Cost sharing is an effective means to reduce the use of health care for trivial or self-limited conditions. Numerous studies, starting with the RAND Health Insurance Experiment, show that copayments also reduce the use of preventive and primary care services by the poor, although not by higher-income groups (Solanki et al., 2000). The same effects have been shown for the use of behavioral health care services (Wells et al., 2000).

As a result of the nation's increased awareness of bioterrorist threats, there are concerns about the implications of copayments and other financial barriers to health care. Cost sharing may discourage early care seeking, impeding infectious disease surveillance, delaying timely diagnosis and treatment, and posing a threat to the health of the public. The committee encourages health care policy makers in the public and private sectors to reexamine these issues in light of the concerns about bioterrorism.

This committee was not constituted to make specific recommendations about health insurance. The issues are complex, and the failures of health care reform efforts over the past 30 years testify to the difficulty of crafting a solution. However, the committee finds that both the scale of the problem and the strong evidence of adverse health effects from being uninsured or underinsured make a compelling case that the health of the American people as a whole is compromised by the absence of insurance coverage for so many. Assuring the health of the population in the twenty-first century requires finding a means to guarantee insurance coverage for every person living in this country.

Adequate population health cannot be achieved without making comprehensive and affordable health care available to every person residing in the United States. It is the responsibility of the federal government to lead a national effort to examine the options available to achieve stable health care coverage of individuals and families and to assure the implementation of plans to achieve that result.

Safety-Net Providers

Absent the availability of health insurance, the role of the safety-net provider is critically important. Increasing their numbers and assuring their viability can, to some degree, improve the availability of care. The IOM Committee on the Changing Market, Managed Care and the Future Viability of Safety Net Providers defined safety-net providers as “[t]hose providers that organize and deliver a significant level of health care and other health-related services to uninsured, Medicaid, and other vulnerable patients” (IOM, 2000a: 21). That committee further identified core safety-net providers as having two distinguishing characteristics: “(1) by legal mandate or explicitly adopted mission they maintain an ‘open door,' offering access to services to patients regardless of their ability to pay; and (2) a substantial share of their patient mix is uninsured, Medicaid, and other vulnerable patients” (IOM, 2000a: 3).

The organization and delivery of safety-net services vary widely from state to state and community to community (Baxter and Mechanic, 1997). The safety net consists of public hospital systems; academic health centers; community health centers or clinics funded by federal, state, and local governmental public health agencies (see Chapter 3); and local health departments themselves (although systematic data on the extent of health department services are lacking) (IOM, 2000a). A recent study of changes in the capacities and roles of local health departments as safety-net providers found, however, that more than a quarter of the health departments surveyed were the sole safety-net providers in their jurisdictions and that this was more likely to be the case in smaller jurisdictions (Keane et al., 2001).

Safety-net service providers, which include local and state governmental agencies, contribute to the public health system in multiple ways. Services provided by state and local governments often include mental health hospitals and outpatient clinics, substance abuse treatment programs, maternal and child health services, and clinics for the homeless. In addition, an estimated 1,300 public hospitals nationwide (Legnini et al., 1999) provide free care to those without insurance or resources to pay. A survey of 69 hospitals belonging to the National Association of Public Hospitals indicated that in 1997, public hospitals provided more than 23 percent of the nation's uncompensated hospital care (measured as the sum of bad debt and charity care) (IOM, 2000a). These demands can overwhelm the traditional population-oriented mission of the governmental public health agencies. Furthermore, changes in the funding streams or reimbursement policies for any of these programs or increases in demand for free or subsidized care that inevitably occur in periods of economic downturn create crises for safety-net providers, including those operated by state and local governments (see the section Collaboration with Governmental Public Health Agencies later in this chapter for additional discussion).

The IOM committee that produced the report America's Health Care Safety Net: Intact but Endangered (IOM, 2000a: 205–206) had the following findings:

Despite today's robust economy, safety net providers—especially core safety net providers—are being buffeted by the cumulative and concurrent effects of major health policy and market changes. The convergence and potentially adverse consequences of these new and powerful dynamics lead the committee to be highly concerned about the future viability of the safety net. Although safety net providers have proven to be both resilient and resourceful, the committee believes that many providers may be unable to survive the current environment. Taken alone, the growth in Medicaid managed care enrollment; the retrenchment or elimination of key direct and indirect subsidies that providers have relied upon to help finance uncompensated care; and the continued growth in the number of uninsured people would make it difficult for many safety net providers to survive. Taken together, these trends are beginning to place unparalleled strain on the health care safety net in many parts of the country. . . . The committee believes that the effects of these combined forces and dynamics demand the immediate attention of public policy officials. (IOM, 2000a: 206)

The committee fully endorses the recommendations from America's Health Care Safety Net: Intact but Endangered (IOM, 2000a), aimed at ensuring the continued viability of the health care safety net (see Box 5–2).

BOX 5–2

Recommendations Concerning Safety-Net Services. Federal and state policy makers should explicitly take into account and address the full impact (both intended and unintended) of changes in Medicaid policies on the viability of safety-net providers and (more...)

Clinical Preventive Services

The evidence that insurance makes a difference in health outcomes is well documented for preventive, screening, and chronic disease care (IOM, 2002b). Clinical preventive services are the “medical procedures, tests or counseling that health professionals deliver in a clinical setting to prevent disease and promote health, as opposed to interventions that respond to patient symptoms or complaints” (Partnership for Prevention, 1999: 3). Such services include immunizations and screening tests, as well as counseling aimed at changing the personal health behaviors of patients long before clinical disease develops. The importance of counseling and behavioral interventions is evident, given the influence on health of factors such as tobacco, alcohol, and illicit drug use; unsafe sexual behavior; and lack of exercise and poor diets. These risk behaviors are estimated to account for more than half of all premature deaths; smoking alone contributes to one out of five deaths (McGinnis and Foege, 1993).

Coverage of clinical preventive services has increased steadily over the past decade. In 1988, about three-quarters of adults with employment-based health insurance had a benefit package that included adult physical examinations. Two years later, the proportion had risen to 90 percent (Rice et al., 1998; Kaiser Family Foundation and Health Research and Educational Trust, 2000). The type of health plan is the most important predictor of coverage (RWJF, 2001). The use of financial incentives and data-driven performance measurement strategies to improve physicians' delivery of services such as immunizations (IOM, 2002c) may account for the fact that managed care plans tend to offer the most comprehensive coverage of clinical preventive services and traditional indemnity plans tend to offer the least comprehensive coverage.

Although the trend toward inclusion of clinical preventive services is positive, such benefits are still limited in scope and are not well correlated with evidence regarding the effectiveness of individual services. The U.S. Preventive Services Task Force (USPSTF), a panel of experts convened by the U.S. Public Health Service, has endorsed a core set of clinical preventive services for asymptomatic individuals with no known risk factors. In the committee's view, this guidance to clinicians on the services that should be offered to specific patients should also inform the design of insurance plans for coverage of age-appropriate services. However, the USPSTF recommendations have had relatively little influence on the design of insurance benefits, and recommended counseling and screening services are often not covered and, consequently, not used (Partnership for Prevention, 2001) (see Box 5–3). As might be expected, though, adults without health insurance are the least likely to receive recommended preventive and screening services or to receive them at the recommended frequencies (Ayanian et al., 2000).

BOX 5–3

Partnership for Prevention Survey of Employer Support for Preventive Services. Counseling to address serious health risks—tobacco use, physical inactivity, risky drinking, poor nutrition—is least likely to be covered by an employer-sponsored (more...)

Having any health insurance, even without coverage for any preventive services, increases the probability that an individual will receive appropriate preventive care (Hayward et al., 1988; Woolhandler and Himmelstein, 1988; Hsia et al., 2000). Studies of the use of preventive services by Hispanics and African Americans find that health insurance is strongly associated with the increased receipt of preventive services (Solis et al., 1990; Mandelblatt et al., 1999; Zambrana et al., 1999; Wagner and Guendelman, 2000; Breen et al., 2001; O'Malley et al., 2001). However, the higher rates of uninsurance among racial and ethnic minorities contribute significantly to their reduced overall likelihood of receiving clinical preventive services and to their poorer clinical outcomes (Haas and Adler, 2001). For example, African Americans and members of other minority groups who are diagnosed with cancer are more likely to be diagnosed at advanced stages of disease than are whites (Farley and Flannery, 1989; Mandelblatt et al., 1991, 1996; Wells and Horm, 1992).

Medicare Coverage of Preventive Services

Preventive services are important for older adults, for whom they can reduce premature morbidity and mortality, help preserve function, and enhance quality of life. Unfortunately, the Medicare program was not designed with a focus on prevention, and the process for adding preventive services to the Medicare benefit package is complex and difficult. Unlike forms of treatment that are incorporated into the payment system on a relatively routine basis as they come into general use, preventive services are subject to a greater degree of scrutiny and a demand for a higher level of effectiveness, and there is no routine process for making such assessments. Box 5–4 lists the preventive services currently covered by Medicare.

BOX 5–4

Preventive Services Covered by Medicare. For individuals with Medicare, the following services are covered by Medicare Part B: Bone mass measurements for people at risk of losing bone mass

The level of use of preventive services among older adults has been relatively low (CDC, 1998). This may reflect the limited range of benefits covered by Medicare, as well as other barriers such as copayments, participants' unfamiliarity with the services, or the failure of physicians to recommend them. Cardiovascular disease and diabetes exemplify the problem. Although cardiovascular disease is the leading cause of death and diabetes is one of the most significant chronic diseases affecting Medicare beneficiaries, physicians cannot screen for lipids disorders or diabetes unless the patient agrees to pay out-of-pocket for the tests.

Medicaid Coverage of Preventive Services

Medicaid benefits vary by state in terms of both the individuals who are eligible for coverage and the actual services for which coverage is provided. The exception is preventive services for children. In 1976, the U.S. Congress added the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program to the federal Medicaid program. This entitled poor children to a comprehensive package of preventive health care and medically necessary diagnostic and treatment services. In 1996, 22.9 million children (20 percent of the nation's children) were eligible for EPSDT benefits. Given its potential to reach such a high proportion of the nation's neediest children, the program could have a very positive, widespread impact on children's health. Unfortunately, data on the program's progress are incomplete and inconsistent across the country, despite federal requirements for state reports (GAO, 2001a). However, some studies have demonstrated that EPSDT has never been fully implemented, and the percentage of children receiving preventive care through it remains low for reasons ranging from systemic state or local deficiencies (e.g., a lack of mechanisms for follow-up, issues related to managed care contracting, and confusing program requirements) to barriers at the personal level (e.g., transportation and language) (GAO, 2001a; Strasz et al., 2002). Of the 22.9 million children eligible for EPSDT in 1996, only 37 percent received a medical screening procedure through the program (Olson, 1998) (see Box 5–5). Additionally, data show that as many as 50 percent of children who have an EPSDT visit are identified as requiring medical attention, but if they are referred for follow-up care, only one-third to two-thirds go for their referral visit (Rosenbach and Gavin, 1998).

BOX 5–5

Children's Preventive Health Care under Medicaid. Number of eligible children. Between 1991 and 1996, the number of children eligible for the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program increased by roughly 5.7 million, with (more...)

Mental Health Care

The Surgeon General's report on mental illness (DHHS, 1999) estimates that more than one in five adults are affected by mental disorders in any given year (see Box 5–6) and 5.4 percent of all adults have a serious mental illness. Data for children are less reliable, but the overall prevalence of mental disorders is also estimated to be about 20 percent (DHHS, 1999). Mental disorders are a major public health issue because they affect such a large proportion of the population, have implications for other health problems, and impose high costs, both financial and emotional, on affected individuals and their families. The cost to society is also high, with indirect costs from lost productivity for affected individuals and their caretakers estimated at $79 billion in 1990, the last year for which estimates are available (Rice and Miller, 1996).

BOX 5–6

Facts About Mental Illness. About 40 million people (more than one in five) ages 18 to 64 are estimated to have a single mental disorder of any severity or both a mental and an addictive disorder in a given year (Regier et al., 1993; Kessler et al., 1994). (more...)

For the most prevalent mental health disorders such as depression and anxiety, receipt of appropriate care is associated with improved functional outcomes at 2 years (Sturm et al., 1995), but the majority of individuals suffering from mental illness are not treated for their condition (DHHS, 1999). Access to care is constrained by limitations on insurance coverage that are greater than those imposed for other diseases. Annual and lifetime coverage limits are frequently less, and mental health coverage often has more hidden costs in the forms of copayments and higher deductibles (Zuvekas et al., 1998). Table 5–2 shows the distribution of sources of payment for treatment for mental health and addictive disorders in 1996. Additionally, those with no insurance all year paid nearly 60 percent of costs out-of-pocket, whereas those with some private insurance paid 40 percent of costs out-of-pocket in 1996 (Zuvekas, 2001).

TABLE 5–2

Distribution (percent) of Sources of Payment for Mental Health/Substance Abuse Treatment, by Type of Use, 1996.

Adults' use of mental health services in both the general and the specialty mental health sectors correlates highly with health insurance coverage (Cooper-Patrick et al., 1999; Wang et al., 2000; Young et al., 2001), and health insurance coverage specifically for mental health services is associated with an increased likelihood of receiving such care (Wang et al., 2000; Young et al., 2000). Recent studies have shown impressive results for treatment of depression in primary care settings (Sturm and Wells, 2000; Schoenbaum et al., 2001). The provision of such services is cost-effective and comparable to the cost-effectiveness of other common procedures. However, reimbursement policies for primary care do not support the services necessary to provide evidence-based care for depression (Wells et al., 2000; Schoenbaum et al., 2001).

Adults with either no insurance coverage or coverage that excludes or limits extended treatment of mental illness receive less appropriate care and may experience delays in receiving services until they gain public insurance (Rabinowitz et al., 2001). Adults with mental disorders are also more likely to lose health insurance coverage within a year following their diagnosis than those without a mental disorder (Sturm and Wells, 2000).

The limited and unstable nature of insurance for treatment of mental illness has several implications for governmental public health agencies because the severely mentally ill are likely to end up receiving care in publicly funded safety-net programs (Rabinowitz et al., 2001). Funding to support the public mental health system comes from reimbursements for services provided to Medicare and Medicaid participants, from federal block grants to states, and from state and local funds that support community-based programs and hospital care. Taken in the aggregate, these funding streams are neither adequate nor reliable enough to meet the needs of individuals with serious mental disorders (IOM, 2000a). As with other forms of safety-net care, the urgency of providing treatment to the severely mentally ill erodes funds available for prevention purposes.

Treatment for Substance Abuse

In the United States, more than 18 million people who use alcohol and nearly 5 million who use illicit drugs need substance abuse treatment (SAMHSA, 2001). Substance abuse, like mental illness, exacts enormous social costs across all segments of society. The total social costs of alcohol abuse alone were estimated at $177.3 billion in 1997 (Coffey et al., 2001). In that same year, $6.4 billion was spent on treatment. Total spending on drug abuse treatment equaled $5.5 billion in that year, compared with estimated social costs of drug abuse of $116.9 billion.

Most recipients (87 percent) of specialty treatment for alcohol or drug abuse receive it in outpatient settings (RWJF, 2001), but overall, less than one-fourth of those who need treatment get it. Barriers to treatment include stigma, lack of available treatment facilities, unwillingness to admit that treatment is needed, and inability to pay for care. Public sources provide more than two-thirds of the funding for alcohol and drug treatment facilities. Half of such funds come from dedicated funding at the federal, state, and local levels in the form of various block grants to state safety-net programs. Medicaid and Medicare cover 21 percent of treatment, private insurance covers 14 percent, and 10 percent is paid directly by patients as out-of-pocket costs. Another 5 percent is covered through various charitable sources.

Insurance policies held by many individuals constrain the use of substance abuse services by the exclusion of benefits for such services and by the use of annual and lifetime limits on benefits and other controls on service utilization. Between 1987 and 1997, private insurance for substance abuse services fell 0.2 percent per year on average (inflation adjusted). Over the same period, out-of-pocket payments for specific types of substance abuse treatment increased (Coffey et al., 2001). However, the high out-of-pocket costs faced by individuals who pay for their own treatment discourage many who need care from seeking it.

Oral Health Care

Like mental illness and addiction disorders, oral health has been neglected in the health care delivery system. The consequences in terms of individual and population health are significant—oral health is a matter of public health concern because it affects a large proportion of the population and is linked with overall health status (see Box 5–7). Oral diseases are causally related to a range of significant health problems and chronic diseases, as well as individuals' ability to succeed in school, work, and the community (DHHS, 2000b). The effects of oral diseases are cumulative and influence aspects of life as fundamental as the foods people can eat, their ability to communicate effectively, and their social acceptability. The problems in the way the health care delivery system relates to oral health include lack of dental coverage and low coverage payments, the separation of medicine and dentistry in training and practice, and the high proportion of the population that lacks any dental insurance. The committee focused on the problem of insurance and access to care.

BOX 5–7

Oral Health as a Component of Total Health. When people think about the components of good health, they often forget about the importance of good oral health. This oversight is often reflected by health insurance coverage restrictions that exclude oral (more...)

According to the Department of Health and Human Services (DHHS) Office of Health Promotion and Disease Prevention, more than 150 million Americans have limited or no dental insurance, nearly four times the number who lack insurance for medical care (cited by Allukian, 1999). As with other types of health services, insurance is a strong predictor of access to and use of dental services, and minorities and low-income populations are much less likely to have dental insurance or to receive dental care.

Individuals and families living below the poverty level experience more dental decay than higher-income groups, and their cavities are less likely to be treated (GAO, 2000). More than a third of poor children (ages 2 to 9) have one or more primary teeth with untreated decay, compared with 17.3 percent of nonpoor children (DHHS, 2000b). Mexican-American adults and children are more likely to have untreated decayed teeth than any other population group. Poor Mexican-American children ages 2 to 9 have the highest proportion of untreated decayed teeth (70.5 percent), followed by poor non-Hispanic African-American children (67.4 percent). The pattern for adults is similar (DHHS, 2000b: 63–64).

Medicare excludes coverage of routine dental care, and many state Medicaid programs do not provide dental coverage for eligible children or adults. According to a report of the Surgeon General, fewer than one in five Medicaid-covered children received a single dental visit in a recent year-long study period (DHHS, 2000b). Low-income Hispanic children and adults are less likely to be eligible for Medicaid than other groups, so even the limited Medicaid benefits are unlikely to be available to them. The forecast for major oral health problems among the nation's fastest-growing population group, Hispanics, is especially alarming.

The committee found that preventive, oral health, mental health, and substance abuse treatment services must be considered part of the comprehensive spectrum of care necessary to help assure maximum health. Therefore, the committee recommends that all public and privately funded insurance plans include age-appropriate preventive services as recommended by the U.S. Preventive Services Task Force and provide evidence-based coverage of oral health, mental health, and substance abuse treatment services.

Disparities in Health Care

A principal finding from Crossing the Quality Chasm (IOM, 2001b: 53) is that “the quality of care should not differ because of such characteristics as gender, race, age, ethnicity, income, education, disability, sexual orientation, or place of residence.” Disparities in health care are defined as “racial or ethnic differences in the quality of health care that are not due to access-related factors or clinical needs, preferences and appropriateness of intervention” (IOM, 2002b: 4).

Evidence shows that racial and ethnic minorities do not receive the same quality of care afforded white Americans. These findings are consistent across a range of illnesses and health care services and remain even after adjustment for socioeconomic differences and other factors that are related to access to health care (IOM, 2002b). Furthermore, poor-quality health care is an important independent variable contributing to lower health status for minorities (IOM, 2002b). For example, racial differences in cervical cancer deaths have increased over time, despite the greater use of screening tests by minority women (Mitchell and McCormack, 1997). The lower quality of care also compounds the adverse health effects of other disadvantages faced by minorities, including lower incomes and education, less healthy living environments, and a greater likelihood of being uninsured.

As discussed in Unequal Treatment (IOM, 2002b), the factors that may produce disparities in health care include the role of bias, discrimination, and stereotyping at the individual (provider and patient), institution, and health system levels. The report found that aspects of the health care system—its organization, financing, and availability of services—may have adverse effects specifically for racial and ethnic minorities. For example, time pressures on physicians hamper their ability to accurately assess presenting symptoms, especially when cultural or language barriers are present. Nearly 14 million people in the United States are not proficient in English.

Changes in the financing and delivery of health care services, such as the emphasis on cost controls and the almost complete conversion to managed care for the delivery of services under Medicaid, may be especially problematic for racial and ethnic minorities. The disruption of traditional community-based care and the displacement of providers who are familiar with the language, culture, and values of ethnic communities create barriers to effective care (Leigh et al., 1999). In addition, segmentation of health care plans was found to play a significant role in producing poorer care for racial and ethnic minorities because they are more likely than whites to be enrolled in “lower-end” health plans (IOM, 2002b). Such plans are characterized by higher per capita resource constraints and stricter limits on covered services (Phillips et al., 2000). Fragmentation of health plans along socioeconomic lines engenders different clinical cultures, with different practice norms (Bloche, 2001).

The committee encourages the health care system and policy makers in the public and private sectors to give careful consideration to the interventions that are identified in Unequal Treatment (IOM, 2002b) and aimed at eliminating racial and ethnic disparities in health care (see Box 5–8).

BOX 5–8

Legal, Regulatory, and Policy Interventions to Eliminate Racial and Ethnic Disparities in Health Care. Avoid fragmentation of health plans along socioeconomic lines. Strengthen the stability of patient–provider relationships in publicly funded (more...)

Care for Chronic Conditions

Americans now live longer. A child born today can expect to live more than 75 years, and advances in medicine have also extended the life spans of earlier generations. As detailed in Chapter 1, the result is that individuals over age 65 constitute an increasingly large proportion of the U.S. population—13 percent today, increasing to 20 percent over the next decade. Embedded in these demographic changes is a dramatic increase in the prevalence of chronic conditions. Chronic conditions, defined as illnesses that last longer than 3 months and that are not self-limiting, affect nearly half of the U.S. population. An estimated 100 million Americans have one or more chronic conditions, and that number is estimated to reach 134 million by 2020 (Pew Environmental Health Commission, 2001). Nearly half of those with a chronic illness have more than one such condition (IOM, 2001a). Additionally, disabling chronic conditions affect all age groups, but about two-thirds are found in individuals over age 65. With the projected growth in the number of people over age 65 increasing from 13 percent of the population to 20 percent, the need for care for chronic conditions will also continue to grow.

As detailed in Crossing the Quality Chasm (IOM, 2001b: 27), effective health care for chronic disease management is a collaborative process, involving the “definition of clinical problems in terms that both patients and providers understand; joint development of a care plan with goals, targets, and implementation strategies; provision of self-management training and support services; and active, sustained follow-up using visits, telephone calls, e-mail, and Web-based monitoring and decision support systems.”

The current health care system does not meet the challenge of providing clinically appropriate and cost-effective care for the chronically ill. Crossing the Quality Chasm (IOM, 2001b: 28) found that “the prevailing model of health care delivery is complicated, comprising layers of processes and handoffs that patients and families find bewildering and clinicians view as wasteful . . . a nightmare to navigate.” Although this reality is a challenge for anyone seeking care, the effects become especially damaging for those with chronic conditions. Wagner and colleagues (1996) identified five elements required to improve outcomes for chronically ill patients:

1.

Evidence-based planned care.

2.

Reorganization of practices to meet the needs of patients who require more time, a broad array of resources, and closer follow-up.

3.

Systematic attention to patients' need for information and behavioral change.

4.

Ready access to necessary clinical expertise.

5.

Supportive information systems.

The health care delivery system as it exists today cannot deliver those elements. Recent surveys have found that less than half of U.S. patients with hypertension, depression, diabetes, and asthma are receiving appropriate treatments (Wagner et al., 2001). Delivery of high-quality care to chronically ill patients is especially challenging in a decentralized and fragmented system, characterized by small practices (AMA, 1998). Smaller practices have great difficulty in organizing the array of services and support needed to efficiently manage chronic disease. The result is poor disease management and a high level of wasted resources. As the proportion of old and very old increases, the system-wide impact in terms of cost and increased disability may well overwhelm the human and financial resources available to care for chronically ill patients.

Shortages of Health Care Professionals

The committee took special note of certain shortages of health care professionals, because these shortages are having a significant adverse effect on the quality of health care. The committee's particular concerns are the underrepresentation of racial and ethnic minorities in all health professions and the shortage of nurses, especially registered nurses (RNs) practicing in hospitals.

However, the focus on these two health care professional shortage areas does not suggest the absence of problems in other fields. Acute shortages of primary care physicians exist in many geographic areas, in certain medical specialties, and in disciplines such as pharmacy and dentistry, to name two. In addition, a growing consensus suggests that major reforms are needed in the education and training of all health professionals. To deliver the type of health care envisioned in Crossing the Quality Chasm (IOM, 2001b), health care professionals must be trained to work in teams, to utilize information technology effectively, and to develop the competencies necessary to deliver care to an increasingly diverse population. Health professions education is not currently organized to produce these results.

Hospitals and the Capacity for Emergency Response

Hospitals contribute in various ways to assuring the health of the public, particularly by providing acute care services, educating health professionals, serving as a site for research, organizing community health promotion and disease prevention activities, and acting as safety-net providers. However, hospitals play a uniquely important role by serving as the primary source of emergency and highly specialized care such as that in intensive care units (ICUs) and centers for cardiac care and burn treatment.

Recent changes in the structure of the hospital industry, the reimbursement of hospitals by public- and private-sector insurance programs, and nursing shortages have raised questions about the ability of hospitals to carry out these roles. Although the terrorist incidents in the fall of 2001 did not directly test the ability of hospitals to respond to a medical crisis, they drew particular attention to hospitals' limited “surge capacity”—the ability to absorb a large influx of severely injured patients—in their emergency departments and specialty units.

During the 1990s, the spread of managed care practices contributed to reductions in overall hospital admissions, in the length of hospital stays, and in emergency department visits. As a result of decreasing demand for hospital services and a changing financial environment, hospitals in many parts of the country reduced the number of patient beds, eliminated certain services, or even closed (McManus, 2001). The American Hospital Association (AHA, 2001a) reports that from 1994 to 1999, the number of emergency departments in the nation decreased by 8.1 percent (see Table 5–3). Over the same period, medical and surgical bed capacities were reduced by 17.7 percent, ICU bed capacities were reduced by 2.8 percent, and specialty bed (including burn bed) capacities were reduced by 3.4 percent. Although these reductions may have improved the efficiencies of hospitals, they have important implications for the capacity of the health care system to respond to public health emergencies.

TABLE 5–3

Change in Hospital Capacity, 1994–1999.

Crowding in hospital emergency departments has been recognized as a nationwide problem for more than a decade (Andrulis et al., 1991; Brewster et al., 2001; McManus, 2001; Viccellio, 2001). According to the American Hospital Association (2001a), the demand for emergency department care increased by 15 percent between 1990 and 1999. In a random survey of emergency department directors in 1998 and 1999, 91 percent of the 575 respondents reported overcrowding problems (Derlet et al., 2001). The overcrowding was severe, resulting in delays in testing and treatment that compromised patient outcomes. The emergency departments of hospitals in many areas of New York City routinely operated at 100 percent capacity (Brewster et al., 2001). Patients regularly spent significant portions of their admission on gurneys in a hallway.

One consequence of this crowding is the periodic closure of emergency departments and the diversion of ambulances to other facilities. Ambulance diversions have been found to impede access to emergency services in metropolitan areas in at least 22 states (U.S. House of Representatives, 2001); at least 75 million Americans are estimated to reside in areas affected by ambulance diversions. Looking at 12 communities, Brewster and colleagues (2001) found that on average in 2001, two hospitals in Boston closed their emergency departments each day and the Cleveland Clinic emergency departments were closed to patients arriving by ambulance for an average of nearly 12 hours a day.

The increase in demand for emergency care is attributed to several factors (Brewster et al., 2001). In particular, managed care rules have changed to allow increased coverage of care provided in emergency departments. Hospitals are in better compliance with the federal Emergency Medical Treatment and Labor Act, which requires emergency departments to treat patients without regard for their ability to pay. In addition, uninsured patients are making greater use of emergency departments for nonurgent care.

Access to Primary Care

The adequacy of hospital capacity cannot be assessed without considering the system inefficiencies that characterize current insurance and care delivery arrangements. These include the demands placed on hospital emergency and outpatient departments by the uninsured and those without access to a primary care provider. The unique characteristic of primary care is the role it plays as a regular or usual source of care for patients and their families. Good primary care assures continuity for the patient across levels of care, comprehensiveness of services according to the level of health or illness, and better coordination of these services over time (Starfield, 1998).

Defining the right level of immediate and standby capacity for emergency and inpatient care depends in part on the adequacy and effectiveness of general outpatient and primary care. For example, chronic conditions like asthma and diabetes often can be managed effectively on an outpatient basis, but if the conditions are poorly managed by patients or their health care providers, emergency or inpatient care may be necessary. Billings and colleagues (1993) demonstrated strong links between hospital admission rates for such conditions and the socioeconomic and insurance status of the population in an area. For example, admission rates for asthma were 6.4 percent higher in low-income areas than in higher-income areas, with more than 70 percent of the variation explained by household income (Billings et al., 1993). Differences in disease prevalence accounted for only a small portion of the differences in hospitalization rates among low- and high-income areas.

Although Billings and colleagues did not draw conclusions about the causal pathways leading to these higher admission rates, it is likely that the contributing factors include those discussed in this chapter, such as a lack of insurance or a regular source of care and the assignment of Medicaid populations to lower-cost health plans. A follow-up analysis found the situation to be growing worse for low-income populations, as economic pressures, including lower reimbursements rates, higher practice costs, and limitations on payment for diagnostic tests, squeeze providers who have historically delivered care to academic health centers' low-income populations (Billings et al., 1996). Bindman and colleagues (1995) similarly concluded that at the community level, “there is a strong positive association between health care access and preventable hospitalization rates, suggesting that these rates can serve as an indication of access to care.” It would be a costly mistake to create additional emergency and inpatient capacity before decompressing demand by improving access to primary care services. Good primary care is associated with better birth weights (Politzer et al., 2001), lower smoking rates, less obesity, and higher rates of seat belt use (Shi et al., 1999) and is a major determinant of receiving preventive services such as blood pressure screening, clinical breast exams, and Pap smears (Bindman et al., 1996). Geographically, areas with higher primary care physician-to-population ratios experience lower total health care costs (Welch et al., 1993; Mark et al., 1996; Franks and Fiscella, 1998; Starfield and Shi, 2002). Additionally, there is evidence that primary care is associated with reduced disparities in health; areas of high income inequality that also had good primary care were less likely to report fair or poor self-rated health (Starfield, 2002). The link between the availability of primary care and better health is also supported by international evidence, which shows that nations that value primary care are likely to have lower mortality rates (all causes; all causes, premature; and cause specific), even when controlling for macro- and micro-level characteristics (e.g., gross domestic product and per capita income) (Macinko et al., in press).

The Unfulfilled Potential of Managed Care

Although Billings and colleagues focused on the preventable demands for hospital care among low-income and uninsured populations, Closing the Quality Chasm (IOM, 2001b) makes clear that the misuse of services also characterizes disease management among insured chronically ill patients.

In the early 1990s, managed care became a common feature of the health care delivery system in the United States. In theory, managed care offers the promise of a population-based approach that can emphasize regular preventive care and other services aimed at keeping a defined group as healthy as possible. These benefits are most easily achieved under a fully capitated, group practice model: patients enroll with a health care organization that is paid a certain amount per member per month to provide all necessary or indicated services to the enrolled population, and physicians are paid a monthly fee or are salaried, which separates payment from the provision of individual services. This model allows a relatively stable enrolled population for whom benefits and services can be customized; knowledge of the global budget within which care is to be delivered; and a salaried workforce in which health care providers have an incentive to keep patients healthy and reduce unnecessary use of services but also have a culture in which they monitor each others' practices and quality of care. For the patient, the model provides comprehensive care, an emphasis on prevention, and low out-of-pocket costs. Kaiser Permanente Medical Group pioneered the model more than 50 years ago on the basis of early experiences providing health care programs for employees of Kaiser industrial companies (e.g., construction, shipyards, steel mills) in the late 1930s and 1940s.¹

An important opportunity was lost when insurance companies, health plans and health providers, and the state and federal governments saw managed care primarily as a cost-containment mechanism rather than a population-based approach to delivering comprehensive and effective health care services. Reimbursement rate reductions, restrictions on care and choice of physician, and other aspects of plan management disaffected millions of Americans from the basic concept of managed care. Furthermore, rapid turnover in enrollment, particularly in Medicaid managed care, ruined economic incentives for plans to view their enrollees as a long-term investment. This loss of trust in the idea of managed care is also the loss of a great opportunity to improve quality and restrain costs. Loosely affiliated physician networks have no ability to identify their populations and develop programs specifically based on the epidemiology of the defined group. There is little ability to use data systems, shared protocols, or peer pressure to improve quality and reduce variations in health care practices.

Managed care is undergoing rapid changes, some of which are likely to further undermine its viability. Consumer demands for more choice and greater flexibility are weakening restrictions on access to providers and limitations on services. Physicians are proving more aggressive and successful in their negotiations with plans to decrease constraints, and to date, most employers have been willing to accept the higher costs that result. Employer acceptance may change in the face of double-digit insurance premium increases.

Predicting the next configuration of insurance and plan delivery systems is dangerous in a system undergoing such rapid transition. A number of major insurance plans have announced that they will begin to offer defined-contribution options.² This may be attractive to employers, whose liability will be defined by a specific premium amount rather than by a specified set of benefits. Consumers will be expected to shop for their own care with a medical spending account coupled with catastrophic benefits for very large expenses. This could significantly undermine the current pooling of risk and create incentives for overuse of high-technology services once a deductible for catastrophic benefits has been met. However, such plans have yet to assume a significant role in the insurance market, and few employers offer them as an alternative.

Information Technology

The development of enhanced information technology and its use in hospitals, individual provider practices, and other segments of the health care delivery system are essential for improving the quality of care. Better information technology can also support patients and family caregivers in crucial health decisions, strengthen both personal and population-based prevention efforts, and enhance participation in and coordination with public health activities. (See Chapter 3 for a discussion of the information technology needs of the governmental public health infrastructure.)

Crossing the Quality Chasm (IOM, 2001b) formulated the case that information technology is critical to the redesign of the health care system to achieve a substantial improvement in the quality of care. A strong clinical information infrastructure is a prerequisite to reengineering processes of care; coordinating patient care across providers, plans, and settings and over time; supporting the operation of multidisciplinary teams and the application of clinical support tools; and facilitating the use of performance and outcome measures for quality improvement and accountability.

From the provider perspective, better information systems and more extensive use of information technology could dramatically improve care by offering ready access to complete and accurate patient data and to a variety of information resources and tools—clinical guidelines, decision-support systems, digital prescription-writing programs, and public health data and alerts, for example—that can enhance the quality of clinical decision making. Computer-based systems for the entry of physician orders have been found to have sizable benefits in enhancing patient safety (Bates et al., 1998, 2001; Schiff et al., 2000).

Despite profound growth in clinical knowledge and medical technology, the health care delivery system has been relatively untouched by the revolution in information technology that has transformed other sectors of society and the economy. Many health care settings lack basic computer systems to provide clinical information or support clinical decision making. Even where electronic medical record systems are being implemented, most of those systems remain proprietary products of individual institutions and health plans that are based on standards of specific vendors.

The development and application of interoperable systems and secure information-sharing practices are essential to gain greater benefits from information technology. At present, only a few institutions have had the resources to build integrated information systems that meet the needs of diverse specialties and environments. Those efforts illustrate both the costs involved in developing health information systems and some of the benefits that might be expected. Kaiser Permanente, for example, is investing $2 billion in a web-based system encompassing all of the critical features needed to provide patient-centered, high-quality care: a nationwide clinical information system, a means for patients to communicate with doctors and nurses to seek medical advice, access by clinicians to clinical guidelines and other knowledge resources, and computerized order entry (Krall, 1998).

So far, however, adoption of even common and less costly information technologies has been limited. Only a small fraction of physicians offer e-mail interaction (13 percent, in a 2001 poll), a simple and convenient tool for efficient communication with their patients (Harris Interactive, 2001). Some of the documented reasons for the low level of physician–patient e-mail communication include concerns about lack of reimbursement for this type of service and concerns about confidentiality and liability. These legitimate issues are slowly being addressed in policy and practice, but there is a long way to go if this form of communication is to achieve its potential for improving interactions between patients and providers.

Enhanced information technology also promises to aid patients and the public in other ways. The Internet already offers a wealth of information and access to the most current evidence to help individuals maintain their own health and manage disease. In addition, support groups and interactive programs offer additional approaches to empower consumers. Personalized systems for comprehensive home care may improve outcomes and reduce costs. Medicare's pilot project IdeaTel—Informatics for Diabetes Education and Telemedicine—offers web-based home systems to rural and inner-city diabetics to support home monitoring, customized information, and secure links to providers and to the patients' own medical records (www.dmi.columbia.edu/ideatel/info.html).

Other efforts to build a personal health record (PHR) created or cocreated and controlled by the individual—and instantly available to support treatment in any setting—suggest that the PHR may provide a comprehensive, accurate, and continuous record to support health and health care across the life span (Jones et al., 1999).

A sophisticated health information infrastructure is also important to support public health monitoring and disease surveillance activities. Systems and protocols for linking health care providers and governmental public health agencies are vital for detecting emerging health threats and supporting appropriate decisions by all parties. The committee cautions, however, that systems dedicated to a single use, such as bioterrorism, will not be optimal; systems designed to be comprehensive and flexible will be of greater overall value. Ultimately, such systems should also allow the public to contribute and receive information to get the most complete database possible.

For information technology to transform the health sector as it has banking and other forms of commerce that depend on the accurate, secure exchange of large amounts of information, action must be taken at the national level to develop the National Health Information Infrastructure (NHII) (NRC, 2000). The committee endorses the call by the National Committee on Vital and Health Statistics (NCVHS) (2002) for the nation to build a twenty-first century health support system—a comprehensive, knowledge-based system capable of providing information to all who need it to make sound decisions about health. Such a system can help realize the public interest related to quality improvement in health care and to disease prevention and health promotion for the population as a whole. The rapid development and widespread implementation of an extensive set of standards for technology and information exchange among providers, governmental public health agencies, and individuals are critical.

Nevertheless, as the NCVHS report describes, neither the opportunities nor the barriers to the development of the NHII are related solely to information technology. To realize the full potential of the NHII, supportive changes in the social, economic, and legal infrastructures are also required. Policies promoting the portability and continuity of personal health information are essential. Values, practices, relationships, laws, and investment and reimbursement policies must support the creation and use of data and information systems that are consistent with the vision for the NHII (see Chapter 3 for an additional discussion and recommendation).

The Emergence of Separate Systems

Within the public health system in the United States, collaboration between the health care sector and governmental public health agencies is generally weak. This reflects the divergence and separate development of two distinct sectors following the Second World War. Lasker and colleagues observed, “[t]he dominant, highly respected medical sector focused on individual patients, emphasizing technologically sophisticated diagnosis and treatment and biological mechanisms of disease. The considerably smaller, less well-appreciated public health sector concentrated on populations, prevention, nonbiological determinants of health, and safety-net primary care” (Lasker et al., 1997: 274). As disciplines and professional fields, medicine and public health evolved with minimal levels of interaction, and often without recognition of the lost opportunities to improve the health of individuals and the population. The health care and governmental public health sectors are also very unequal in terms of their resources, prestige, and influence on public policy.

The failure to collaborate characterizes not only the interactions between governmental public health agencies and the organizations and individuals involved in the financing and delivery of health care in the private sector but also financing within the federal government. Within the Department of Health and Human Services (DHHS), the Centers for Medicare and Medicaid Services (CMS) administer the two public insurance programs with little interaction or joint planning with agencies of the U.S. Public Health Service (PHS). Even the congressional authorizing committees for these activities are separate. For example, the Substance Abuse and Mental Health Services Administration, a PHS agency, administers block grants to states to augment funding for mental health and substance abuse programs, neither of which is well supported under Medicaid. Until recently, the Medicaid waiver program, administered by CMS on behalf of the Secretary of Health and Human Services, did not provide protection of reimbursement rates for clinics within the safety-net system. At the same time, the Health Resources and Services Administration, the PHS agency charged with funding federally qualified safety-net clinics for the poor, and the Indian Health Service were both seeking funds to support the increasing deficits of these clinics due to the growing number of uninsured individuals and the low rates of reimbursement for Medicaid clinics.

The operational separation of public health and health care financing programs mirrors the cultural differences that characterize medicine and public health. American fascination with technology, science, and medical interventions and a relatively poor understanding of the determinants of health (see Chapter 2) or of the workings of the governmental public health agencies also contribute to the lower status, fewer resources, and limited influence of public health. The committee views these status and resource differences as barriers to mutually respectful collaboration and to achieving the shared vision of healthy people in healthy communities. The committee also urges greater efforts on the part of the health care delivery system to meet its public health responsibilities and greater efforts on the part of governmental public health agencies to reach out to health care providers and purchasers and engage them more fully in the public health system.

The Role of Governmental Public Health Agencies as Health Care Providers

Public health departments have always differed greatly in regard to the delivery of health care services, based on the availability of such services in the community and other reasons (Moos and Miller, 1981). Some provide no personal health care services at all, whereas others provide some assortment of primary health care and safety-net services. In general, however, there has been a decrease in the number of local governmental public health agencies involved in direct service provision. In a recent survey of public health agencies, primary care or direct medical care services were the least common services provided (NACCHO, 2001). Despite this, 28 percent of local public health departments report that they are the sole safety-net providers in their communities (Keane et al., 2001).

During the 1990s, Medicaid shifted from a fee-for-service program to a managed care model. This change has been a challenge to the multiple roles of public health departments as community-based primary health care providers, safety-net providers, and providers of population-based or traditional public health services. The challenge has been both financial and organizational. First, managed care plans reimburse safety-net providers less generously than fee-for-service Medicaid providers do (under Medicaid, federally qualified health centers benefited from a federal requirement for full-cost reimbursement), and they impose administrative and service restrictions that result in reduced overall rates of compensation (IOM, 2000a). In many states and localities, these changes have decreased the revenue available to public health departments and public clinics and hospitals. In many cases, funds were no longer available for population-based essential public health services or had to be diverted to the more visibly urgent need of keeping clinics and hospitals open (CDC, 1997). The result of this interplay is that many governmental public health agencies have found themselves in a strained relationship with managed care organizations: on the one hand, encouraging their active partnership in an intersectoral public health system and, on the other, competing with them for revenues (Lumpkin et al., 1998). Second, the shift of Medicaid services to a managed care environment led some public health departments to scale down or dismantle their infrastructure for the delivery of direct medical care. The recent trend of the exit of managed care from the Medicaid market has left some people without a medical home and, in cases of changes in eligibility, has left some people uninsured. This problem may be most acute in rural areas, where public health departments are often the sole safety-net providers (Johnson and Morris, 1998).

One strategy to help lessen the negative impacts of changes in health care financing undertaken by some public health departments has been the development of formal relationships (e.g., negotiating and implementing memoranda of agreement) with local managed care organizations that provide Medicaid and, in some cases, safety-net services. Such arrangements have made possible some level of integration of health care and public health services, enhanced information exchange and continuity of care, and allowed public health departments to be reimbursed for the provision of some of the services that are covered by the benefits packages of managed care plans (Martinez and Closter, 1998). At this time, governmental public health agencies are still called on to play a role in assurance broader than that which may be compatible with their other responsibilities to population health. However, closer integration between these governmental public health agencies and the health care delivery system can help address the needs of the uninsured and underinsured. Denver Health, in Colorado, provides an intriguing example of a hybrid, integrated public–private health system (Mays et al., 2000). Denver Health is the local (county and city) public health authority, as well as a managed care organization and hospital service. Although changes in the Medicaid program continue to challenge Denver Health, it continues to balance its broad responsibilities to the public's health with its role and capacity as a large health care provider.

Disease Surveillance and Reporting

Disease surveillance and reporting provide a classic exemplar of essential collaboration between the health care system and the governmental public health agencies. The latter rely on health care providers and laboratories to supply the data that are the basis for disease surveillance. For instance, in the fall of 2001, reports from physicians who diagnosed the first cases of anthrax were essential in recognizing and responding to the bioterrorism attack.

States mandate the reporting of various infectious diseases (e.g., AIDS, hepatitis B, measles, rabies, and tuberculosis) and submit data to federal disease surveillance systems (CDC, 1999). Governmental public health agencies also depend on astute clinicians to inform them of sentinel cases of recognized diseases that represent a special threat to the public's health and of unusual cases, sometimes without a confirmed diagnosis, that may represent a newly emerging infection, such as Legionnaires' disease or West Nile virus in North America. Other types of public health surveillance activities, such as registries for cancer cases and for childhood immunizations, also depend on reporting from the health care system.

Effective surveillance requires timely, accurate, and complete reports from health care providers. In the case of infectious diseases, if all systems work effectively, the necessary information regarding the diagnosis for a patient with a reportable disease is transmitted to the state or local public health department by a physician or laboratory. For unusual or particularly serious conditions, public health officials offer guidance on treatment options and control measures and monitor the community for any additional reports of similar illness. For diseases like tuberculosis and sexually transmitted diseases, public health agencies facilitate active tracking and prophylactic treatment of persons exposed to an infected individual. Disease reporting requirements vary from state to state, although most states include diseases identified by the Centers for Disease Control and Prevention (CDC) as part of the National Notifiable Disease Reporting System.

Disease reporting is not complete, however. For diseases under national surveillance, from 6 to 90 percent of cases are reported, depending on the disease (Teutsch and Churchill, 1994; Thacker and Stroup, 1994). Incomplete reporting may reflect a lack of understanding by some health care providers of the role of the governmental public health agencies in infectious disease monitoring and control. In some instances, physicians and laboratories may be unaware of the requirement to report the occurrence of a notifiable disease or may underestimate the importance of such a requirement. The difficulty of reporting in a busy practice is also a barrier.

Notifiable disease reporting systems within public health departments with strong liaisons with the health care community are important in the detection and recognition of bioterrorism events. However, this valuable tool has not been well supported and, as noted earlier, suffers from issues of lack of timeliness and incomplete reporting, as well as complex or unclear reporting procedures and limited feedback from governmental public health agencies on how data are used (Baxter et al., 2000; Stagg Elliott, 2002). Health care delivery systems may fear that the data will be used to measure performance, and concerns about patient confidentiality can also contribute to a reluctance to report some diagnoses. New federal regulations regarding the confidentiality of medical records, required by the Health Insurance Portability and Accountability Act (P.L. 104–191) have generated enormous uncertainty and apprehension among health care providers and health systems regarding the sharing of individual clinical data.

Health care providers may also reduce their use of laboratory tests to confirm a diagnosis. This may be because of cost concerns or insurance plan restrictions or simply professional judgment that the test is unnecessary for appropriate clinical care. However, when fewer diagnostic tests are performed for self-limiting illnesses like diarrhea, there may be delays in recognizing a disease outbreak. Reduced use of laboratory testing prevents the analyses of pathogenic isolates needed for disease tracking, testing of new pathogens, and determining the levels of susceptibility to antimicrobial agents.

Other changes in the health care delivery system also raise concerns about the infectious disease surveillance system. As patterns of health care delivery change, old reporting systems are undermined, but the opportunities offered by new types of care systems and technologies have not been realized. For example, traditional patterns of reporting may be lost as health care delivery shifts from inpatient to outpatient settings. Hospital-based epidemiological reporting systems no longer capture many diagnoses now made and treated on an outpatient basis. This would not be a problem if health care systems used currently available information technologies, including electronic medical records and internal disease surveillance systems.

Better information systems that allow the rapid and continuous exchange of clinical information among health care providers and with public health agencies have the potential to improve disease surveillance as well as aid in clinical decision making while avoiding the use of unnecessary diagnostic tests. With such a system, a physician seeing an influx of patients with severe sore throats could use information on the current community prevalence of confirmed streptococcal pharyngitis and the antibiotic sensitivities of the cultured organisms to choose appropriate medications. From a public health perspective, such a system would permit continuous analysis of data from a number of clinical sites, enabling rapid recognition and response to new disease patterns in the community (see Chapter 3 for a discussion of syndrome surveillance). For example, toxic or infectious exposures could be tracked more easily if the characteristics of every patient encounter were integrated into one system and if everyone had unimpeded access to systems of care that could generate such data.

A CDC-funded project of the Massachusetts Department of Public Health and the Harvard Vanguard Medical Associates (a large multi-specialty group) offers a glimpse of the benefits to be gained through collaboration between health care delivery systems and governmental public health agencies and specifically through the effective use of medical information systems (Lazarus et al., 2002). The Harvard Vanguard electronic medical system is queried each night for specific diagnoses assigned during the preceding day in the course of routine care. Diagnoses of interest are grouped into syndromes, and rates of new episodes are computed for all of eastern Massachusetts and each census tract. Expected numbers of new episodes are obtained from a generalized linear mixed model that uses data from 1996 to 1999. These expected numbers allow estimates of the probability of observing specific numbers of cases, either overall or in specific census tracts, and the rapid identification of an unusual cluster of events. The value of this type of real-time monitoring of unusual disease outbreaks is obvious for early identification of bioterrorism attacks as well as for improvements in clinical care and population health.

Preparing Health Care Professionals

Academic health centers (AHCs) serve as a critical interface with governmental public health agencies in several ways. First, as noted earlier, AHCs are an important part of the safety-net system in most urban areas. Second, they are the principal providers of specialized services and serve as regional referral centers for smaller towns or cities and rural areas. Both in normal periods and especially when confronted with either natural disasters or terrorist events, the specialized care units are an essential resource for public health. Moreover, they are also primary loci for research and training. AHCs also have a unique and special set of values that they bring to health care that transcend the discrete functions they perform.

The environment in which AHCs operate has changed substantially over the past decade. The advent of managed care plans that seek services from the lowest-cost appropriate provider and changes in federal (Medicare) reimbursement policies that reduced subsidies for costs associated with AHCs' missions in education, research, and patient care have created considerable pressure on academic institutions to increase efficiency and control costs. At the same time, advances in information technology and the explosion of knowledge from biomedical research have enormous implications for the role of AHCs in the health care system and in population health. Scientific and technological advances will permit clinical care to intervene early in a disease process by identifying and modifying personal risk. The burgeoning knowledge base will require different educational approaches to use the continuously expanding evidence base, with an emphasis on continuing education and lifetime learning.

These changes may result in a broader mission for AHCs that explicitly includes improving the public's health, generating and disseminating knowledge, advancing e-health approaches (i.e., that utilize the Internet and electronic communication technologies), providing education to current health professionals, providing community service and outreach, and delivering care that has the attributes necessary for practice. The ability of academic medicine to evolve into a broader mission will depend on changes in payment systems that may be difficult to achieve and on internal changes within AHCs that may be equally difficult.

Governmental public health agencies may also play an important role in preventive medicine and public health education. Health departments, for example, provide unique venues for the training of nurses, physicians, and other health care professionals in the basics of community-based health care and gain an understanding of population-level approaches to health improvement. Furthermore, public health students and preventive medicine residents gain practical experience in health department rotations, where they participate in program planning and evaluation and learn about assessing a community's health care needs and implementing strategies that change the conditions for health.