Introduction and commentary
Are We There Yet?: Seizing the Moment to Integrate Medicine and Public Health

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Historical Context

After the first half of the 20th century realized a dramatically increased life span resulting from potable water, infectious disease control, and increased access to medical care, the 1960s experienced new social justice movements and efforts to expand access to primary care, with a focus on working with communities to design and plan services that worked best for the underserved and uninsured. Experiments in community medicine and family medicine were derived from the community-oriented

Community Health Centers

Both Geiger7 and Gibson8—the initial advocates of community health centers and of ensuring access to primary care services—came from a medical perspective, albeit one infused with public health notions of concern for the denominator, a focus on the patients enrolled in the community health center's panel, and the community the center served. Of note, these leaders in the community health center movement, although trained in both medicine and public health, operated from a medical school

Managed Care

The 1980s and 1990s experienced another opportunity for the integration of medicine, primary care, and public health as employers and government payers turned to managed care health plans to attempt to control escalating health costs. One of the promises of managed care was to realize cost savings through a focus on prevention and attempts to bring more disease prevention strategies in line with payment mechanisms.14 The emphasis on value, quality, and cost and the improvement in population

Medicine Public Health Initiative

A more recent effort to heal the schism between medicine and public health involved the American Medical Association and the American Public Health Association and began in 1994 amid calls for coordinated actions on shared concerns.15 This initiative began with an agenda that called for the following:

  • 1

    engaging the community;

  • 2

    changing the educational processes of both medicine and public health;

  • 3

    joining research efforts;

  • 4

    devising a shared view of health and illness;

  • 5

    working together to provide

Lessons

Perhaps the most striking, although not surprising, lesson learned from prior efforts to integrate medicine and primary care with public health is that efforts to improve population health require infrastructure and funding if this integration is to occur and be maintained. The medical reimbursement system supports medical piecework and provides limited support for indirect patient care activities (e.g., practice analysis or time spent on efforts to identify those in need or requiring

What's New?

An alignment of tools and incentives providing new opportunities for cost savings and system improvement exists today. Two major changes stand out. First, the Affordable Care Act has provided dollars to drive change in population health. Although the Affordable Care Act's ultimate fate will not be known for some time, it is providing new funding and new life for integrating medicine and public health. For example, the CDC's Community Transformation Grants program (//www.cdc.gov/communitytransformation

What Now?

How do we harness this moment? First, we must ensure that long-term financial support for population health is designed into new healthcare delivery and public health systems (optimally regarded as one health system). At the same time, we need to recognize the vagaries of the economy and government funding and seriously consider how effective collaborations can be sustained in a changing world. Second, we must optimize the use of electronic health records and the data they generate so that we

Conclusion

As we did a century ago and periodically since, we appear to have the opportunity to align clinical medicine—in particular, primary care—with community health. Our challenge will be to seize the opportunity to facilitate change; measure the changes accurately, including economic impact; and communicate the process and results effectively. However, we must retain the flexibility to adapt to local variation and to social and environmental changes that inevitably will arise. We also should bring

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