Reintegrating healthcare: Primary care and public health

Those of you who visit this site often know that we often highlight the importance of primary care and public health (amongst other things). One of the reasons we do this is that 1) primary care is the largest platform of healthcare delivery and 2) public health is a critical cornerstone for population health.

The irony to both of these important pieces of the healthcare delivery system is that they have historically operated in silos. Thankfully, a report released yesterday by the Institute of Medicine takes on this issue. And it could not come at a better time.

First, for those of you not familiar with the Institute of Medicine (IOM):

“The Institute of Medicine (IOM) is an independent, nonprofit organization that works outside of government to provide unbiased and authoritative advice to decision makers and the public.  Established in 1970, the IOM is the health arm of the National Academy of Sciences, which was chartered under President Abraham Lincoln in 1863. Nearly 150 years later, the National Academy of Sciences has expanded into what is collectively known as the National Academies, which comprises the National Academy of Sciences, the National Academy of Engineering, the National Research Council, and the IOM.”

The IOM has released some of the most influential reports on healthcare – period. I could spend hours describing some of these reports, and would encourage many of you to look into these reports on the IOM website.

Back to the report on primary care and public health integration – one key element highlighted in the brief report is that integration occurs on a continuum. It is pointed out that one goal is to move away from isolation towards merging the two entities. The committee recognizes that different communities will be at different stages of readiness to integrate and therefore propose a continuum of primary care and public health integration.

Similar to other multidimensional efforts to integrate, the IOM takes the following approach:

“The interactions between the two sectors are so varied that it is not possible to prescribe a specific model or template for how integration should look. Instead, the IOM identifies a set of core principles derived from successful integration efforts – including a common goal of improving population health, as well as involving the community in defining and addressing its needs. The time is right for action, and the principles provided in this report can serve as a roadmap to move the nation toward a more efficient health system. The challenges in integrating primary care and public health are great – but so are the opportunities and rewards.”

So why integrate? Well, according to the IOM, the integration of primary care and public health has the capacity to enhance both sectors and accomplish their respective missions and improve population health. Moving beyond the conceptual importance of this, the committee offered a few case studies to demonstrate this integration.

Community Care of North Carolina (CCNC): This statewide network is a public/private partnership with the goal of “changing the health care experience by changing the way health care is delivered.” And they are doing just that. With over $1.5 billion in savings in just over 3 years, CCNC has truly demonstrated some of what we can expect when we integrate.

Healthy San Francisco: This program run by the San Francisco Department of Public Health is a program designed to make healthcare services accessible and affordable to uninsured San Francisco residents. What is very interesting about this program is that it is essentially a “reinvention” of the San Francisco health care safety net. The goal is to enable folks to have all have access to a medical home (read primary care) with a focus on preventive care.

At the heart of the IOM report, and almost all efforts to better integrate healthcare, lies the fundamental reason we are fragmented to begin with – our payment mechanisms. Here at OH we have taken on the area of payment many times over, but it is worth mentioning again in the context of this report. While some of the core mission areas may be the same between primary care and public health (e.g. prevention), they often are funded separately, research only themselves and not each other, and prepare a workforce that may not be at the intersect of the two. The report does highlight recommendations to better “heal this divide”, and the two case studies above are great examples of exactly how to do just that.

Healthcare will become better integrated. It has to. The IOM routinely calls for our system to push for more substantive change, and this report is no different. I highly encourage many of you, at a minimum, to look at the brief report and to think about ways you can help work to better integrate these two critical pieces of healthcare.