Where’s the Public Health?

Greetings. Thanks first to Frank Pasquale and Glenn Cohen for extending the invitation to comment on this terrific, provocative book and the important issue of fragmentation in the health care system. I enjoyed the book a great deal. The impressive list of contributors make a compelling case of how fragmentation runs across and unduly complicates many dimensions of the health care system. As a descriptive project alone, the book is immensely useful to scholars and policy-makers. It produces extensive evidence of fragmentation, demonstrating how lack of integration, misaligned incentives, too many decision-makers, unclear obligations and responsibilities of multiple actors in a complicated system, etc. generally result in underpowered, less effective medical care.

Because the book does such a great job of documenting and providing a typology of fragmentation problems and possible causes, I am hesitant to quibble about things that might have also been included but were not. Nonetheless, here is my quibble: where’s the public health?

Very few chapters in the book directly consider fragmentation issues arising in the field of public health. This is not to say that public health considerations get no mention. For example. Chapter 13 by Arthur Daemmrich and Jeremy Greene, From Visible Harm to Relative Risk: Centralization and Fragmentation of Pharmacovigilance, draws attention to the need for greater integration of case reporting and population-based assessments of medication risk as the regulatory system shifts from relying on doctor-initiated case reports to epidemiological studies of large databases.   Also, to be fair, the book grew out of a conference where the Petrie-Flom Center issued an open call to scholars, and presumably any fragmentation topic was seemingly fair game to discuss, so the book’s direction was not rigidly set down ex ante but took shape by who actually participated.  But, it is telling and somewhat amusing, in my view, that a book devoted to fragmentation in health care arguably pays only scant attention to the public health dimension. This merely underscores the depth of fragmentation problems when it comes to public health – it can’t even get equal billing with the regular delivery system in terms of acknowledging it’s got fragmentation issues.

Indeed, public health is the much neglected, sorry step-child, and the clear “other” in the health care universe. Public health has traditionally been operating in its own silo, relegated to public health agencies and safety net providers, and often disconnected from the rest of the delivery system.  Public health has been considerably underfunded for years while public health responsibilities are confusingly dispersed among many federal, state, and local governmental entities.  Moreover, there is lack of integration of public health activities with the rest of the health care system – including importantly with private health care providers- reflecting the deep schism between individual health and population health (I’m using the terms loosely and broadly here and thus equating “population health” with “public health”).  In the regular medical system, individual health considerations dominate over population health as providers form treatment relationships with specific patients to provide individually tailored care. But the crude individual/population divide ignores the fact that individual health activities very much impact population health. Example: While reporting of STDs is critical for public health surveillance, physicians tend to have low reporting rates, well below recommended practice guidelines and reporting rates are low even when legally mandated. There simply is poor coordination between public health departments and private physicians. Another example: physicians tend to be imprudent stewards of the antibiotic supply, adopting prescribing patterns that favor providing marginal benefit, and in some instances quite small marginal benefit, to their individual patients even while this can increase risks of antibiotic resistance and threaten population health over the long run. In such scenarios, front-line individual health care providers understandably neglect population health responsibilities because they have limited training for such tasks, face limited incentives (including usually no additional reimbursement) to take on such duties, and may consider such work more the responsibility of other actors (such as public health agencies) and thus peripheral to the clinician’s mission of caring for specific patients. Indeed, studies suggest physicians tend to feel stronger obligations to help their known patients than larger groups.

Along these lines, Bill Sage has written thoughtfully about a bias in the health care system that emphasizes the physician’s “relational duties” to each patient, a bias supported and encouraged by health law. This bias crowds out proper consideration of the physician’s alternative “regulatory duties” – obligations to society as a whole.

The recent push for health care reform also raises concerns of public health vs. individual health fragmentation. Debates are underway whether the new health care reform law will strengthen the public health system and improve population health or whether public health was a mere after-thought to reform of the regular delivery system. Plug: co-blogger Elizabeth Weeks Leonard is organizing an upcoming symposium issue in the Journal of Law, Medicine, and Ethics around just this theme.

So the book brings much needed attention to fragmentation problems undermining the overall health care system.  And with public health, unfortunately, the fragmentation problems seem quite excessive.

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4 Responses

  1. Gwendolyn Majette says:

    Richard aptly points out a coverage gap that I too noticed about the topics in Fragmentation. While the book overlooks the topic of public health, the U.S. Senate committees working on health care reform did not view public health as a minor or side issue. As a Fellow working with a Senator on the Health Subcommittee of the Senate Finance Committee, I was a part of the conversations laying the framework for the health care reform legislation. Our framework was three-fold: (1) Coverage, (2) Delivery System Reform, and (3) Prevention, Wellness & and Public Health. Staffers for both the Health Subcommittee of the Senate Finance Committee and the Health, Education, Labor, and Pension Committee attended regular meetings on these topics. In thinking about public health, some of our conversations included speaking with the US Preventive Services Task Force, the Task Force on Community Preventive Services, Trust for America, and Partnership for Prevention.

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  3. Elizabeth Weeks says:

    Gwendolyn, Your comments and perspective on this question are terrific. I am guest editing a Journal of Law, Medicine, & Ethics Symposium on public health and health reform this spring. It would be wonderful if you would contribute. The call for papers is here: http://www.aslme.org/JLME_Call_For_Papers

  4. Frank Pasquale says:

    This is a very important angle that needs to be explored more fully in future books on the topic. I believe the book was planned in 2008, before the battles over what became ACA. Those battles revealed a huge obstacle to a public health perspective: demagoguery based on “death panels” and other imagery. As Doug Coupland recently quipped, “The future of politics is the careful and effective implanting into the minds of voters images that can never be removed.”

    For example, any expert who has read, say, Kevin Outterson and Aaron Kesselheim’s work on conserving antibiotics would likely agree with your concern that “physicians tend to be imprudent stewards of the antibiotic supply.” But can you imagine the outrage if remedial measures were legislated? We might hope that payment systems could reflect the need for conservation here, as O & K propose. (http://healthaffairs.org/blog/2010/09/13/fighting-antibiotic-resistance-by-paying-for-appropriate-use/)

    I am afraid that, in the current political climate, it will be very hard to promote statutes designed to promote public health via better balancing of physicians’ relational and regulatory duties. Nevertheless, discussion of these matters is a good step toward “consciousness raising” among physicians themselves.