William L. Roper

Effectiveness in Health Care

ALTHOUGH modern medicine provides great benefits to large numbers of people, medical professionals and clinical researchers have expressed concern about the effectiveness and appropriateness of man...

The New Tuberculosis

Events during the past decade have dramatically changed the nature and magnitude of the problem of tuberculosis. Much of what many physicians learned in training about this disease is no longer tru...

Performance measurement in public health: conceptual and methodological issues in building the science base.

The use of scientific methods for examining performance in the field of public health has lagged behind comparable efforts in medical practice. Accomplishments in other health care settings demonstrate that performance measurement systems can, if pursued rigorously and systematically, advance scientific knowledge and enhance the production of information to support improvements in public health practice. Numerous conceptual and methodological issues need to be addressed in order to use public health performance measurement processes for scientific inquiry. Nonetheless, the reward for careful analytic work in this area will be an expanding body of evidence to inform policy and administrative decision making in public health.

The Potential Impact of Measuring Healthcare Quality on Pharmaceutical-Related Costs and Outcomes

Quality measurement has achieved a powerful momentum across the spectrum of healthcare, driven primarily by the search for strategies to contain rapidly rising healthcare costs without sacrificing quality of care. Because pharmaceutical care is involved in almost all elements of healthcare, it is subject to the general impact of quality measurement on the healthcare system as well as quality measurements of pharmaceutical care. The assumption that measuring quality improves the processes and outcomes of care lies behind the drive for quality measurement, but this assumption remains largely untested. Whether the assumption is true depends upon the attributes of measures (importance, perspective, reliability, validity and responsiveness), the quality of the data used, and how and by whom the measures are collected, interpreted and used. Focusing attention on aspects of care that get measured may ‘crowd out’ attention on equally important, but unmeasured elements and may not contribute to allocative efficiency. Successfully turning quality measurement into quality improvement in pharmaceutical care will require two essential elements: continued research to develop, refine and update measures of quality, and education in how to use them.

The Management Academy for Public Health: Together We Can Make a Difference

This issue of the Journal of Public Health Management and Practice (Vol. 12, Issue 5) focuses on the Management Academy for Public Health. This is a management development program jointly offered by the School of Public Health and the Kenan-Flagler Business School at the University of North Carolina at Chapel Hill since 1999. Initially funded by the Centers for Disease Control and Prevention, the Health Resources Services Administration, the W.K. Kellogg Foundation, and the Robert Wood Johnson Foundation, and originally taking students from four southern states, the Management Academy is now a revenue-supported program that attracts participants from every region of the country. It is an intensive, 9-month, team-based program, using coursework in Chapel Hill, distance learning activities, and a capstone project consisting of a complete business plan that participants are expected to implement after being graduated from the program. A hallmark of the program is that it is thoroughly crossdisciplinary between public health and business, with the goal of applying business methods of management and business planning to public health issues. This orientation affects every aspect of the program and models the type of partnering between public health and business people that program planners believe is essential for successfully meeting the challenges faced by public health managers every day. A major theme of my tenure as Dean of the UNC School of Public Health was collaboration across departments, disciplines, schools, and sectors. I was fortunate to have colleagues in the school and across campus who shared the ideal of strengthening the whole by cooperative endeavor. We believed—we still believe—that cross-disciplinary, collaborative initiatives can make a real change in important arenas. When the Request for Proposals for the Management Academy was issued, we at the University of North

Breaking the "Immunization Cycle"

The Institute of Medicine (IOM) report, Calling the Shots: Immunization Finance Policies and Practices,1 and the articles in this supplement to the American Journal of Preventive Medicine show that the degree of vigilance required is not diminishing. First, progress in the science of vaccines has expanded and will further expand what effective immunization delivery can achieve. Second, our goals are becoming more refined and more demanding. A generation ago, our goals focused on school entry; now we think in terms of reaching children earlier and with a more complex immunization schedule. Third, changes in finance and the rise of managed care have changed the traditional role of public health agencies. That traditional role, embodied in the public health nurse staffing an immunization clinic, speaks to a smaller share of immunization needs. Fourth, the focus on children must not lead to neglecting older populations. One of the messages of the articles in this supplement is that vigilance is easier when financial support for infrastructure is consistent. The key variable for the size of the immunization challenge is the size of the birth cohort. That variable is not highly correlated with the size of the public purse or political interest in immunization. Those variables respond to the business cycle and the cycle of issues at the center of the public agenda. As much as one wants to be optimistic, realism requires recognizing this low correlation. Still, those who want to achieve and sustain high rates of coverage are not powerless. The political-issues cycle sends issues that are perceived as having been “fixed” off to the periphery. The rise and fall of infrastructure funds provided by the federal government through the Section 317 program may show this cycle at work. But the public health community can influence the definition of the problem. The measles outbreaks of 1989– 1991 helped to define immunization as an area requiring more rather than less effort. The IOM committee report on immunization finance to which this supplement is tied may have a similar effect. The contents of this supplement suggest areas where work must be done. We need to make the various measures of immunization come together to paint a single portrait. We need to explain how service delivery fits into “infrastructure” at a time when managed care, done well, seeks to push service delivery out of immunization clinics and into medical homes. In addition, we have to show that fiscal federalism is not the same as “let the feds pay.” At present, we have a continuum of “fiscal federalisms.” Some states make substantial financial contributions to support universal purchase policies while others get by without dipping into their own funds. Let me conclude by noting two areas addressed in this supplement that will be crucial to achieving the promise of immunization: registries and pockets of need. Immunization registries have consumed significant amounts of resources to develop systems and put them in place. To date, the promise of potential performance has outweighed actual returns. This has less to do with the registries themselves than with the relatively slow adoption of information technology in the health care sector. It would be a lot easier for registries to succeed if every clinician charted on a computer. It may be the case that the potential of registries to improve service delivery will not be realized until the day when computer-based patient records are widespread. Meanwhile, immunization program managers may face difficult choices between supporting further development of registries and activities with more immediate returns. Everyone who has been involved in immunization for a decade or more experienced the measles outbreaks at the beginning of the 1990s. That memory reminds us that the coverage rate in pockets of need is as important as the overall national rate. Johnson et al.,2 writing in this supplement, suggest that there has been an “immunization cycle” in which outbreaks are followed by higher resources, then lower resources and then outbreaks again. If we again face outbreaks, they are most likely to be in the same kinds of places as a decade ago, pockets of underimmunized children. Experience and the National Immunization Survey suggest that there are concentrations of these children in large cities. The concentration of underimmunized children is not recognized in how the federal government allocates support for infrastructure through the Section 317 program. Section 317 allocates dollars to all states; under the IOM committee’s recommendations, it From the School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina Address correspondence to: W.L. Roper, MD, MPH, School of Public Health, University of North Carolina-Chapel Hill, Chapel Hill, NC 27599. E-mail: bill_roper@unc.edu.

Quality Measurement and Improvement

distributed equitably across all payers and phased out over time. Point-of-service design. HMOs would be required to provide a point-of-service option under the plan. The implied objective is to ease the transition from unlimitedchoice-of-physician plans to plans with more limited choice. This is the way such plans are now being used in the market. However, the benefit design in the Clinton proposal is substantially different than current point-of-service plans. It does not contain a deductible, covets all services, and requires 40 percent coinsurance by the member. The point-of-service option, we believe, should closely resemble those plans that are used successfully as transition products in the current market. Regional alliance size. Groups of 5,000 or fewer employees would purchase their coverage through the regional alliances. We at Kaiser Permanente believe that this number is too large, at least initially. It is very important to the administration’s approach that the regional alliances work well. The more people enrolling through them, the more difficult the task will be. With such large employer groups, plus all government employees and Medicaid beneficiaries, regional alliances will cover between 80 and 90 percent of the non-Medicare population. Enrolling all of these people at one time through alliances would be a major challenge. It would be far better to start small with the part of the market that needs insurance reform and purchasing assistance-individuals and the 100–200 employee-group