Thursday, July 17, 2014

The Role of Prevention and Population Health in the Texas 1115 Medicaid Waiver ― Part I

by Jeffrey Levin, MD, MSPH; Daniel Deslatte, MPA; Joseph Woelkers, MEd; and Kirk Calhoun, MD

from The Center for Rural Community Health
at The University of Texas Health Northeast

The following invited remarks were prepared for the Code Red Task Force deliberations as it updates its recommendations. The comments were delivered on June 18, 2014, in Dallas, Texas. They are presented here as the first of a brief two-part series.

Background and the Waiver

There is little doubt that there are many definitions of public health, and in recent times, the Institute of Medicine (IOM) has given careful consideration to the interface between major population health challenges of the last century and the present-day medical care delivery system in the United States. It has commented that, “Creating health more efficiently throughout the population will require both addressing the social and environmental determinants of health and taking a more systematic and concerted look at the clinical care delivery system’s effectiveness in creating health through the services that it delivers.” (IOM, 2012)

There have been a number of recent trends that have shaped public health and prevention in the industrialized world. (Wallace, 2007) Included among these have been:

  • Increased incorporation of business and administrative practices into prevention and public health service delivery;
  • Changes in the definition of the group or population, the fundamental unit of public health;
  • Enhanced conceptualization and measurement of personal health status;  
  • Increased codification and interpretation of scientific findings relevant to prevention and public health;
  • Establishment of goals for communities to attain improvement in health status; and
  • Application of more advanced community health information systems. 

(Wallace, 2007)

In the short time since the Code Red 2012 report, Texas continues to witness an unprecedented pace of change in approach to health care delivery for the Medicaid population and uninsured. The complexity of this change is tied to a combination of many variables, including growth in traditional and nontraditional health care workforce development initiatives, early unfolding of the Affordable Care Act, and implementation of the 1115 Demonstration Waiver or the Texas Healthcare Transformation Quality Improvement Program.

The Role of Prevention and Population Care

Over the last two decades, it remains clear that our nation and our state continue on an unsustainable trajectory in which resource utilization is outstripping availability. By any number of measures, the health condition of Texans is poor. As articulated in Code Red 2012, “significant improvements in health outcomes and the reduction of healthcare costs will require additional investment in public health and prevention.” (Code Red, 2012)

Though this statement, on its face, may seem or appear quite intuitive, its implications are not. In a society accustomed to receiving medical care rather than health care, we have a tendency to focus disproportionately on identifying health problems in their advanced stages. We concentrate our resources on managing those problems (referred to as “tertiary prevention”) with considerable limitations of return on this investment, whether in terms of mortality, morbidity, or length and quality of life. The end result has been a growing recognition of our need to push forcefully upstream along the continuum of prevention if we are to make substantive progress toward achieving the goal of “significant improvements in health outcomes and the reduction of healthcare costs.” That upstream focus must be on risk factor intervention along the continuum (referred to as “primary prevention”) or early identification and management of disease (also known as “secondary prevention”). Though we cannot stifle new discovery to identify and clarify risk factors, there must be a more balanced approach. We should examine and derive a scientific and evidence-based approach to population and public health practice while advancing prevention through health promotion and health maintenance.

In the context of medical delivery systems, we are accustomed to thinking about these three levels of prevention in a very classic or traditional sense. Paternalistic providers advise patients (“you need to quit smoking”), order screening tests to uncover early disease (if people have access and participate), and prescribe (“take this medication”).  We fail to identify the many gaps or opportunities for intervention success by not taking a system-approach or considering the continuum of health care delivery and prevention. The perspective is a fragmented one, inwardly focused more on the process rather than on the population or people. This fragmented system is perpetuated by its very design, up to and including mechanisms for funding and reimbursement of care. Is it any wonder that overuse of hospital emergency departments and readmissions to hospitals have been significant contributors to our high cost of medical care? The corollary then to a need to invest in public health and prevention was also eloquently stated in Code Red 2012, namely, that it “can be achieved by redirecting funds from high-dollar, low-value services and delivery methods.” (Code Red, 2012)

In short, it is imperative that we, in the medical and public health communities, work together aggressively to shift from perpetuating an unsustainable system of care, intensify our focus on primary and secondary prevention efforts in a broader sense, and completely transform our systems of delivery to that end.


Code Red.  (2012). Code red: The critical condition of health in Texas, 2012.  Accessed June 8, 2014, at

Institute of Medicine (IOM). (2012). For the public’s health: Investing in a healthier future., p. 35.

Wallace, RB. (2007). Public health and preventive medicine: Trends and guideposts. In Wallace, R. B., & Kohatsu, N. (Eds.), Maxcy-Rosenau-Last public health & preventive medicine (15th ed., pp. 3-4). New York, NY: McGraw Hill Medical.

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