The 1990's have been witness to major changes in the Health Care environment. The ingredients of increasing health care cost and employer/federal government dissatisfaction with paying this cost have redefined the largest service industry over the past decade. The attempts by government to implement major reform were overshadowed by concurrent changes in the private health care environment. Physicians, other health care professionals, hospitals, insurance companies, HMO's, pharmaceutical companies, and other interested parties reexamined their priorities and participated in the changes to some degree. What was accomplished for the patient in this process depends on one's point of view and is difficult to measure.
One result of the changes has been the growth of the financing and delivery of health care through managed care plans. The definition of managed care is the subject of many books and articles. Most authors describe a range of health care programs and products from minimally managed indemnity insurance to staff model Health Maintenance Organizations.1 The alphabet soup of PPO, POS, IPA model HMO, and Staff model HMO defines Managed Care Organizations that differ even within the same category. Similar characteristics include active supervision of the financing of medical care, management of delivery systems, emphasis on primary care physicians as the center of care, and efforts to control cost. The programs and products of these organizations have reshaped aspects of the doctor-patient interaction. Concerns have been raised that the modification of traditional fee-for-service medicine has left patients without physicians as their advocate in this interaction. Also, the explosion of health related information and the technology to disseminate it, has revised many patient's expectations of their physician as well as their health plan. Commenting on these factors, the former U.S. Surgeon General, C. Everett Koop, described the need for the right balance of physician autonomy, patient rights, and managed care to evolve.2 Within this context of the physician, the patient, and managed care, Preventive Medicine has received renewed interest.
Preventive Medicine has been variously defined but most broadly focuses on promoting health and preventing disease in individuals and defined populations.3 Training in Preventive Medicine complements activities in individual patient care and in population based programs. The core knowledge areas of Preventive Medicine (Epidemiology, Health Services Administration, Occupational and Environmental Health, Behavioral Sciences, Clinical Preventive Medicine) add value to multiple areas of the health care landscape including Public Health practice, Occupational Medicine, and Aerospace Medicine. Though a recognized independent specialty by the American Board of Medical Specialties, important aspects of Preventive Medicine are incorporated into the training and practice of most Medical Specialties, as well as Allied Health Care Professions. In fact, Clinical Preventive Medicine (evaluation of an individual's health risk factors and the use of appropriate interventions such as screening, immunizations, chemoprophylaxis and counseling) is an expertise of all Primary Care Specialties such as Internal Medicine, Family Medicine, Pediatrics, and Obstetrics & Gynecology and practiced to some extent by most other specialties.
Professionals practicing Clinical Preventive Medicine apply principles of risk assessment before suggesting preventive interventions. Risk assessment describes the collection of risk factors that increase the likelihood a patient has or will develop a disease. Risk factors are defined as personal characteristics (such as smoking, family history), physiological parameters (such as a lipid profile, weight), symptoms, or preclinical disease states.4 Appropriate preventive interventions depend on good history and risk assessment. The United States Preventive Task Force (USPTF) classifies clinical preventive services that practitioners should provide as screening tests, immunizations, chemoprophylaxis and counseling interventions.5 Screening tests are special tests or standardized examinations for the early detection of preclinical disease (Pap smear for cervical dysplasia) or risk factors (elevated serum cholesterol) in asymptomatic people. Immunizations include vaccines and immunoglobulins to prevent selected infectious diseases. Chemoprophylaxis describes the use of drugs or supplements in asymptomatic persons to prevent disease (estrogen replacement therapy in peri and postmenopausal women). Counseling interventions describe efforts to educate patients about risk factor modification (tobacco use, sexual practices). The bulk of preventive services interventions can be classified as counseling interventions. In fact, the United States Preventive Task Force publishes evidence-based recommendations of which more than half are behavior counseling.6 Other groups have issued reports on prevention recommendations including the Canadian Task Force on the Periodic Health Examination and the American College of Physicians.
Good practice of Clinical Preventive Medicine incorporates the concepts of evidence-based medicine. The practice of evidence-based medicine requires the integration of individual clinical expertise with the best available evidence from peer reviewed research.7 A professional also needs an understanding of the accuracy and precision of screening tests, and the efficacy and safety of preventive interventions.
A useful concept that has reemerged is Leavell's levels of prevention.8 The levels of prevention include primary prevention with the desired outcome of health promotion and specific protection (counseling against smoking, immunization for measles), secondary prevention with the desired outcome of presymptomatic diagnosis and treatment (screening asymptomatic women for breast cancer with mammography, screening asymptomatic women for cervical cancer with Pap smear testing), and tertiary prevention with the desired outcome of disability limitation for early symptomatic disease and rehabilitation for late symptomatic disease (treatment of high cholesterol after myocardial infarction, occupational therapy following a stroke). These levels define strategies that are available to practitioners to promote health and prevent disease. Though some interventions do not fit neatly into the classification, the concept is most useful in educating patients about screening interventions (a secondary prevention) that are frequently confused with a primary prevention strategy.
In her book, Market-Driven Health Care, Who Wins, Who Loses in the Transformation of America's Largest Service Industry, Professor Regina E. Herzlinger relates three major forces reshaping health care economics — organization change, technology, and consumers.9 By her definition, the patient is the consumer. She describes a new generation of consumer that is more informed and more assertive in their selection of health care interventions. Though her generalizations do not define the average patient, she does indicate a trend that is influencing health care, a patient population exposed to varied sources of specific health care information and a portion of that population willing to act on the information. Mass media sources such as television, radio, newspapers, and magazines regularly feature health related issues including discussions of preventive services. The number of health related Web sites on the Internet has quickly grown and, if one includes in the definition specific sites such as the Duval County Medical Society <www.jaxmed.com/dcms>, it is easily into the thousands. Patients are now frequently referred to Web sites on the Internet by their physicians for additional information.10 Hospitals, health plans, pharmaceutical companies, specialty societies, and government agencies compete in the environment of providing information to patients as consumers.
Given the differing aims and agendas of various interest groups, it is not surprising that recommendations for preventive services are not uniform. In 1997 the National Cancer Institute ignored the advice of the NIH Consensus Panel on Mammograms and opted to recommend routine mammograms for all woman starting at age 40 (versus the recommendation that each woman in her 40's should make an individual informed decision).11 This issue highlights the forces and people at work when recommendations are made and the potential for consumers to get conflicting messages.
Patients as consumers sort through good information along with poor information. Putting information on preventive services in the context of the levels of prevention and educating how individual risk factors influence recommendations for preventive services benefits patients. Physicians, other health care professionals, and health plans have opportunities in the current environment to coordinate their efforts and encourage preventive interventions that lead to improved health care outcomes and healthier lifestyles.
The relationship between preventive medicine and managed care evolved from the early Health Maintenance Organizations that historically included preventive services in their prepaid arrangements. The spectrum of health plans provided by the emerging and growing Managed Care Organizations try to coordinate care systems around defined member populations and provider networks. These health plans are accountable to individual members, purchasers, and regulatory agencies at the state and sometimes federal level.
Both purchasers of health plans and individual consumers demand access to quality services at a reasonable price. Currently, the American public sees managed care organizations as cost driven systems in need of commitment to quality.12 This emphasis on quality has also focused attention on preventive services as an important component of a comprehensive health plan. Defining quality has been difficult for the experts and communicating quality to the public is a greater challenge. Several agencies, including the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the National Committee for Quality Assurance (NCQA), and the Health Care Financing Administration (HCFA) have developed quality standards for managed care plans.13
The National Committee for Quality Assurance (NCQA) is an independent, not-for-profit organization that assesses and reports on the quality of managed care plans, including health maintenance organizations (HMOs).14 They are governed by a Board of Directors that includes employers, consumer and labor representatives, health plans, quality experts, regulators, and representatives from organized medicine. The NCQA Board's stated mission is providing information that enables purchasers and consumers of managed health care to distinguish among plans based on quality, thereby allowing them to make more informed decisions.15 NCQA's efforts are organized around two activities, accreditation and performance measurement (report cards). The accreditation process designates whether a plan has structures and systems in place to deliver good care. Most states require accreditation by some major agency or organization. The performance measurement attempts to report if a plan meets important care and service objectives. Preventive services are among these measures. Historically, NCQA administered accreditation and performance measurement as separate programs. Future accreditation requirements are to include performance measurements in its report card.
HEDIS, the Health Plan Employer Data and Information Set, is the evolving performance measurement tool developed and maintained by NCQA since 1992. The newest version, HEDIS 3.0 includes eight domains, or major areas of performance: 1) effectiveness of care, 2) access to / availability of care, 3) member satisfaction, 4) informed health care choices, 5) health plan descriptive information, 6) cost of care, 7) health plan stability, and 8) use of services.16 The effectiveness of care domain includes preventive services such as childhood and adolescent immunization status, breast cancer screening, cervical cancer screening, counseling against smoking, eye exam for patients with Diabetes Mellitus, and flu shots for the elderly. The measures reflect intermediate outcomes at the plan level. Though the science of performance measurement as applied to health services is new, HEDIS as a tool has become widely used. HEDIS has been implemented by hundreds of plans nationwide, and underlies many employer and plan `report cards'. The Health Care Financing Administration (HCFA) contributed support to the development of HEDIS 3.0 and required that managed care plans serving Medicare beneficiaries submit data on those HEDIS measures relevant to their Medicare populations in 1997.
Accreditation requires a health plan to pass a survey that addresses standards for important care and services it delivers. Standards for Preventive Health services are a key category for this process. Plans also have to demonstrate programs in place that improve the care and services delivered. Some Managed Care Organizations have been innovative with prevention programs and successful in improving preventive services rates.17 These programs can be aligned with local public health initiatives and provide benefits to the community beyond the plan's membership.
As noted previously, a balance incorporating the interest of patients, physicians, and health plans has the best chance of meeting the goal of improving health care services. Given their population based- and evidence-based origins, clinical preventive services provide one area of focus to measure our progress at meeting this goal. Ideally, challenges for the future must be addressed by all three groups. Managed Care Organizations should provide health plans with comprehensive services and share information with patients and health care professionals about the performance of the plan. They should be active in the development of better information systems incorporating clinical as well as traditional administrative data. Physicians and other health care professionals need their autonomy supported. They should be willing to participate in programs to improve their performance in providing preventive services. Patient rights should be protected. They should take more responsibility for participation in health promotion and disease prevention when appropriately recommended. At a minimum, the current health care environment has brought Clinical Preventive Medicine to a higher degree of awareness.
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