Managed care plans and public health agencies are taking their first tentative steps to building data linkages that will support their common goal of community-based health assessment and management. But, efforts to develop these data-sharing partnerships will take time because of the many issues that must still be resolved. These include: confidentiality issues, consensus on data definitions and terms, availability of needed data, agreement on who should pay for generating data, coordination among different data suppliers and the technical challenges of getting their different information systems to work together. There also is the matter of different perspectives. Managed care organizations ultimately view community-based health care as part of a business strategy to keep costs in check. Public health agencies want to be able to monitor changes in population-based health status, particularly as private-sector health plans become increasingly responsible for delivering care to Medicaid and Medicare recipients. Accordingly, public health’s posture toward managed care has been more regulatory than cooperative. "That makes it harder for the plans to open up and expose their weaknesses," notes Liza Greenberg, director of medical affairs for the American Association of Health Plans (AAHP). "The plans want to know that if they aren’t perfect, that the public health community is going to work with them on improvement rather than punish them." HEDIS aids data linkages Despite these stumbling blocks, some statewide, regional and local efforts are taking shape. Many of these initiatives are taking their cues from the Health Plan Employer Data and Information Set (HEDIS), a collection of managed care quality indicators developed under the auspices of the National Committee for Quality Assurance. In Missouri, health care providers, plans, purchasers and public health officials have built on HEDIS to develop their own Missouri Health Indicator Set (MoHIS) for assessing the quality of care delivered there. And they are looking to the state Department of Health to supply some of the needed data. "We recognized that we have a lot of data in the state health department that can be used to monitor quality of care," explains Garland H. Land, director of the department’s Center for Health Information Management and Epidemiology. "We’ve tried to use those data sets where ever possible, as opposed to having the plans go out and collect the data separately." Public birth records, for example, can be linked with plans’ enrollment files to provide rates of low birth weight or Cesarean sections. Those same records also contain information on mothers’ race and education and the number of prenatal care visits they received, Mr. Land says. Matching birth records Because the birth records are already available in an electronic format, matching them with enrollment files is simple, he says, adding that data abstraction, definition and compatibility are not issues. Death records, hospital discharge records and information from the state’s cancer registry can be used in much the same way as birth records, he says. MoHIS ultimately will be used to produce consumer guides on managed care, Mr. Land says. Several plans have inquired about purchasing data sets from the state or paying to have those data manipulated to meet some of their other reporting requirements and demands. In Arizona, health officials have tapped a software program developed by the U.S. Centers for Disease Control and Prevention (CDC) to construct a statewide immunization registry. The system will set up local databases that can be accessed by physicians and that are compatible with their billing codes. Every month, information on patients who have been immunized will be downloaded into the system. The goal, says Debbie McCune Davis, project coordinator for the Arizona Partnership for Infant Immunization, is to improve immunization rates by helping physicians perform accurate assessments. The new "PC-Immunize" program will provide physicians with up-to-date immunization information and reminders for keeping immunizations current. In Maryland, where a new mandatory Medicaid managed care program takes effect Feb. 1, health officials have established baseline data on infant mortality and low-birth-weight infants so that outcomes on maternal and child health can be tracked and private-sector providers can be held accountable for the services they provide. "We really see [data] as a critical link in terms of monitoring the surveillance function of health departments," says Frances Phillips, health officer for the Anne Arundel County Health Department. "Surveillance without data is like sailing a boat without water." Medicaid providers will be responsible to the state health department for meeting certain data reporting requirements, which the local health departments will monitor. California requires managed care plans with Medicaid risk contracts to enter into separate agreements with local health departments to ensure that certain public health services are available to enrolled members. Those services include family planning, a range of maternal and child health services, immunization, treatment for tuberculosis, diagnosis and treatment of sexually transmitted diseases and HIV confidential testing, according to Bob Prentice, deputy health director of community public health services for the City and County of San Francisco Department of Health. Mr. Prentice heads the Association of Bay Area Health Officials (ABAHO), which has formed a public health planning group in order to develop formal memoranda of understanding (MOUs) with health plans. While the state is attempting to "incorporate some type of public health into Medicaid managed care," ABAHO is coming from a different perspective and is trying to "incorporate managed care into public health," Mr. Prentice explains. ABAHO has developed a plan to identify data elements for assessing progress in meeting public health objectives. But Mr. Prentice says that health officials need to be discerning in their data requests. "If it’s anything outside of HEDIS, which may be the common denominator, it’ll be idiosyncratic," he notes. Ms. Phillips agrees. "There are very real administrative costs to generating data; so on both a local and state level, we need to be very judicious about what we ask for ... and have a clear sense of how we want to use these data," she says. The development and dissemination of HEDIS has helped achieve some consensus among payers on the kinds of quality indicators relevant to managed care. "We are trying to be consistent with the mainstream about what we’re asking for," Ms. Phillips says. Jan Malcolm, vice president for public affairs at Minneapolis-based Allina Health System, believes that data planning between managed care organizations and public health agencies is best accomplished — at least initially — at the local or regional level. In Minnesota, managed care plans are developing relationships with 50 community health services agencies throughout the state, as provided under Minnesota’s health reform laws. Those agencies are "all working off of a common planning template, but they have different approaches to gathering data," Ms. Malcolm says. "Rather than trying to figure out one perfect approach, it probably makes more sense to try to work through these locally based planning agencies for several years before we figure out all the master databases," she says. Although officials in managed care and public health agree that data-sharing is a critical long-term issue, it is readily subsumed by other, more pressing concerns. Many public health agencies, for example, are struggling with budget cuts. And some managed care plans say they are still trying to figure out how to develop integrated information systems within their own organizations — let alone link with outside groups. Several health officials say they hoped to make significant progress in the area of data coordination during the coming year. While they believe the rewards will be worth it, they expect to be grappling with this issue for a long time. —Mary Darby Contact Mr. Garland at 573-751-6001, Mr. Prentice 415-554-2620, Mr. Phillips at 410-222-7375, Mr. Jacobs at 202-789-5600, Ms. McCune Davis at 602-266-1920, Ms. Malcolm at 612-992-3481 and Mr. Jacobs at 202-789-5600.