Public health + medicine = healthy people

The Institute of Medicine's J. Michael McGinnis presents during Wednesday
morning's session on public health and clinical care.

Medicine cannot exist without public health. Public health cannot exist without medicine. That’s the case made by physician and long-time health leader J. Michael McGinnis, MD, MPP, during this morning’s Midyear Meeting plenary session on integrating public health and clinical care.

“The relationship between medicine and public health … is in my view the central health policy issue of our time,” said McGinnis, a senior scholar at the Institute of Medicine.

He described the continuum of care: “At one end are those prevention efforts that are exclusively targeted to an entire population to the other end where treatment is targeted exclusively to one individual or patient. The other [interventions] lie scattered like a bell-shaped curve in the middle.”

He founded his case on three points:

1.    Medicine cannot provide effective and informed treatment to the patient without public health.
2.    Public health cannot advance the health of the population without medicine.
3.    The nation’s health and economic security will be at a disadvantage as long as financial incentives work in the middle.

McGinnis, a long-time member of APHA, argued that the 10 greatest public health achievements of the last century as outlined by the Centers for Disease Control and Prevention, such as vaccinations, healthy work places, motor vehicle safety and control of infectious disease, “are all a result of close collaboration between medicine and public health.”

So what happened to cause a split between the two communities?

“Throughout the 1960s, it was the success of this partnership that ironically frayed the ties,” according to McGinnis. The extension of the lifespan brought an increasing prevalence of chronic conditions and a more medically needy population around which developed a vast network of highly technical interventions and diminished attention to public health. And that was compounded by a dramatic change in financing with the creation of Medicare and Medicaid.

“Health expenditures going to prevention fell to below 5 percent, which is where it sits today,” he said. “What’s really changed are the economic incentives.”

He pressed his case for increased collaboration, asking the full room of meeting attendees to consider CDC Director Tom Frieden’s winnable battles, including food safety, immunizations, health care-associated infections, mother-to-child infection of HIV, motor vehicle injuries and tobacco use.

“How many of these battles can only be won by public health? How many can only be won by medicine?” he asked. “Virtually none.”

But, as he sees it, collaboration is trending. McGinnis pointed to a long list of items that are forging the relationship between medicine and public health, including an aging population, the potential for bioterrorism, information technology and new and emerging infectious diseases.

“It’s very clear that vigilance (on communicable disease) cannot be practiced effectively without very tight seamless communications between those treating them and those watching the habits of those individuals,” he said.

And regarding the impact of rising health care costs, “we already see that $2.7 trillion [in annual health care spending] is driving a stronger focus on prevention and public health. It’s a good thing, but it’s coming at a very high price.”

And with the Supreme Court opinion on the Affordable Care Act pending, “we hope tomorrow that those (prevention) elements will be retained,” as those are among the most important provisions, he said.

Despite the formidable challenges of the future, “I’m optimistic because I know the public health community. And I believe we’re seeing a ‘greening’ of the medical community,” McGinnis said.

By that, he meant in four ways: (1) the environmental sense — taking medical care outside the doors of the clinic and into the community; (2) the enlightened sense —health is shaped by so much more than medical care — even for those who are ill; (3) the restorative sense — the caring dimension is a vital contributor to the healing process; and (4) the fiscal sense — recognition of improving payments and payment structures for prevention and population health.

“Fee-for-service really doesn’t work,” according to McGinnis. The medical community itself if ready to abandon it and it drives a wedge between medicine and public health, he said.

Regardless of the Supreme Court opinion, McGinnis is hopeful: “Even if the Affordable Care Act is overturned, the spirit is there.”