By Jeffrey Barg

Published June 1997

• React to this article in the Discussion Forum.

Roz D. Lasker, M.D., director of the Division of Public Health at the New York Academy of Medicine, is director of a national project designed to foster more collaboration between medicine and public health.

PND: Why is it desirable or important that physicians and public health professionals learn to collaborate more together?

RL: It’s moved beyond desirable to become imperative. It’s important to do this with a disease like diabetes. We know that we need good medical care because if we treat these diseases, we can prevent a lot of complications. But in order to get people active in good medical care, you need to provide them with a variety of public support services so they can overcome logistical barriers like problems with transportation, translation or child care. To get them to keep up with therapy for diseases like hypertension, which is a financial hardship, to convince people to take drugs, sometimes home visits are very helpful. We need public health strategies like population-based screening because these diseases do a lot of damage when they are asymptomatic. Think about hypertension. People don’t know they have hypertension. If we don’t do population-based screening and identify it, a lot of damage has already been done. And finally, we have looked at individual issues like counseling for diet and exercise. You can tell somebody it’s better to eat a good diet and it’s better to exercise, but it’s a whole lot easier to follow that advice if the environment in which you live actively supports it. So in fact, we need public health strategies that move towards food labeling so we know what foods are healthful, which are not, where there are good healthy food choices, in school cafeterias, where you work, in restaurants, sports events, where there are safe places to exercise, opportunities and incentives to exercise, at school and at work and other places in the community.

As to why it’s happening now, it’s because of some dramatic changes that are occurring in the health system. Managed care is doing some interesting things. First of all, it’s moving a whole patient population that use to be cared for in public health clinics—the Medicaid population—over to the mainstream private medical sector. Many of these patients come from minority populations that have a very high prevalence of diseases like hypertension and diabetes. Successful medical care for these patients depends on a lot more than knowing what the right medical treatment is. As I said before, you need to link up these services with transportation and translation and child-care and home visiting. These services used to be available in public health settings and linked to medical care; right now they’re not. So one of the kinds of collaboration we’re seeing quite a lot around the country begin to bring these public health services to the mainstream medical sector.

A lot of the money for Medicaid used to go to public health agencies and clinics and they used that money to finance medical care for the uninsured and also to support some population-based services that they did as well. As this money has been going to the private medical sector, all of a sudden they can’t subsidize the care for the uninsured anymore. This is just not a public health problem anymore. Think about what is happening in the medical sector. They’re taking on a lot of financial risks, whether they’re a managed care organization or a large physician group practic. All of a sudden, hospitals have to provide indigent care for people who don’t have access to primary care; it’s very expensive and if there’s an outbreak of Cryptosporidium in the water supply or E. coli in the food supply, these are very expensive and they have to bear the costs of that as well. So the shift in money is making it very important for both sectors to work more closely together.

Another thing that’s happening is the general issue around financial risks, per se. If I’m in a physician practice right now, for the most part, I am getting paid a fixed amount of money per year whether it’s at the individual physician level or at a large practice level. And in order to survive economically and remain viable, I need to be able to know something about the health status and health risks of my practice population and about what the costs of different interventions are, how effective they are, what the most cost-effective approach is. If I am going to become a large force in my neighborhood and want to expand, I need to know more about the health of everybody in my neighborhood because first of all, some of those people might become my patients next year, but even more important, if they have communicable diseases or other problems, they can influence the health of my patients’ population. There are quite a few public health tools; clinical epidemiology, cost effective analysis, information about health status and health risks that public health have that are now crucially important for the medical sector in order for them provide good care for their patients and to remain economically viable.

Another big change that is going on is general interests in controlling costs. Now with limited funds both in the private medical sector and in government, for the first time it doesn’t pay to do everything yourself. If there’s somebody else who has the expertise and can do things more efficiently, you actually want to partner with them now. It’s in your best interest rather than duplicating it.

I think the final reason that we’re seeing this happening is this whole movement towards performance measurement. You’re familiar with the report cards. Well, it has also been happening even longer in the public health sector through things like Healthy People 2000, and many of these health objectives are now being used by legislatures as budgeting and management tools. And what’s happening with this is becoming clearer that neither sector has enough direct control to achieve these things alone. Think about if I wanted to achieve an immunization rate. Achieving an immunization rate for a practice depends on more than just offering immunization to people when they come in to the office because many people won’t think of it and won’t come and it won’t be done even they’re in the office for another reason. So in order to achieve this rate, it’s a whole lot easier for me as a practitioner to do if other things are going on in the community like education and media campaigns making everybody aware of the need for this, some outreach tracking and follow-up services to help people get to the office to get immunization. We’ve seen a lot of immunization registries that not only give you the rate but they automatically generate phone call lists for phoning people who should have come in, reminder letters for people who need immunization and also some programs to get free vaccines. So if this general community approach is going on, it can funnel patients into doctors offices and make it easier for them to play an important role in achieving that rate.

PND: How are you trying to foster such collaboration?

RL: This initiative was started about a year ago funded by the Robert Wood Johnson Foundation. It’s supported by the American Medical Association and the American Public Health Association. They charged the New York Academy of Medicine with convening a panel to look into this. We have a multidisciplinary panel working for the last year. We’ve done focus groups with practitioners and students in public health around the country. We’ve fielded nationwide surveys that has now brought in 500 samples of collaborations that are currently going on. We’ve analyzed that information and we’ve going to be publishing it in a book that will be coming out in November. The book will describe in very concrete terms exactly what can be accomplished through medicine-public health collaboration and exactly how that’s being carried out. Part of the book is going to discuss the organizational structures that can bring these two groups together. They range from coalition to advisory bodies; various types of contractual arrangements; administrative support systems; changes within organizations. We’re also going to talk about how these collaborations help to foster communication and understanding, how they facilitate coordination of resources and skills. Probably most important is how they deal with issues of control and autonomy, which are very important to the two sectors. So we hope that this will be a very practical monograph for people to use in the field and will help them get going. And I know that the Robert Wood Johnson Foundation and AMA, APHA are planning a lot of follow-up activity to help people regionally use this book and move forward with what they think might work for them.

PND: How can people obtain the monograph?

RL: If they fax my office at 212-426-6796, we can put them on a list to get a copy of the monograph when it’s available. There are also a couple of web sites they may want to look into. There’s a web site for the medicine-public health initiative itself, which is based at the University of Texas in Houston: http://www.sph.uth.tmc.edu/mph/ as well as our own web site: http://www.nyam.org.