- Email: [email protected]
Prevention, Public Health, and Managed Care:
Prevention, Public Health, and Managed Care: Obstacles and Opportunities Emily Friedman
T
his conference was convened because managed care and public health have been pursuing quite different paths in terms of prevention, and there is more than a little tension and competition afoot, as there usually is when jobs, prestige, and money are on the line. This is complicated by the fact that neither side is exactly a monolith: in public health, there are contrasts between understaffed, underfunded county health departments nationwide and the wellfunded, renowned national infectious disease program at CDC. The managed care world is similarly characterized by lavishly capitalized health plans, led by multimillionaire chief executive officers, and thinly funded non-profit plans struggling to serve Medicaid, disabled, and other vulnerable patient populations. The lack of a binding sense of unity around prevention is therefore not surprising. Beyond that, there are at least three legitimate differences between public health and managed care that can impede collaboration on prevention. First, although both have responsibility for populations, managed care gets to choose its populations, whereas public health is responsible for everyone. For a long time, managed care’s main constituency was young, employed, reasonably healthy groups of people—not the most intractable population in terms of health. More recently, managed care has expanded into Medicaid and Medicare and is beginning to serve more difficult populations. In some cases, this change is proving to be a far superior way of organizing care for these vulnerable groups. In others, though, it has been a calamity characterized by brutal risk aversion by some managed care plans. The result has been lawsuits, injunctions, and, in many cases, lackadaisical regulatory response. Although Congress and state legislatures have been passing managed care legislation at a breakneck pace, too much of it has consisted of dictating how care is to be provided on a diagnosis-specific or procedure-specific basis, a terrible precedent in terms of clinical autonomy and quality of care.
Contributing Editor, Hospitals and Health Networks and Healthcare Forum Journal and Section Editor, Journal of the American Medical Association. Address correspondence to: Emily Friedmon, Unit G, 851 West Gummison Street, Chicago, Illinois 60640
102
Am J Prev Med 1998;14(3S) © 1998 American Journal of Preventive Medicine
Meanwhile, at least 40 states plan to implement Medicaid managed care. This will increase the number of sicker people in managed care plans; a study by the Kaiser Family Foundation in 1996 found, for example, that 30% of all [welfare] families have at least one disabled member. Seeking to enroll these fragile patients in some managed care plans will not produce a good match in all cases, particularly if plans continue to skim on the basis of patient health status. In contrast, public health does not enjoy the luxury of selectivity; it has to protect everyone. Moreover, as the skimming goes on, public health is ending up with responsibility for more of the sickest and most difficult patients while the money goes elsewhere. Public health is also picking up persons technically enrolled in managed care who continue to seek public health services, as well as those who are being dropped from Medicaid—including the 180,000 persons dropped last year who had been deemed disabled by reason of substance abuse, and long-term [welfare] families and some immigrants who may be dropped soon. The effect, intentional or not, is that even the Medicaid population deemed eligible for managed care is being cleansed of bad risks and difficult populations. As for the uninsured, their numbers keep rising. According to the Census Bureau, 40 to 45 million people lack coverage most or all of the time. The private sector, though, is not hurrying to sign them up. Managed care can pick the populations for which it takes responsibility; public health cannot. This is a major source of tension between the two. A second difference is that public health’s mission is well defined, whereas managed care serves many masters. In managed care, which master you serve has everything to do with ownership and structure. I disagree with Dr. McGuire’s view that the issue is not for-profits versus non-profits or integrated versus non-integrated plans. These are precisely the issues. Most HMOs today are for-profit, and almost all of them are publicly held and are thus accountable to stockholders and to the Wall Street brokers who rate their stock. This is appropriate for a publicly held organization, but it raises questions about whether such accountability is appropriate for health care. In contrast, non-profits are first accountable to their boards, the
0749-3797/98/$19.00 PII S0749-3797(97)00034-2
Internal Revenue Service, the state government, and, in many cases, their members and communities. Furthermore, most HMOs are not integrated. An integrated plan employs or exclusively contracts with physicians in group practices, likely owns some or most of the hospitals that serve its members, and provides most services in a reasonable continuum of care. An IPA or broker-type plan simply makes a deal between payers and providers, transfers much or even all the risk to the providers, and takes as much as a third of the premium money as its payment. An integrated plan actually provides services as well as collecting premiums, and it bears the risk. It makes a difference, in terms of a commitment to prevention, whether you are required by law to provide community benefits or are required by law to maximize profit for stockholders. It makes a difference in terms of access, in terms of quality of care, and in terms of which master you serve. This is not a dilemma faced by public health. Whether its structure facilitates it or not—and often it does not, whether the funding is there or not—and often it is not, public health is supposed to protect the public—all of the public. Some health plans do serve the public and serve it brilliantly. Others do not. It makes a difference. A third area of difference is turf and money. The positions of the combatants appear to be that managed care is attacking and winning public health territory, with public health on the defensive and being beaten back. The question is what managed care will do with the territory it wins if it is able to hang on to it. Fears on the part of the public health community that some plans will just take the money and run are thoroughly justified. Concerns also center on the many faces of prevention. Some consultants and managed care advocates are now suggesting that all prevention and public health activities can be taken over by managed care plans. Well, perhaps in a perfect world; but I cannot see health plans figuring out which part of the water supply to protect because they are only responsible for their own members, or surveying their members about the restaurants they eat in so that they only have to worry about salmonella in those restaurants. This may seem far-fetched, but as competition for patients, turf, and funds increase, many health care entities will be actively seeking new worlds to conquer. On a larger scale, if we decide that the CDC is superfluous, who will do the epidemiology in the face of new disease agents attacking us from all sides? On the other hand, the managed care community’s frustration with the parochialism, paranoia, and arrogance of public health people is also sometimes justified. If public health is so wonderful at prevention, why are so many of our 2-year-olds not immunized? Why are
we struggling with antibiotic-resistant tuberculosis and pneumococci? Why did dozens of American children die of measles in 1991? This is hardly an advertisement for the achievements of public health. Maybe they could learn something from truly integrated, committed health plans. The most remarkable thing about this conference, then, is that so many participants were willing to put aside their differences and start talking to each other. It has not been without suspicion and tension, of course, but, for the most part, this has been a good start. If the overcoming of these differences— or at least the opening of negotiations— has been the most visible accomplishment of this conference, the most important responsibility of the people here is to accept that managed care and public health share an enormous amount when it comes to preventive health. Not all of what they share is positive, but much of it is. First, you share three obstacles to improving both the theory and practice of prevention in this country. As Dr. Smith said, this is not a country or culture that exactly worships at the altar of prevention. We talk a good game, but the fact is that we glorify anorexia; we price health clubs and equipment out of the reach of the persons who could benefit from them the most; we preach fresh fish and vegetables to people who are trying to raise a family on $13,000 a year and whose supermarkets are in 7-Elevens; and we market a healthy lifestyle characterized by grueling exercise, nothing fun to eat, no cigarettes, no alcohol, no drugs, and exhortations to watch the stress levels. And then we wonder why people don’t flock to our banner. At the same time, when people do not live up to our expectations, we scorn them. As Dr. Roger Evans of the Mayo Clinic has written: “As we pursue the ideology of preventive health, those persons who have inherited or acquired health deficiencies for which they are considered responsible will necessarily be viewed as pariahs who place excessive demands on society.”1 He argues that we view these people as failures—and that our sociopolitical system does not like to reward failure. Public health has been able to slip prevention (in small doses) into schools, onto radio and television, and in some cases into the popular culture. On the other hand, managed care has included preventive services in the regular regimen of care, something that the fee-for-service system and the insurers who paid for it not only did not do regularly, but excluded from most policies. So managed care is doing something right in that regard. The fact remains, though, that all of us must work harder to make prevention easier, more accessible, and more attractive in a country that essentially still refuses to take it seriously. Another obstacle is that Americans are distrustful of public functions, whether they are provided in the public or the private sector. This country was settled by
Am J Prev Med 1998;14(3S)
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anti-government radicals whose philosophy still holds sway. Moreover, the average American’s fear of bureaucrats is so pervasive that we seem to be expecting less and less of the public sector. Therefore, even a private HMO trying to encourage smoking cessation and weight control must contend with patient distrust and apprehension about “Big Brother”–like behavior. Managed care and public health both have to do a better job in dealing with paranoia about our intruding too deeply into people’s private lives, asking too many questions, and being careless with data and information that can ruin someone’s life. Also, we must become much more serious about evaluation, outcomes, and implementation. Prevention theory needs to become prevention practice, and guideline theory needs to become protocols that people pay attention to. As for evaluation and outcomes, we see too much anecdotal data being presented as gospel, shady statistics whose origin is always proprietary so that their legitimacy cannot be assessed, public opinion surveys that have been manipulated into meaninglessness, and scare tactics that result in a rush to judgment. Like the rest of health care, prevention has become an industry, and it, too, wants to justify its existence. At these prices, however, maybe we should cast a colder eye on what we are doing and find out what really makes a difference. One clue could come from the great economist Eli Ginzberg, who conducted an exhaustive study of the impact of the health care system on poor people in the United States. In his book, Tomorrow’s Hospital, he concluded that the health care system’s greatest contribution to the health of the poor is to employ them and thereby get them out of poverty—the single most important determinant of a person’s health.2 Thus, there are undoubtedly some problems we should throw money at, but they may not be clinical in nature. These are obstacles faced by anyone and any organization, public or private, that really wants to do prevention. Fortunately, there are three shared opportunities as well. First, although it has been obscured by time, politics, and distractions, managed care and public health started out with a shared vision. The first health plans, which were non-profit, community-oriented, and highly integrated as service providers as well as insurers, put a high premium on keeping people healthy. The almost limitless opportunity to spend money on the front end has always been available to both health plans and the public health community. In the end, the goals are the same, even if they were derived from strikingly different organizations and traditions. The recent emergence of managed care as an investment opportunity and an avoider of risk has obscured that shared vision, but if we clear away the smoke, it is still there. Second, the good guys are in it for the long term.
104
Despite the rumors of its demise, public health isn’t going anywhere. Neither are the oldest integrated health plans. Both plan to stick around, and that means being able to reap the rewards of prevention, i.e., seeing children grow up having never smoked a cigarette, snacked on lead paint, or been struck by a parent in anger. Third, both public health and good managed care can redistribute any savings achieved through successful prevention activities. There are many opportunities to do enormous good with the money saved by organizing care better and practicing meaningful prevention: extension of coverage to the uninsured, environmental health initiatives, real violence prevention on the streets and in our homes, facing up to hunger and homelessness. Of course, any savings achieved by prevention activities can be stolen or squandered, and there is still debate as to whether prevention does, in fact, save money—although I, at least, believe it does. But on the assumption that at least some savings will be achieved, there is a world of opportunity for those organizations, public and private, that can capture the savings and reinvest them in their communities. What a chance! This is what you share. This is what we all share. This is a rich enough possibility that it is worth giving each other the benefit of the doubt. I will close with three suggestions to you as organizations and three to you as individuals. As organizations, first, pick your fights about content and turf. We need to focus more on what matters. My discussions with health plan representatives about what we really know about prevention have yielded three thoughts: (1) tobacco is really bad for you; (2) some exercise—which can be no more complicated than taking a walk—is really good for you; and (3) depression, even mild depression, makes almost all other threats to good health worse. Similarly, in terms of turf, protect what must be protected, and give way when you should. Public health’s turf clearly includes restaurant inspections, food and water safety, epidemiology, and other things that public health has always done and that must be done for everyone. Managed care’s turf centers on more circumscribed populations and goals. Give way when you should. No one will win them all, but know which ones you can win—and what is worth fighting for in the first place. Second, find out who does what best, and support them. That could mean having health plans fund public agencies, public agencies fund health plans, or both fund a third party, e.g., an AIDS hospice, a feeding program, or a summer camp for low-income children. Do not reinvent the wheel. Do not duplicate existing excellence. Do not compete for the sake of competi-
American Journal of Preventive Medicine, Volume 14, Number 3S
tion. Follow the maxim enunciated by Henry Kaiser: find a need, and fill it. Third, do not provide prevention and screening without follow-up. What good is colorectal screening if surgery is not available when tumors are found? What good is violence counseling when a battered woman has nowhere to go except back to her torturer’s home? For that matter, why do we continue to immunize kids against disease and then send them home into violence, poverty, and despair? Prevention is only a means, a first step. Too often, though, it becomes an end in itself. Finally, there are three challenges to you as individuals. First, why are you in prevention? I hope it is not for recognition, job security, or protection of your taxexempt status. Working in prevention is a high calling, the most honorable kind of work. We should all take pride in being involved in it because it protects the length, quality, and dignity of human life—and because it is what a civilized society should do. That has nothing to do with money or turf. Second, what are you willing to give up in the pursuit of prevention? Will you concede some turf? Will you relinquish some power? Will you share your money and resources? Most important, are you willing to risk failure? Joycelyn Elders, MD, our last visible surgeon general, knew that bringing up the possibility of legalizing illicit drugs and discussing masturbation as a means of preventing sexually transmitted diseases was not likely to win her support. She was willing to take the risk in the service of public health, and she got fired. However, she wrote a beautiful piece after her forced resignation in which she said two things: (1) It is time to tone down the rhetoric in our discussions of health policy, and (2) if her actions had saved one child from being infected with HIV, she would find the whole experience worthwhile. In prevention, we are constantly asking others to give things up. We should also ask ourselves what we are willing to give up and what risks we are willing to take on behalf of what we believe. Last, we are, after all, in Atlanta, and yesterday was the birthday of this city’s magnificent son, Martin Luther King, Jr. He, too, was willing to lay it on the line because of a simple belief. He believed, profoundly, in the value of every human being and the dignity of every person. In that sense, he, too, toiled in the vineyards of
public health. He knew that there are some things we can only accomplish together. He knew that, whether it is the rights of men and women to be respected as men or women or the rights of people to have a chance at good health, individual effort can go only so far. It is an understanding echoed by the philosopher Alistair Campbell, who wrote, “The aim of all health care is a shared freedom, whereby one finds one’s aspirations fulfilled, not only by having one’s own needs met, but also by participating in a society in which those who are at the greatest disadvantage can equally find the means to personal fulfillment.”3 That may not be the heart of prevention, but it is close. In Tom Stoppard’s play Rosencrantz and Guildenstern Are Dead, the two main characters have been killed, are being carried off at the end of the play, and are having a chat. (It’s a surrealistic play.) Rosencrantz says to Guildenstem, “You know, somewhere along the line there must have been a point where we could have stopped and said ‘No.’” And Guildenstern replies, “Yeah, but I guess we missed it.” In this country, we are at a crossroads between Alistair Campbell’s vision of health care as a shared value—something we all own and to which we all must have access—and the nightmare of a health care Third World in which a fat, bloated health care system lavishes its services on the insured rich while uninsured children and the excluded poor die of measles and polio. It seems to me that the choice is easy enough, especially in terms of what we want our legacy to be. So I hope that, when those who come after us look back at us from the future, they will know that, in preventing what could be prevented and in protecting those whose sorrows could not be avoided, when the point came when we were asked if we had the courage to do what needed to be done, we stood up and said, “Yes.”
References 1. Evans, R. Rationale for rationing. Health Manage Q 1992; 14(2):14 –17. 2. Ginzberg, E. Tomorrow’s hospital: a look to the 21st century. New Haven: Yale University Press, 1996. 3. Campbell, A. Health as libertion. Cleveland, OH: Pilgram Press, 1995.
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T
his conference was convened because managed care and public health have been pursuing quite different paths in terms of prevention, and there is more than a little tension and competition afoot, as there usually is when jobs, prestige, and money are on the line. This is complicated by the fact that neither side is exactly a monolith: in public health, there are contrasts between understaffed, underfunded county health departments nationwide and the wellfunded, renowned national infectious disease program at CDC. The managed care world is similarly characterized by lavishly capitalized health plans, led by multimillionaire chief executive officers, and thinly funded non-profit plans struggling to serve Medicaid, disabled, and other vulnerable patient populations. The lack of a binding sense of unity around prevention is therefore not surprising. Beyond that, there are at least three legitimate differences between public health and managed care that can impede collaboration on prevention. First, although both have responsibility for populations, managed care gets to choose its populations, whereas public health is responsible for everyone. For a long time, managed care’s main constituency was young, employed, reasonably healthy groups of people—not the most intractable population in terms of health. More recently, managed care has expanded into Medicaid and Medicare and is beginning to serve more difficult populations. In some cases, this change is proving to be a far superior way of organizing care for these vulnerable groups. In others, though, it has been a calamity characterized by brutal risk aversion by some managed care plans. The result has been lawsuits, injunctions, and, in many cases, lackadaisical regulatory response. Although Congress and state legislatures have been passing managed care legislation at a breakneck pace, too much of it has consisted of dictating how care is to be provided on a diagnosis-specific or procedure-specific basis, a terrible precedent in terms of clinical autonomy and quality of care.
Contributing Editor, Hospitals and Health Networks and Healthcare Forum Journal and Section Editor, Journal of the American Medical Association. Address correspondence to: Emily Friedmon, Unit G, 851 West Gummison Street, Chicago, Illinois 60640
102
Am J Prev Med 1998;14(3S) © 1998 American Journal of Preventive Medicine
Meanwhile, at least 40 states plan to implement Medicaid managed care. This will increase the number of sicker people in managed care plans; a study by the Kaiser Family Foundation in 1996 found, for example, that 30% of all [welfare] families have at least one disabled member. Seeking to enroll these fragile patients in some managed care plans will not produce a good match in all cases, particularly if plans continue to skim on the basis of patient health status. In contrast, public health does not enjoy the luxury of selectivity; it has to protect everyone. Moreover, as the skimming goes on, public health is ending up with responsibility for more of the sickest and most difficult patients while the money goes elsewhere. Public health is also picking up persons technically enrolled in managed care who continue to seek public health services, as well as those who are being dropped from Medicaid—including the 180,000 persons dropped last year who had been deemed disabled by reason of substance abuse, and long-term [welfare] families and some immigrants who may be dropped soon. The effect, intentional or not, is that even the Medicaid population deemed eligible for managed care is being cleansed of bad risks and difficult populations. As for the uninsured, their numbers keep rising. According to the Census Bureau, 40 to 45 million people lack coverage most or all of the time. The private sector, though, is not hurrying to sign them up. Managed care can pick the populations for which it takes responsibility; public health cannot. This is a major source of tension between the two. A second difference is that public health’s mission is well defined, whereas managed care serves many masters. In managed care, which master you serve has everything to do with ownership and structure. I disagree with Dr. McGuire’s view that the issue is not for-profits versus non-profits or integrated versus non-integrated plans. These are precisely the issues. Most HMOs today are for-profit, and almost all of them are publicly held and are thus accountable to stockholders and to the Wall Street brokers who rate their stock. This is appropriate for a publicly held organization, but it raises questions about whether such accountability is appropriate for health care. In contrast, non-profits are first accountable to their boards, the
0749-3797/98/$19.00 PII S0749-3797(97)00034-2
Internal Revenue Service, the state government, and, in many cases, their members and communities. Furthermore, most HMOs are not integrated. An integrated plan employs or exclusively contracts with physicians in group practices, likely owns some or most of the hospitals that serve its members, and provides most services in a reasonable continuum of care. An IPA or broker-type plan simply makes a deal between payers and providers, transfers much or even all the risk to the providers, and takes as much as a third of the premium money as its payment. An integrated plan actually provides services as well as collecting premiums, and it bears the risk. It makes a difference, in terms of a commitment to prevention, whether you are required by law to provide community benefits or are required by law to maximize profit for stockholders. It makes a difference in terms of access, in terms of quality of care, and in terms of which master you serve. This is not a dilemma faced by public health. Whether its structure facilitates it or not—and often it does not, whether the funding is there or not—and often it is not, public health is supposed to protect the public—all of the public. Some health plans do serve the public and serve it brilliantly. Others do not. It makes a difference. A third area of difference is turf and money. The positions of the combatants appear to be that managed care is attacking and winning public health territory, with public health on the defensive and being beaten back. The question is what managed care will do with the territory it wins if it is able to hang on to it. Fears on the part of the public health community that some plans will just take the money and run are thoroughly justified. Concerns also center on the many faces of prevention. Some consultants and managed care advocates are now suggesting that all prevention and public health activities can be taken over by managed care plans. Well, perhaps in a perfect world; but I cannot see health plans figuring out which part of the water supply to protect because they are only responsible for their own members, or surveying their members about the restaurants they eat in so that they only have to worry about salmonella in those restaurants. This may seem far-fetched, but as competition for patients, turf, and funds increase, many health care entities will be actively seeking new worlds to conquer. On a larger scale, if we decide that the CDC is superfluous, who will do the epidemiology in the face of new disease agents attacking us from all sides? On the other hand, the managed care community’s frustration with the parochialism, paranoia, and arrogance of public health people is also sometimes justified. If public health is so wonderful at prevention, why are so many of our 2-year-olds not immunized? Why are
we struggling with antibiotic-resistant tuberculosis and pneumococci? Why did dozens of American children die of measles in 1991? This is hardly an advertisement for the achievements of public health. Maybe they could learn something from truly integrated, committed health plans. The most remarkable thing about this conference, then, is that so many participants were willing to put aside their differences and start talking to each other. It has not been without suspicion and tension, of course, but, for the most part, this has been a good start. If the overcoming of these differences— or at least the opening of negotiations— has been the most visible accomplishment of this conference, the most important responsibility of the people here is to accept that managed care and public health share an enormous amount when it comes to preventive health. Not all of what they share is positive, but much of it is. First, you share three obstacles to improving both the theory and practice of prevention in this country. As Dr. Smith said, this is not a country or culture that exactly worships at the altar of prevention. We talk a good game, but the fact is that we glorify anorexia; we price health clubs and equipment out of the reach of the persons who could benefit from them the most; we preach fresh fish and vegetables to people who are trying to raise a family on $13,000 a year and whose supermarkets are in 7-Elevens; and we market a healthy lifestyle characterized by grueling exercise, nothing fun to eat, no cigarettes, no alcohol, no drugs, and exhortations to watch the stress levels. And then we wonder why people don’t flock to our banner. At the same time, when people do not live up to our expectations, we scorn them. As Dr. Roger Evans of the Mayo Clinic has written: “As we pursue the ideology of preventive health, those persons who have inherited or acquired health deficiencies for which they are considered responsible will necessarily be viewed as pariahs who place excessive demands on society.”1 He argues that we view these people as failures—and that our sociopolitical system does not like to reward failure. Public health has been able to slip prevention (in small doses) into schools, onto radio and television, and in some cases into the popular culture. On the other hand, managed care has included preventive services in the regular regimen of care, something that the fee-for-service system and the insurers who paid for it not only did not do regularly, but excluded from most policies. So managed care is doing something right in that regard. The fact remains, though, that all of us must work harder to make prevention easier, more accessible, and more attractive in a country that essentially still refuses to take it seriously. Another obstacle is that Americans are distrustful of public functions, whether they are provided in the public or the private sector. This country was settled by
Am J Prev Med 1998;14(3S)
103
anti-government radicals whose philosophy still holds sway. Moreover, the average American’s fear of bureaucrats is so pervasive that we seem to be expecting less and less of the public sector. Therefore, even a private HMO trying to encourage smoking cessation and weight control must contend with patient distrust and apprehension about “Big Brother”–like behavior. Managed care and public health both have to do a better job in dealing with paranoia about our intruding too deeply into people’s private lives, asking too many questions, and being careless with data and information that can ruin someone’s life. Also, we must become much more serious about evaluation, outcomes, and implementation. Prevention theory needs to become prevention practice, and guideline theory needs to become protocols that people pay attention to. As for evaluation and outcomes, we see too much anecdotal data being presented as gospel, shady statistics whose origin is always proprietary so that their legitimacy cannot be assessed, public opinion surveys that have been manipulated into meaninglessness, and scare tactics that result in a rush to judgment. Like the rest of health care, prevention has become an industry, and it, too, wants to justify its existence. At these prices, however, maybe we should cast a colder eye on what we are doing and find out what really makes a difference. One clue could come from the great economist Eli Ginzberg, who conducted an exhaustive study of the impact of the health care system on poor people in the United States. In his book, Tomorrow’s Hospital, he concluded that the health care system’s greatest contribution to the health of the poor is to employ them and thereby get them out of poverty—the single most important determinant of a person’s health.2 Thus, there are undoubtedly some problems we should throw money at, but they may not be clinical in nature. These are obstacles faced by anyone and any organization, public or private, that really wants to do prevention. Fortunately, there are three shared opportunities as well. First, although it has been obscured by time, politics, and distractions, managed care and public health started out with a shared vision. The first health plans, which were non-profit, community-oriented, and highly integrated as service providers as well as insurers, put a high premium on keeping people healthy. The almost limitless opportunity to spend money on the front end has always been available to both health plans and the public health community. In the end, the goals are the same, even if they were derived from strikingly different organizations and traditions. The recent emergence of managed care as an investment opportunity and an avoider of risk has obscured that shared vision, but if we clear away the smoke, it is still there. Second, the good guys are in it for the long term.
104
Despite the rumors of its demise, public health isn’t going anywhere. Neither are the oldest integrated health plans. Both plan to stick around, and that means being able to reap the rewards of prevention, i.e., seeing children grow up having never smoked a cigarette, snacked on lead paint, or been struck by a parent in anger. Third, both public health and good managed care can redistribute any savings achieved through successful prevention activities. There are many opportunities to do enormous good with the money saved by organizing care better and practicing meaningful prevention: extension of coverage to the uninsured, environmental health initiatives, real violence prevention on the streets and in our homes, facing up to hunger and homelessness. Of course, any savings achieved by prevention activities can be stolen or squandered, and there is still debate as to whether prevention does, in fact, save money—although I, at least, believe it does. But on the assumption that at least some savings will be achieved, there is a world of opportunity for those organizations, public and private, that can capture the savings and reinvest them in their communities. What a chance! This is what you share. This is what we all share. This is a rich enough possibility that it is worth giving each other the benefit of the doubt. I will close with three suggestions to you as organizations and three to you as individuals. As organizations, first, pick your fights about content and turf. We need to focus more on what matters. My discussions with health plan representatives about what we really know about prevention have yielded three thoughts: (1) tobacco is really bad for you; (2) some exercise—which can be no more complicated than taking a walk—is really good for you; and (3) depression, even mild depression, makes almost all other threats to good health worse. Similarly, in terms of turf, protect what must be protected, and give way when you should. Public health’s turf clearly includes restaurant inspections, food and water safety, epidemiology, and other things that public health has always done and that must be done for everyone. Managed care’s turf centers on more circumscribed populations and goals. Give way when you should. No one will win them all, but know which ones you can win—and what is worth fighting for in the first place. Second, find out who does what best, and support them. That could mean having health plans fund public agencies, public agencies fund health plans, or both fund a third party, e.g., an AIDS hospice, a feeding program, or a summer camp for low-income children. Do not reinvent the wheel. Do not duplicate existing excellence. Do not compete for the sake of competi-
American Journal of Preventive Medicine, Volume 14, Number 3S
tion. Follow the maxim enunciated by Henry Kaiser: find a need, and fill it. Third, do not provide prevention and screening without follow-up. What good is colorectal screening if surgery is not available when tumors are found? What good is violence counseling when a battered woman has nowhere to go except back to her torturer’s home? For that matter, why do we continue to immunize kids against disease and then send them home into violence, poverty, and despair? Prevention is only a means, a first step. Too often, though, it becomes an end in itself. Finally, there are three challenges to you as individuals. First, why are you in prevention? I hope it is not for recognition, job security, or protection of your taxexempt status. Working in prevention is a high calling, the most honorable kind of work. We should all take pride in being involved in it because it protects the length, quality, and dignity of human life—and because it is what a civilized society should do. That has nothing to do with money or turf. Second, what are you willing to give up in the pursuit of prevention? Will you concede some turf? Will you relinquish some power? Will you share your money and resources? Most important, are you willing to risk failure? Joycelyn Elders, MD, our last visible surgeon general, knew that bringing up the possibility of legalizing illicit drugs and discussing masturbation as a means of preventing sexually transmitted diseases was not likely to win her support. She was willing to take the risk in the service of public health, and she got fired. However, she wrote a beautiful piece after her forced resignation in which she said two things: (1) It is time to tone down the rhetoric in our discussions of health policy, and (2) if her actions had saved one child from being infected with HIV, she would find the whole experience worthwhile. In prevention, we are constantly asking others to give things up. We should also ask ourselves what we are willing to give up and what risks we are willing to take on behalf of what we believe. Last, we are, after all, in Atlanta, and yesterday was the birthday of this city’s magnificent son, Martin Luther King, Jr. He, too, was willing to lay it on the line because of a simple belief. He believed, profoundly, in the value of every human being and the dignity of every person. In that sense, he, too, toiled in the vineyards of
public health. He knew that there are some things we can only accomplish together. He knew that, whether it is the rights of men and women to be respected as men or women or the rights of people to have a chance at good health, individual effort can go only so far. It is an understanding echoed by the philosopher Alistair Campbell, who wrote, “The aim of all health care is a shared freedom, whereby one finds one’s aspirations fulfilled, not only by having one’s own needs met, but also by participating in a society in which those who are at the greatest disadvantage can equally find the means to personal fulfillment.”3 That may not be the heart of prevention, but it is close. In Tom Stoppard’s play Rosencrantz and Guildenstern Are Dead, the two main characters have been killed, are being carried off at the end of the play, and are having a chat. (It’s a surrealistic play.) Rosencrantz says to Guildenstem, “You know, somewhere along the line there must have been a point where we could have stopped and said ‘No.’” And Guildenstern replies, “Yeah, but I guess we missed it.” In this country, we are at a crossroads between Alistair Campbell’s vision of health care as a shared value—something we all own and to which we all must have access—and the nightmare of a health care Third World in which a fat, bloated health care system lavishes its services on the insured rich while uninsured children and the excluded poor die of measles and polio. It seems to me that the choice is easy enough, especially in terms of what we want our legacy to be. So I hope that, when those who come after us look back at us from the future, they will know that, in preventing what could be prevented and in protecting those whose sorrows could not be avoided, when the point came when we were asked if we had the courage to do what needed to be done, we stood up and said, “Yes.”
References 1. Evans, R. Rationale for rationing. Health Manage Q 1992; 14(2):14 –17. 2. Ginzberg, E. Tomorrow’s hospital: a look to the 21st century. New Haven: Yale University Press, 1996. 3. Campbell, A. Health as libertion. Cleveland, OH: Pilgram Press, 1995.
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