The document proposes that the Texas Department of Insurance adopt new rules allowing insurance payments for non-traditional public health services to help control chronic disease costs. It argues that chronic diseases account for the majority of healthcare spending and can be prevented or better managed through programs like self-management education, community health workers, and lifestyle interventions. New payment rules could help fund these services and reduce insurance premiums for individuals and employers that lower chronic disease rates in their communities. The goal is to bend the healthcare cost curve by preventing chronic diseases before medical treatment is needed through a comprehensive population health model.

1. 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
Image courtesy of www.flchamber.com

2. “
”
THAT’S ONE SMALL
STEP FOR MAN, ONE
GIANT LEAP FOR
MANKIND
Neil Armstrong July 20, 1969 Apollo 11
Photo taken by Buzz Aldrin

3. 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?

4. 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

5. EPIDEMIOLOGY PROVIDES THE RIGORS FOR
STANDARDIZED MEASUREMENT

6. 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.

7. 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”.

8. 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.

9. 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.

10. CHRONIC DISEASE CO-MORTALITIES
INFLUENCED BY LIFESTYLE CHOICE OVER A
TEN YEAR SPAN
ACTUAL CAUSES OF DEATH IN THE UNITED STATES IN 1990 AND 2000
Actual 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.

11. 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.

12. BURDEN OF CHRONIC DISEASES TO THE
PUBLIC TAXPAYER
Chronic condition Healthcare Cost in $
Heart Condition over $107 billion
Cancer nearly $82 billion
COPD/Asthma nearly $64 billion
Diabetes over $51 billion
Hypertension 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

13. 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.

14. 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

15. 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.

16. 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

17. 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

18. 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 people
with chronic diseases. About 70 percent of all health care expenditures are related to
chronic disease. A recent study found that patients with chronic diseases who
participated in a brief self-management training program improved their health or had
less deterioration and used fewer health care services over a 2-year period, compared
with their status before the program. The program resulted in savings of $590 per
participant over the 2 years, due to fewer hospital days and outpatient visits. The
program has been implemented in a number of health care settings across the United
States and abroad.”

19. 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

20. 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

21. 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

22. 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

23. An example of
a novel service
delivery
model

25. VISION: A HEALTHY TEXAS
MISSION: TO IMPROVE HEALTH AND
WELL-BEING IN TEXAS