Integrating Public Health and Primary Care Systems

Abstract

A PRIMARY CARE PHYSICIAN SITS IN HER OFFICE WITH her patient, an overweight 57-year-old man with diabetes and hypertension. She knows that in addition to treating his chronic medical conditions, she also should encourage him to quit smoking, modify his diet, and increase his level of activity to reduce the risk of developing disabling or fatal heart disease or stroke. At the same time, a public health officer in another part of town focuses on overcoming the challenges presented by lack of access to healthy foods and open space for exercise and by the easy availability of cigarettes in the community in which this patient lives—all of which likely have contributed to the development of the patient’s chronic medical conditions. Both the primary care physician and the public health officer are aware of and encouraged by the Million Hearts Initiative recently launched by the Department of Health and Human Services to prevent 1 million myocardial infarctions and strokes in the next 5 years through clinic and community interventions. Although they strive for the same goal—improved health for those whom they serve— the primary care physician and public health officer work in silos, independent of one another. They may wonder how to bridge the worlds of the clinic and community to more effectively serve this patient and those like him. Would the primary care physician be able to do a better job of preventing and treating cardiovascular disease if her local public health department shared information with her about affordable community resources that could help her patients exercise or gain access to healthy foods or if the public health department collaborated with local primary care practices to offer educational programs aimed at improving self-management of blood pressure or diabetes? Would the public health officer be better able to target community interventions if he had information on the adequacy of blood pressure control in different neighborhoods and among specific populations of underserved minorities or on the frequency of emergency department visits for cardiovascular conditions? The Institute of Medicine (IOM) recently issued a report, “Primary Care and Public Health: Exploring Integration to Improve Population Health,” that addresses these questions. The authors of this Viewpoint were members of the IOM committee that produced this report on strategies to promote the integration of public health and primary care. The report is not the first to explore how these 2 sectors might align and coordinate efforts to improve population health. Integration of primary care and public health has always been logical. Both sectors share an emphasis on prevention and population health that requires understanding individuals in the context of their communities and environment. However, many factors have stymied repeated calls in the United States during the past several decades for integration of these sectors. Not the least of these factors is a cultural and organizational separation between primary care and public health that dates back to the early 20th century and the advent of public health schools distinct from medical schools. Both sectors tend to view themselves as underappreciated and underresourced. Payment systems reward primary care physicians for delivering office visits rather than improving population health. Models such as communityoriented primary care that integrate primary care and public health have proved to be impractical to implement broadly in the absence of payment models that support these activities. The United States has not made the same investment in public health infrastructure that it has in biomedical research. Even the calls in the last decade for strengthening the US public health system have focused more on bioterrorism preparedness than on health promotion. Could things be different this time? There are several reasons why there is potential for meaningful progress on in-