Four years ago, in January 1998, this journal published an issue devoted in its entirety to the interaction between managed care and public health. Great interest in this interaction sprung from the replacement of fee-for-service Medicaid by managed care delivery systems. Substantial promise was seen as these interactions developed. Specifically, preventive benefits could be extended to enrolled populations. The prior fee-for-service Medicaid system had not been successful in providing satisfactory levels of preventive interventions to both children and adults, including immunizations, screening for lead toxicity, and mammography. Also, public health officials understood the potential for monitoring receipt of preventive interventions by accumulating data from various managed care organizations (MCOs).

These optimistic projections are balanced with caution because the agendas of MCOs and public health departments are fundamentally different. Focus on the financial bottom line versus health improvement introduces conflict to development of productive affiliations.

This issue contains two articles (by Cukor et al. and Zahner) that provide valuable information on the successes and pitfalls of these interactions. Cukor et al. examine the quality mechanisms for Medicaid managed care plans and Zahner researches the role of memoranda of understandings (MOUs) between local health departments and managed care organizations in California. A third article by Scutchfield et al. looks to the future by addressing the public health competencies needed by those who staff MCOs.

Cukor uses data from a quality monitoring system employed by New York state. She finds that a set of performance indicators designated as Quality Assurance Reporting Requirements (QARR) yielded disappointing results. For example, in 1998, only 64 percent of children were up to date for immunizations. While these performance indicators have improved significantly since 1998, the major point of this article is that the providers of care, for the most part, do not receive feedback about this performance monitoring and are not held to a standard. Samples used for monitoring provide information at the plan level but are meaningless to individual providers, who may only have a few of their charts selected for review or who work for multiple MCOs.

Zahner reports on the success in California in implementing MOUs and an associated increase in some types of collaborative activities with public health entities. However, she reaches no conclusion on the critical issue of whether these MOUs served to actually impact on public health services.

Also in this issue, Lazzarini and Elman's article provides an insightful analysis of the role of contracts between public health agencies and managed care organizations.

Limited progress and obstacles have emerged in the past 5 years on the road to a productive managed care interaction. Notwithstanding Cukor's significant findings on less than satisfactory feedback to individual providers, managed care monitoring systems in states, including New York and Missouri, have improved managed care plan performance on delivery of important preventive services. Agreements between managed care and public health agencies at the local level are still the best mechanism to collaborate on shared interests and common resource needs.

Managed care is the dominant form of health care delivery in the public and private sectors. Health plans need to work with the public health priorities and resources of their service areas. Another article by Scutchfield addresses attuning managed care staff to public health competencies as a method to accomplish this. In addition to this useful recommendation, states-the payers for these health care services-need to become more involved with the public health of the enrolled groups. Insistence on prevention for individuals and populations needs to be pursued aggressively. Unquestionably, both public health and managed care must look toward improved modes of achieving what is indeed a difficult collaboration.