PUBLIC HEALTH CAN BEND THE COST CURVE

Non-traditional medical service delivery payments for public health: A necessary rule adoption by the Texas Department of Insurance

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THAT’S ONE SMALL STEP FOR MAN, ONE GIANT LEAP FOR MANKIND

Neil Armstrong July 20, 1969 Apollo 11

Photo taken by Buzz Aldrin

PARADIGM SHIFT FROM ENTITLEMENT TO SELF RESPONSIBILITY

What is the Texas Department of Insurance (TDI) regulatory authority?

Where is the regulatory language calling for non-traditional medical providers to become qualified service providers?

What steps must we take in-step with TDI to ensure that evidence-based public health service programs are viable economically in a public-private partnership?

PARETO PRINCIPLE AND CARRYING CAPACITY

Industry “shock-loss” claims are the bulk of insurance expenses created by very few individuals

Furthermore most shock-loss claims could have been prevented by the use of non-medical prevention health services including self-management techniques for those with diagnosed chronic diseases

Chronic disease is exacerbated by increased prevalence rates due to advances in medical treatments and the subsequent growth of life expectancy

EPIDEMIOLOGY PROVIDES THE RIGORS FOR STANDARDIZED MEASUREMENT

State of the Science:Public Health

Prevention Efforts

EPIDEMIOLOGY IS THE STUDY OF DISEASE ETIOLOGY IN MAN

The rise and fall of humankind is predetermined by external factors that can be systematically controlled by mankind. When we look at those factors we do so through the lens of person, place and time to quantify the variables that we can change to mitigate the effects of disease in the population.

Chronic disease has become the largest medical epidemic costing us billions of dollars to treat after diagnosis and countless lives are currently burdened with unnecessary comorbidities and co-mortality.

By not correcting chronic disease incidence and prevalence rates we will continue to have soaring healthcare costs.

SOURCE 09/2014 HTTP://WWW.CDC.GOV/CHRONICDISEASE/

“As a nation, 75% of our health care dollars goes to treatment of chronic diseases. These persistent conditions—the nation’s leading causes of death and disability—leave in their wake deaths that could have been prevented, lifelong disability, compromised quality of life, and burgeoning health care costs”.

CHRONIC DISEASE AND COMMUNICABLE DISEASE CAN BE CONTROLLED BY PUBLIC HEALTH PRACTITIONERS

While traditional epidemiology is rooted in communicable disease by characterizing disease exposure in terms of person, place and time there is a concerned effort for epidemiology to control chronic diseases by risk factor behavior. This duel role for epidemiologists was created by McGinnis and Foege’s landmark study in 1993.

CHRONIC DISEASE RISK FACTORS ILLUMINATED BY LANDMARK STUDIES

The McGinnis and Foege study published in JAMA in 1993 exposed the leading “Actual causes of death in the United States,” which illuminated the role of lifestyle health risk behaviors as a causal mechanism underlying mortality and morbidity rates.

Later in 2004 a study by Mokdad AH et al. published in JAMA validated the original McGinnis and Foege study findings in 1993.

CHRONIC DISEASE CO-MORTALITIES INFLUENCED BY LIFESTYLE CHOICE OVER A TEN YEAR SPAN

ACTUAL CAUSES OF DEATH IN THE UNITED STATES IN 1990 AND 2000Actual Cause     No. (%) in 1990* No. (%) in 2000**         Tobacco     400 000 (19%) 435 000 (18.1%)Poor diet and physical inactivity     300 000 (14%) 400 000 (16.6%)Alcohol consumption     100 000 (5%) 85 000 (3.5%)Microbial agents     90 000 (4%) 75 000 (3.1%)Toxic agents     60 000 (3%) 55 000 (2.3%)Motor vehicle     25 000 (1%) 43 000 (1.8%)Firearms     35 000 (2%) 29 000 (1.2%)Sexual behavior     30 000 (1%) 20 000 (0.8%)Illicit drug use     20 000 (< 1%) 17 000 (0.7%)         

Total     1 060 000 (50%) 1 159 000 (48.2%)

*Data are from McGinnis and Foege. "Actual causes of death in the United States." JAMA 1993; 270 (18): 2207-12.**Data are from Mokdad AH et al. "Actual causes of death in the United States, 2000." JAMA 2004; 291: 1238-45.

The percentages are for all deaths.

DEBATING INDIVIDUAL CHOICE VS. PUBLIC HEALTH POLICY

With the work of McGinnis and Foege more emphasis was given to chronic disease theory to lessen the morbidity and mortality of chronic diseases. Primary models tried to control individual choice of high risk lifestyle behaviors focusing on changing individual health risk behavior

Current development has evolved into the policy arena for social determinants of health to be improved by means of inclusionary law and/or policy that strongly encourages healthy lifestyles centered on nutrition, nutrient dense food availability, reduction in trans-fats, tobacco control, built environments, exercise and weight loss.

BURDEN OF CHRONIC DISEASES TO THE PUBLIC TAXPAYER

Chronic condition Healthcare Cost in $

Heart Condition over $107 billionCancer nearly $82 billionCOPD/Asthma nearly $64 billionDiabetes over $51 billionHypertension nearly $43 billion

The five most costly and preventable chronic conditions cost the U.S. nearly $347 billion—30% of total health spending—in 2010

Agency for Healthcare Research and Quality, Medical Expenditure Panel

Data source: http://www.apha.org/NR/rdonlyres/9A621245-FFB6-465F-8695-BD783EF2E040/0/ChronicDiseaseFact_FINAL.pdf

CURRENT STATE OF TRADITIONAL MEDICINE IN RESPONSE TO CHRONIC DISEASES

Americans typically have become indifferent towards our current medical model with increased legislation through the Affordable Care Act, Electronic Health Records, Health Exchanges and the creation of Accountable Care Organizations as a counterbalance for traditional providers to remain in control of the medical treatment offered through the primary care model.

ANALYSIS OF MANAGED CARE SPENDING FOR HIGH-COST ILLNESSES

“Recent AHRQ research revealed that the use of health care services is highly concentrated – just 1 percent of the population accounts for 27 percent of all health care expenditures”AHRQ Pub. No. 02-P033 September 2002

THE ROLE OF PREVENTION AND SELF-MANAGEMENT BY PUBLIC HEALTH DEPARTMENTS OFFERS A SOLUTION

Often overlooked as a viable treatment method is the ability to prevent chronic diseases and to apply self-management education tools for people to become responsible for their own health and to rely less on the treatment of symptoms which is ineffective and much more costly to the public.

INFORMATION REPRODUCED FROM A WEBINAR ENTITLED: “DIABETES SELF-MANAGEMENT PROGRAM MODEL FOR AREA AGENCIES ON AGING”. PRESENTED AUGUST 2012, BY TIMOTHY P. MCNEILL, RN, MPH

“Community Health Workers can play an integral role in delivering chronic disease self-management”

“This has been noted in a CDC policy brief, Addressing Chronic Disease through Community Health Workers: A Policy and Systems-Level Approach” http://www.cdc.gov/dhdsp/docs/chw_brief.pdf

2011 EMPLOYER WELLNESS SURVEY UNDERSTANDING HOW LARGE, SELF-INSURED EMPLOYERS APPROACH EMPLOYEE WELLNESS BY SHAPEUP, INC. HTTP://WWW.WELLNESSINDIANA.ORG/WP-CONTENT/UPLOADS/2012/07/SHAPEUP-EMPLOYER-WELLNESS-SURVEY-20111.PDF

HEALTH CARE COSTS FACT SHEET. AGENCY FOR HEALTHCARE RESEARCH AND QUALITY. AHRQ PUB. NO. 02-P033, SEPTEMBER 2002

“Self-management programs reduce the use of health care services among peoplewith chronic diseases. About 70 percent of all health care expenditures are related tochronic disease. A recent study found that patients with chronic diseases whoparticipated in a brief self-management training program improved their health or hadless deterioration and used fewer health care services over a 2-year period, comparedwith their status before the program. The program resulted in savings of $590 perparticipant over the 2 years, due to fewer hospital days and outpatient visits. Theprogram has been implemented in a number of health care settings across the UnitedStates and abroad.”

WHAT DOES PUBLIC HEALTH OFFER OVER THE TRADITIONAL MEDICAL PAYMENT SYSTEM

Always have worked within communities and national associations as collaborators not competitors

Public health practitioners understand the mechanisms that allow for increases in chronic disease treatment efficacy by using program process, impact and outcome measures

A trained workforce of prevention specialists, community lay health workers, parish nurses, nutritionists, nurse practitioners, exercise physiologists and other para-professional health educators

Can show empirical evidence for cost-benefit outcomes with public intervention program measurements that justify taxpayer dollars spent on non-traditional medical services

Use of peer-reviewed, scientifically based community level interventions through the CDC’s community guide and the IOM’s promoting health report

Standardized scientific rigors to show cause and effect relationships towards meeting HP2020 and other national benchmarks for a healthy population

A COMPREHENSIVE POPULATION-BASED MODEL OF CHRONIC DISEASE TREATMENT

Use of electronic health records to identify people suffering from chronic disease or at a high risk

Creation of TDI rules and policies that regulate the payment system to allow for non-traditional medical service payments to public health departments which utilize evidence-based community interventions

Premium payment reductions for employers and individuals that decrease catastrophic loss claims by measured outcomes

Tax credits for community level health programs offered by schools, workplaces, faith-based entities, and not for profit civic organizations

WHAT A TDI RULE CHANGE ACCOMPLISHES BY INCLUDING NEW SERVICE DELIVERY INSURANCE PAYMENT METHODS

Create opportunity for people to become healthier Lessen the cost burdens of chronic diseases The payment method will relieve taxpayer burden while

simultaneously allowing public health infrastructure development By requiring insurance providers to pay for non-traditional medical

services they will save money on high shock loss claims Community level groups (i.e. employers) provide a majority of financial

burden for health insurance coverage so they should benefit financially when they decrease chronic diseases within their environments

Individuals should be financially rewarded when they comply with lifestyle modification attempts that lessen their own morbidity and mortality from chronic diseases by lowered premiums

CLOSING REMARKS

Public health has the responsibility to protect the public’s health Current payment system mechanisms don’t always work Technology exists to capture those individuals that have chronic disease Creation of sustainable funding streams Decrease morbidity and mortality from chronic disease Relief of taxpayer burden caused by current medical service payments to treat

symptoms and not the root causes of chronic disease Economic growth of health and wellness job fields created on both a public and private

scale Accepted standardization of non-traditional medical service alternative treatment

methodologies Most all non-medical service interventions are replicatable in rural and urban

environments with existing infrastructure and existing health practitioners A new payer policy creates a value-chain for providers, payer's, public health and

individuals

An example of a novel service

delivery model

VISION: A HEALTHY TEXAS

MISSION: TO IMPROVE HEALTH AND WELL-BEING IN TEXAS