It was striking to us how many times interviewees stressed the need for federal leadership. While our report stresses the need for proactive change among states in defining, protecting, and enhancing the role of PHLs, some consideration of the federal role is clearly in order. The fragmentation of responsibilities vis-à-vis the labs within the CDC, as documented above, is of particular concern to effective support of PHL functions. The themes that emerge in this regard are laboratory system structure, information technology, and facilitation of communication.
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Structure of Laboratory System
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Just as the laboratory system in the private sector is consolidating in light of new technology and the need to achieve economies of scale, many believe that consolidation would also be desirable in the public sector. Why should there be 50 state PHLs when geographic borders bear little relation to population centers and disease burdens?
The argument for status quo is typically rooted in political imperative and the need for states to control the full scope of public health services. However, while there is undoubtedly a role for some form of laboratory in every state, this does not mean that all laboratories need to be equally capable. Indeed, there is already considerable variation across states in services provided, and, as we have shown, many states contract out to have tests carried out in other state or private laboratories.
The notion of regionalization needs to be more carefully studied by the CDC. Issues that need to be considered include the capacity of state laboratories to perform complex reference testing, economies of scale in purchasing new capital equipment, mechanisms for laboratory funding, the current role of Medicaid funding, and categorical grants.
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Information Technology
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A central finding of this report is that there appears to be a widening gap between the public and private sectors in the area of information technology. Private sector funding appears to be outstripping public funding, and, as a result, the information infrastructure is simply not being built in PHLs. While the CDC does have a number of small grants in this area, they have been insufficient to generate substantial activity. Building information infrastructure is a clear priority of the present Administration, and applications to public health function should be further explored by the CDC or DHHS.
Unfortunately, the locus for leadership in this area has yet to be identified on the federal level. Leadership might come from the Health Information Systems and Surveillance Board (HISSB) within the CDC. However, there are clearly other divisions and agencies that have a strong interest. In addition, commitment would also need to emanate from the states, as most PHL funding continues to come from state governments. Current interest in integrated information systems for public health and knowledge-based systems among SHAs affords an opportunity to strengthen information technology in PHLs, and significant focus on this issue from federal government is needed.
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Outreach and Communication
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One of the challenges faced by the PHLs is that their routine services - while clearly important contributions to the maintenance of public health - are generally outside of the public eye. Indeed, typical PHL operations imply that PHLs will rarely take center stage in any standard public health activities.
The more successful PHLs, and those that have more positive outlooks on PHLs' future, share some common features. These PHLs work hard at outreach and communication to ensure that public health agencies, state and local government, MCOs and providers, other laboratory stakeholders, and the general public are aware of and informed about the PHL's unique value and responsibilities. These PHLs are also actively involved in collaborative activities among stakeholders and strategic planning for such activities.
While the efforts of these few PHLs are noteworthy, national leadership is needed to heighten awareness of PHLs' importance, build ties among laboratory stakeholders, and help set the agenda for public-private cooperation. Individual PHLs cannot be expected to shoulder the entire burden of outreach and communication. Not only should effective national leadership help preserve core PHL activities, it should also buoy the morale and leadership within the PHLs, thereby helping them to help themselves.
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