Treatment Goal #2: Increased Prevention and Personal Accountability

If an apple a day keeps the doctor away, so too does exercising regularly, quitting smoking, and obtaining a flu shot. The goal is to eliminate the preventable diseases that ravage our bodies and strain our health care finances. "At least 50 percent of health care expenditures are lifestyle-related," says Texas Commissioner of State Health Services Eduardo Sanchez, MD, MPH, "and therefore, potentially preventable." It is incumbent on individual Texans and their families, physicians and other health care professionals, employers, health plans, and the government to focus on wellness and prevention. We cannot afford, physically or fiscally, to do otherwise.

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Texans must take more individual responsibility for the financing of their employer-provided or individually owned health insurance products.

•  Patients who have a stake in the cost of their health care treatment decisions are more likely to make decisions that are cost-effective. TMA believes employers and health plans should aggressively pursue innovations in health insurance benefit design to encourage affordability, accessibility, disease prevention, health promotion, and individual enrollee participation in health care financing.

Consumer-directed health care plans offer a promising option for improving efficiency and increasing personal responsibility by excluding the insurance company from financing a large portion of routine primary care services. Under these plans, businesses establish high-deductible insurance plans for their employees, coupled with accounts that employees can use to cover their family's routine medical expenses with pre-tax dollars.

This approach improves efficiency if these plans bypass the usual process of submitting formal medical claims to insurance companies and waiting for lengthy review and payment. It strengthens the practices of primary care physicians who are particularly overburdened by the demands of health plans to have every small service pass through their scrutiny. To the employer, the employee, and the physician, the value of consumer-directed health plans lies in their simplicity.

To be successful, high-deductible health plans must not just shift more costs to workers who may not be able to afford the higher costs and may thus decline coverage. These accounts should be seeded with initial funds and allowed to grow with tax-free employee savings that roll over from year to year. Benefits should promote employees' use of preventive health care services, such as cancer screenings, immunizations, and prenatal care. Administrative overhead must be minimized through the use of debit cards or other methods that limit transaction costs for all parties.

To promote individual responsibility, TMA recommends:

1. Enacting tax breaks or other incentives for employers who offer appropriately structured, consumer-directed health plans to their workers.

2. Directing the Employees Retirement System of Texas to devise innovative and affordable ways to offer appropriately structured, consumer-directed health plans to state workers.

3. Encouraging employers and health plans to engage in educational efforts to make employees better-informed health care consumers.

•  The obesity epidemic threatens Texas' physical and fiscal health. Demand for treatment for obesity-related conditions is beginning to overburden the health care system. Obesity is responsible for 27 percent of the growth in health care spending. Treating obese patients costs 37 percent more than treating normal-weight patients.

Research shows that increased fitness levels correlate positively with student academic performance and test scores. A child who is overweight at age 12 has a 75-percent chance of being overweight as an adult. The 2001 Texas Legislature passed Senate Bill 19 (expanded by Senate Bill 1357 in 2003), requiring daily physical activity for all children in kindergarten through grade 6. There still are many questions about whether schools are implementing this law, and if so, how.

Vending machines provide additional revenue for schools. However, most serve primarily low-nutritional value food and drinks that only exacerbate the obesity problems among schoolchildren.

To combat this epidemic, TMA recommends:

1. Providing state employees or their family members incentives - for example, reduced health insurance cost-sharing - for making healthy lifestyle choices, such as maintaining a healthy weight, quitting smoking, or keeping their children immunized. The state should test effectiveness of similar incentives for Medicaid and CHIP.

2. Reinstating the smoking cessation benefit for CHIP and testing the effectiveness of including weight loss and smoking cessation programs as covered benefits under Medicaid and CHIP.

3. Assuring full compliance with Senate Bills 19 and 1357, including an appropriate means of reporting daily physical activity and expanding daily physical activity requirements to all grade levels.

4. Improving school nutrition by (1) codifying the public school nutrition policy developed by the Texas Department of Agriculture, and (2) evaluating compliance and accountability concerning the new requirements to replace food and drinks of low nutritional value with those of documented value.

•  Immunization is one of the safest and most cost-effective ways of protecting young children. However, a close look at the poor reimbursement levels for providing and administering vaccines explains one of the barriers to vaccine administration in the physician's office. As these costs are 50 to 100 percent greater than the doctor's reimbursement for giving the shot, many physicians find it cost-prohibitive to provide immunizations to their patients. This obliges more-motivated parents to take their children to publicly funded clinics. Others skip the vaccines altogether until public school requirements force the issue. With the advent of Texas' conscientious objector law, even that hammer has lost some of its impact.

The destruction of medical records and mass migration of Gulf Coast residents that accompanied Hurricane Katrina brought to light a new problem related to immunizations. States and parents are responsible for maintaining vaccination records. When the parents' paper records are lost and the state's computers are down or inaccessible, physicians in shelters and clinics or in the hurricane victims' newly adopted hometowns don't know the children's vaccination status. Adults' immunization records, even for those who have never moved or weathered a hurricane, are even more difficult to find. When seeing a patient with an unknown immunization history, physicians will err on the side of caution and administer the shots they think the patient needs. This wastes precious health care dollars, time, and resources. A national immunization registry, especially for children, would integrate data from the 50 state-level registries.

To promote immunizations, TMA recommends:

1. Supporting the Texas Department of State Health Services' request for increased appropriations to enhance vaccine services through the Texas Vaccines for Children Program.

2. Opposing any expansion of the conscientious objector law.

3. Increasing funding for education and practitioner vaccine administration reimbursement fees.

4. Strengthening Texas' ImmTrac immunization registry.

5. Establishing a national immunization registry based on state-level data.

•  Mental illnesses account for more than one in every 10 days lost to illness. That's second only to heart disease, and closing fast. Untreated mental illness costs the United States $300 billion each year. The Wall Street Journal has estimated that depression alone costs American companies $70 billion annually in absenteeism, lost productivity, and direct medical costs. Untreated mental illnesses also can cause what's been termed "presenteeism," when employees show up but are not able to work to the best of their abilities due to their psychiatric symptoms. A recent Rand Corporation study showed that an annual investment of $500 per employee in mental health more than pays for itself in increased worker productivity. [47]

Suicide is the eighth leading cause of death in the United States. About 20 percent of the 2 million people in American prisons suffer from severe mental illnesses. Mental illness contributes to dropout rates, special education placements, and grade retention in our schools. It is associated with teenage pregnancy, drug and alcohol abuse, and unemployment. [48]

These diseases touch a fifth of all Americans and are the second-leading cause of disability in the United States. However, we spend only 7 percent of our health care dollars to treat them. There's less health care coverage for behavioral issues, higher costs to consumers, and lower reimbursement rates for providers. In addition, there is a dearth of mental health professionals to deal with the magnitude of the problem, particularly for children and persons living in rural areas. [49]

To strengthen our mental health system, TMA recommends:

1. Encouraging employers to include mental health components in their workplace wellness programs and strong mental illness coverage in their health insurance benefit plans.

2. Requiring mental health equitable treatment (parity) of health insurance coverage for psychiatric brain disease and malfunction (mental illness including substance abuse/chemical dependency) equal to that for other medical conditions.

3. Increasing funding for mental health research and graduate medical education programs in psychiatry, child psychiatry, and family practice.

4. Funding core mental health services and support to those persons with severe and persistent mental illness who are most in need, indigent, and have no third-party coverage.

Next: Goal 3: Wise and Effective Use of Health Care Information Technology