Biology

 j b c t d p h t p T c h

Are We There Yet? Seizing the Moment to Integrate

Medicine and Public Health

F. Douglas Scutchfield, MD, J. Lloyd Michener, MD, Stephen B. Thacker, MD, MSc

Multiple promising but unsustainable attemptshave been made to maintain programs inte-grating primary care and public health since he middle of the last century. During the 1960s, social ustice movements expanded access to primary care and egan to integrate primary care with public health con- epts both tomeet community needs formedical care and o begin to address the social determinants of health. Two ecades later, the managed care movement offered op- ortunities for integration of primary care and public ealth as many employers and government payers at- empted to control healthcare costs and bring disease revention strategies in line with payment mechanisms. oday, we again have the opportunity to align primary are with public health to improve the community’s ealth.

For scientifıc progress has greatly modifıed his ethical responsibility. His relation was formerly to his patient—at most to his patient’s family; and it was almost altogether remedial . . . But the physician’s function is fast becoming social and preventive rather than individual and curative. Upon him society relies to ascertain . . . the conditions that prevent disease and make positively for physical and moral well-being.

—Abraham Flexner1

Although the American educator Abraham Flexner (1866–1959) made this observation more than a century ago in his assessment of the state of U.S. medical schools, the U.S. remains one of the few developed economies in which public health and medical care exist in isolation from each other. It was not always this way; physicians and their organizations once nurtured and developed the public health system. The divergence in the two disci-

From the Colleges of Public Health andMedicine (Scutchfıeld), University of Kentucky, Lexington, Kentucky; the Department of Community and Family Medicine (Michener), Duke University Medical Center, Durham, North Carolina; Surveillance, Epidemiology, and Laboratory Services (Thacker), CDC, Atlanta, Georgia

Address correspondence to: J. Lloyd Michener, MD, Professor and Chairman of the Department of Community and Family Medicine, Duke University Medical Center, Box 2914 DUMC, Durham NC 27710. E-mail: miche001@mc.duke.edu.

0749-3797/$36.00 http://dx.doi.org/10.1016/j.amepre.2012.04.001

©2012Published byElsevier Inc. on behalf ofAmerican Journal of Preventive

plines, according to Starr,2 occurred at the turn of the 20th century, when the direct care of mothers and chil- dren by public health clinics prompted concerns that public health would begin to compete with physicians for the direct provision of medical care services. This diver- gence continued with medical specialization and was likely further enhanced by the Rockefeller Foundation’s 1916 decision to create schools of public health that are separate from schools of medicine.3 The ultimate conse- quences of this schism were the failure to attract physi- cians to public health, with a concomitant decline in the numbers of preventive medicine physicians, and the fail- ure of most other physicians to understand or appreciate the population (or public health) perspective.4

Multiple attempts have been made since the 1916 de- cision to reconnect primary care and public health; how- ever, these innovations never expanded far beyond the site where they began, and even fewer were sustained. Today, new opportunities, needs, and tools offer us another opportunity to reintegrate public health and medicine—specifıcally primary care—in a way that im- proves population health outcomes and enhances quality of life in the U.S. By integration of primary care and public health we mean “the linkage of programs and activities to promote overall effıciency and effectiveness and achieve gains in population health.”5 However, if we are to seize the opportunity to bring primary care and public health together successfully, we must learn the lessons of past attempts.

Historical Context After the fırst half of the 20th century realized a dramat- ically increased life span resulting from potable water, infectious disease control, and increased access to medi- cal care, the 1960s experienced new social justice move- ments and efforts to expand access to primary care, with a focus on working with communities to design and plan services that worked best for the underserved and unin- sured. Experiments in community medicine and family medicine were derived from the community-oriented primary care (COPC) movement Kark and Cassel devel- oped in SouthAfrica, which integrated public health con-

ceptswith clinicalmedicine.6 These early efforts led to theMedicine Am J PrevMed 2012;42(6S2):S97–S102 S97

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development of community health centers, clinical epi- demiology, and multidisciplinary teams. Physicians, nurses, health educators, and community lay health workers provided integrated medical and public health care to communities, often led by the community.6 The OPC movement emerged in the U.S. subsequently and ontained many of these elements. In fact, those who ark and his colleagues trained in these concepts pro- ided leadership, in some measure, of this movement in he U.S. These experiments demonstrated how pri- ary care and public health can intertwine to meet an bvious need for medical care and address the socio- cologic determinants of health problems in under- erved communities.

Community Health Centers Both Geiger7 and Gibson8—the initial advocates of com- munity health centers and of ensuring access to primary care services—came from a medical perspective, albeit one infused with public health notions of concern for the denominator, a focus on the patients enrolled in the com- munity health center’s panel, and the community the center served. Of note, these leaders in the community health center movement, although trained in both medi- cine and public health, operated from a medical school environment. Theymaintained primary appointments in schools of medicine and not in schools of public health, and primarily medical schools supported these efforts. Rarely were schools of public health engaged in leading the development of community health centers, in other programs focused on direct service to the poor and unin- sured, or on broader concerns of the communities that surrounded those community health centers. Few if any schools of public health applied for support for these community health centers; the majority of applicants were medical schools because academic medical centers often believed the needs of the residents in surrounding communities were not being addressed in those medical centers. Governmental health entities (e.g., city hospital and

health department units) did get involved in this effort. This particularly applied to large urban entities that in- cluded hospitals, local primary care clinics, and public health clinics under one organization’s structure that had the capacity to pursue the development of such commu- nity health centers. One of the fırst community health centers was centered at a local health department that collaborated with a university medical center, but public health leaders, both academic and governmental, re- garded this as a provision of medical care and not the purview of public health. In certain cases, the entry of

public health into community clinic sponsorship revived tthe concern Starr laid out: that the health department was in the business of competing with the private practice of medicine, a philosophical and fınancial concern formed- icine.2 Meanwhile, health departments were concerned that the provision of illness services might detract from the population services only the health department could provide, whereas others could serve a patient care role. The schism remained. Although these initiatives focused primarily on the

uninsured, the broader problems of fınancial access to medical care for older and poor people resulted in the creation and growth of Medicare and Medicaid. Those two major social insurance programs greatly expanded access to care for the underserved. However, the pro- grams’ incentiveswere to treat rather than prevent illness, and, consequently, they focused less on primary and pre- ventive services than on procedures and hospital care. Notably, the nature of this initial foray into social insur- ance set the tone for the continued estrangement of med- ical and public health through the fınancial incentives that were provided. Payment was made for procedures and major illness more than for primary care or commu- nity interventions that address the underlying etiologies of illness, much less payment for quality of care or the health of a population. In fact, in the initial legislation, Medicare was precluded specifıcally from paying for clin- ical preventive services. The interest in primary care grew in parallel with or

was the result of the community health centermovement. The specialty of family medicine developed and gained popularity in the U.S., achieving American Board of Medical Specialties specialty recognition in 1969. A focus on individuals, families, and communities and on treat- ment, prevention and community medicine was part of the initial scope of the new discipline, reflecting the social movement that supported its establishment.9

These movements—community health centers, pri- mary care (especially family medicine), and community medicine—were infused and supported by the larger COPC movement in the U.S. in the 1970s and 1980s, which brought together the notions of primary care and the practice of epidemiology to examine the health of the population of enrollees in a particular practice (e.g., that of the community health center) and to design, imple- ment, and evaluate efforts to address broader community health problems.10 Disciplines of public health, particu- arly epidemiology, health behavior, and health educa- ion, were leveraged to the benefıt of both the individual atient and the community. However, the movement oon faltered as attention shifted to growing national oncerns about escalating costs. Community health cen- ers came under pressure to increase their self-support

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expense of other direct nonmedical roles for the health of the population they served, but fınancial incentives to continue these efforts were lacking.11 These pressures led o constraints on innovations designed to bridge the chism and went so far as to require community health enters to deliver clinical services only. Philosophical and deological concerns existed about the expanded role of ommunity health centers, and support for efforts other han the provision of direct patient service declined.Once gain, progress in population health was suppressed and ains rarely were sustained. This development included certain ironies. One was

he key role of medical schools. Departments of preven- ive, social, and community medicine in medical schools ed the community health center movement. The initial nvolvement of schools of public health faculty was lim- ted despite the role that epidemiology and the emerging ciences of medical care organization and administration ould play in this new effort. Some suggested that public ealth knowledge and education should not be focused olely in schools of public health but also contained in chools of medicine because the public health sciences ere as integral to medicine as were the basic sciences of natomy and physiology.12

In a similar way, these same medical school depart- ments became home to the growing family medicine movement. Community, social, and preventive medicine departments were subsumed by that movement and morphed into departments of community and family medicine. However, as family medicine turned its atten- tion to establishing legitimacy with traditional medical specialties12 and as medical schools placed increasing emphasis on practice income, the community medicine portion of these departments withered and, in certain cases, disappeared. By 1982, when Deuschle13 reviewed the problems of aintaining primary care and public health innovation

n COPC and community health centers that he was esponsible for founding, the dominance—philosophically nd fınancially—of the traditional medical practice and iscomfort with organizational innovations clearly had ecome major obstacles to maintaining that effort.

Managed Care The 1980s and 1990s experienced another opportunity for the integration of medicine, primary care, and public health as employers and government payers turned to managed care health plans to attempt to control escalat- ing health costs.One of the promises ofmanaged carewas to realize cost savings through a focus on prevention and attempts to bring more disease prevention strategies in

linewith paymentmechanisms.14 The emphasis on value,une 2012

quality, and cost and the improvement in population health, measured by the health status of subscribers, were regarded by many as the sine qua non of effective man- aged care organizations. Unfortunately, themanagement and implementation of certain forms of managed care became concerned primarily with cost. The phrase “We are only saving Medicare money with prevention” was heard in the discussions of manymanaged care organiza- tions. To echo Stephens’s comments, effıciency trumped equity.11On the positive side, settings inwhich the prom- se of managed care continues still exist—notably the aiser Foundation Health Plans in California—and they ppear to be effective in achieving those goals.

Medicine Public Health Initiative Amore recent effort to heal the schism betweenmedicine and public health involved the American Medical Asso- ciation and the American Public Health Association and began in 1994 amid calls for coordinated actions on shared concerns.15 This initiative began with an agenda that called for the following:

1. engaging the community; 2. changing the educational processes of both medicine and public health;

3. joining research efforts; 4. devising a shared view of health and illness; 5. working together to provide health services; 6. developing health assessment measures; and 7. translating initiatives into action.

Despite continued concern, for example, an American Medical Association presidential address in 2007 stated that leadership turnover and the changing political agenda of the two organizations and their members had resulted in a lack of pursuit of this effort to bring medi- cine and public health together.16 Against that backdrop resides the current efforts calling for the integration of primary medical care and public health. Today, the need and opportunities have never been

greater. In 1960, the Congressional Budget Offıce esti- mated that healthcare costs were less than 5% of the gross domestic product; by 1980, that estimate reached 8%. Now it is approaching 20%, and the Congressional Bud- get Offıce estimates that by 2025, this number will reach 25% of the gross domestic product.17 Meanwhile, the Patient Protection and Affordable Care Act, new initia- tives at the Centers for Medicare and Medicaid Services, and new information technology offer a fresh opportu- nity to integrate public health and medicine. Whether those attempts will be successful depends largely on our ability to learn lessons from the past, in particular, the

experiences with COPC and managed care.

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Lessons Perhaps themost striking, althoughnot surprising, lesson learned from prior efforts to integrate medicine and pri- mary care with public health is that efforts to improve population health require infrastructure and funding if this integration is to occur and be maintained. The med- ical reimbursement system supports medical piecework and provides limited support for indirect patient care activities (e.g., practice analysis or time spent on efforts to identify those in need or requiring additional support or counseling other than by physicians) to succeed. Linking medicine and public health has the potential to produce cost savings, especially through avoiding more costly hospitalizations by the tighter coordination of clinical services for populations at risk (e.g., ensuring that chil- dren with asthma and their families know how to use their medications or providing in-home clinical services for frail persons). Achieving these savings requires devel- oping and funding an infrastructure that links practices into larger networks and provides the analytic and com- munity intervention capacity lacking in individual prac- tices but common to health departments. TheNorth Car- olinaMedicaid program has sustained continued savings for longer than a decade by redesigning primary care services to reduce preventable admissions, often through close collaborations between primary care groups and local health departments.18 In the process, both primary are and public health change, with primary care moving uch services as health education and care coordination ut of the offıce. Additionally, public health departments re shifting from a focus on categorical services to assis- ancewith analysis of preventable illness and to becoming artners in service delivery to populations at risk. A second lesson is to avoid counting on integration for ajor short-term cost savings. Prevention interventions lone can save money (e.g., vaccination and disease erad- cation), but they often do not realize cost savings in the hort term. Companies that insure working-age adults llustrate the challenge of attributing savings to earlier unding for prevention. Savings from preventive services ften occur after individuals retire, when that company o longer insures them.With the advent ofMedicare Part and the growth of Medicare managed care among

ommercial insurers, that is no longer as true as it was in he past, illustrating the alignment of incentives for to- ay’s activities with those who will reap later rewards. A third lesson is that change in the professional culture

s needed, but such change is diffıcult. Physicians and the ealthcare organizations for which they work have a long istory of professional autonomy and personal account- bility for their patients. Theymight fınd the transition to

ollaborative teams, especially with members of otherrofessions and in other organizations, challenging and ometimes threatening. Bridging from the biomedical odel of medicine to the social determinant and policy

ocus of public health is even more diffıcult. After a cen- ury of separation, medicine and public health no longer peak a common language, and all too oftenwhen the two ome together, the medical voice is the louder. However, ailure to recognize and manage the cultural change cre- tes considerable risks, especially for public health. Oth- rwise, when medicine and public health are combined, edicine dominates—fınancially, morally, and adminis-

ratively. As an illustration of this continued problem, at his writing, the healthcare bill before the U.S. House of epresentatives calls for the sustained growth-rate reduc- ion in physicianMedicare reimbursement to be offset by rawing from the prevention trust fund, pittingmedicine nd public health against each other in the national polit- cal arena. This dramatically illustrates the diffıcult policy nvironment, prompted by the economic downturn, hich threatens both public health and primary care. Yet s Abraham Flexner demonstrated, change can happen ith striking speed.1 We have reason to believe that a imilar transition might be upon us.

What’s New? An alignment of tools and incentives providing new oppor- tunities for cost savings and system improvement exists today. Two major changes stand out. First, the Affordable CareAct has provided dollars to drive change in population health.Although theAffordableCareAct’s ultimate fatewill notbeknownfor sometime, it isprovidingnewfundingand new life for integrating medicine and public health. For example, the CDC’s Community Transformation Grants program (www.cdc.gov/communitytransformation) pro- vides funding for achieving broad population-based goals by calling on all of a community’s resources. Similarly, the Centers for Medicare and Medicaid Services’ Innovation Center is rolling out an array of programs that bring new attention to the potential for public health and primary care partnership by supporting clinical system redesign for large populations, supporting redirection of funds from inpatient care to outpatient and from treatment to prevention, and encouraging experiments designed to achieve this aim. For the fırst time, sustaining a flow of funds to support contin- ued improvements in population health is possible. Second, the $27 billion being invested in electronic

health records is moving health data from paper re- cords to large-scale digital data warehouses, permit- ting the rapid analysis of changes in illness patterns in locations that can aggregate across sites of care, as well as the detection of previously unknown community

illness clusters. This ability to aggregate data aboutwww.ajpmonline.org

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individuals across care settings and to “roll up” these data to practices and neighborhoods largely obviates the long-standing problem of identifying the popula- tion served while also opening a new set of concerns regarding how to aggregate, attribute, and report accu- rately while respecting privacy.19 Combining these ools with new policy mandates to bolster population ealth can allow direct, coordinated efforts to reduce isease burden and costs at the community level. The ole of public health in identifying and focusing on opulation concerns, combined with a practice’s abil- ty to use these aggregate data for population health nterventions, is an excellent illustration of this inte- ration of information technology for medical care nd population health. The New York City Primary are Information Project supports the adoption and se of electronic health records among primary care roviders in underserved communities and has dem- nstrated increases in preventive service delivery, in- luding screenings as well as blood pressure and cho- esterol control.20 Health information exchanges (e.g., he one in Indiana) link primary care providers, hos- itals, laboratories, pharmacies, and health depart- ents to provide information exchange and two-way ommunication for more effıcient and effective popu- ation and clinical care.21 However, the fact that only $30 million (1%) of this investment was allotted to public health reveals that the public health perspective is once again regarded as secondary to traditional clin- ical medicine.

What Now? How do we harness this moment? First, we must ensure that long-term fınancial support for population health is designed into new healthcare delivery and public health systems (optimally regarded as one health system). At the same time, we need to recognize the vagaries of the econ- omy and government funding and seriously consider how effective collaborations can be sustained in a chang- ing world. Second, wemust optimize the use of electronic health records and the data they generate so that we understand more fully patterns of illness in the commu- nity. We then can use this understanding to improve prevention and care across the nation’s disparate com- munities. Third, population health measures should be used more effectively in monitoring the nation’s health and reporting not only to clinicians, health insurers, and other major healthcare actors but also to the general public and those in public health at the local, state, and federal levels. By contrast, state and local health depart- ments should defıne their roles in relation to Affordable

Care Act–funded organizations, medical homes, andJune 2012

other innovations at the intersection of population health and clinical care. Finally, and perhaps hardest of all, cli- nicians and public health offıcials should begin rebuild- ing their connections and collaborating tomeet the needs of the communities they both serve, recognizing that the needed cultural changes are signifıcant. If we do all these, we will have seized the moment and begun to integrate medicine and public health.

Conclusion As we did a century ago and periodically since, we appear to have the opportunity to align clinical medicine—in particular, primary care—with community health. Our challenge will be to seize the opportunity to facilitate change; measure the changes accurately, including eco- nomic impact; and communicate the process and results effectively. However, we must retain the flexibility to adapt to local variation and to social and environmental changes that inevitably will arise. We also should bring the conversation back to something more than simply cost savings, to the fundamental questions of health, quality of life, equity, and community. Perhaps the most important message is that we have had the opportunities before, but never with the same tools or the same dire outcomes if we fail to act. The impact on the economy is one of those outcomes. In today’s global economy, we simply cannot afford to let this continue. An adverse impact on the nation’s health will follow inevitably unless we actwisely as a nation. This time, we have no option but to accelerate the slow process of bridging the cultures of medicine and public health to the service of our commu- nities and the nation.

Publication of this article was supported by the U.S. DHHS Health Resources and Services Administration (HRSA) and the NIH National Institute on Minority Health and Health Disparities. The fındings and conclusions in this article are those of the

authors and do not necessarily represent the offıcial position of the CDC. No fınancial disclosures were reported by the authors of this

paper.

References 1. Flexner A. Medical Education in the U.S. and Canada: A Re-

port to the Carnegie Foundation for the Advancement of Teaching. New York: Carnegie Foundation for the Advance- ment of Teaching; 1910. Bulletin Number 4:26. www.archive. org/details/medicaleducation00flexiala.

2. Starr P. The Social Transformation of American Medicine: The Boundaries of Public Health. New York: Basic Books,

Inc.,1982.

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