The Institute of Medicine's Forum on Emerging Infections was established in 1996 in response to a request from the National Center for Infectious Diseases, Centers for Disease Control and Prevention, and the National Institute of Allergy and Infectious Diseases, National Institutes of Health. The forum provides structured opportunities for representatives of academia, industry, professional and special-interest groups, and government agencies to examine and discuss scientific and policy issues related to research and prevention, detection, and management of emerging infectious diseases. The forum, which fosters the exchange of ideas, identifies areas for study, clarifies policy issues, and updates decision-makers, seeks to illuminate issues rather than resolve them; it does not provide advice or recommendations on any policy pending before any agency or organization. Its strengths are the diversity and dedication of its membership.

The forum sponsors a series of workshops. The first of these addressed public- and private-sector collaboration (1). The second explored many aspects of antimicrobial resistance, surveillance, and response (2). The third workshop (3), which we summarize here, examined opportunities posed for managed-care systems and challenges to their ability to address the threat of emerging infectious diseases.

Representatives of managed-care organizations, hospitals, government agencies, pharmaceutical companies, and academia convened to discuss issues, suggest solutions, and highlight impediments to be overcome in five key areas: basic and clinical infectious disease research, clinical practice guidelines, emerging infections surveillance and monitoring, education and outreach, and drug formularies and product development. A common theme of the discussions was the heterogeneity and rapid evolution of the managed-care industry. Although a few large health maintenance organizations (HMOs) were mentioned as effective research partners, others have different capabilities and corporate cultures. The participants recognized that, as the restructuring of the nation's health-care system evolves, forging stronger partnerships with managed-care systems will likely have a positive effect not only on health-care delivery but on many aspects of public health.

The workshop revealed that the structure of managed-care organizations provides few incentives for taking the broader and longer-term public health view. Some incentives, even those concerning quality assurance for individual patients and formulary restrictions, may actually intensify public health problems. For example, one presenter cited a study in which, for every condition except otitis media, increased formulary restrictions were associated with increased numbers of physician office visits, emergency department visits, hospitalizations, and prescriptions, along with an increased cost of prescriptions over a 12-month period. The evidence regarding managed care's actual performance and impact on emerging infections needs clarification. Some managed-care plans have integrated services and sophisticated research capabilities, whereas others provide little more than cost reimbursement for conventional health-care services.

The managed-care industry by itself cannot be expected to develop and implement solutions for those challenges. The industry could become a more productive partner in combating emerging infections. Incentives might include support to cover the marginal costs of research and demonstration activities, for example, the gathering of drug-dispensing data and crude surveillance for multidrug resistance among the organisms that cause tuberculosis and sexually transmitted diseases. Some HMOs may garner a competitive advantage in being viewed as progressive, research-oriented organizations. Major purchasers of managed care will also have an important role alongside the managed-care industry in developing and implementing solutions to emerging infections problems. Likewise, academic health centers and government agencies can act as catalysts, as well as partners in research, to allow greater participation by managed care in addressing emerging infections.

The need for better information to support the provision of quality health care was also addressed by the workshop. For example, an expert at the workshop reported on preliminary studies indicating that formulary practices may have an adverse impact on antibiotic resistance, prompting the need for additional comprehensive data about these practices and their impact. The use of outcomes information was identified as one way to develop and implement new clinical practice guidelines. Another promising outcome of the workshop was the identification of the potential for integrated, electronic information systems to assist physicians in diagnosing and treating infectious diseases; managed-care organizations in tracking antibiotic use, costs, and outcomes; and public health agencies in monitoring and even preventing emerging infections and antibiotic resistance.

Many of the issues raised during the workshop, including drug formularies and surveillance, have international as well as domestic implications. For example, there are three health systems in Latin America—private, public, and employee systems—but many of the providers in the region work with all three systems. As governments face increasing pressure to downsize, the impact of that change on the vital public health functions of surveillance, control, and prevention of infectious diseases concerns all systems. In the United States, the National Institutes of Health, the Centers for Disease Control and Prevention, and private groups that are working on these issues should be involved in international deliberations, and managed care should be part of foreign policy initiatives in the area of infectious diseases.

For more information about the Institute of Medicine, visit the Institute's home page at http://www.iom.edu

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