Pat DeLeon (former APA President) Column, March 2016airplane

I have been fortunate to serve for two terms on the Board on Children, Youth, and Families (BCYF) of the National Academies of Sciences, Engineering, and Medicine.  There is a strong mental health presence on the Board including psychologist Ann Masten.  Natacha Blain, who is the Director, is a former APA Congressional Science Fellow.  This spring we heard from a number of national education and health experts who addressed a wide range of critical issues affecting our nation’s children and their families.  One of the most exciting aspects of BCYF is its emphasis on bringing together professionals from a wide range of disciplines to explore issues of national concern from their unique vantage points.  In developing its reports, discussion papers, etc. BCYF often convenes open sessions in Washington, DC and across the nation to hear from those most directly involved.  The Institute of Medicine (IOM), which is in the process of undergoing internal reorganization and name/brand change, was established in 1970 by the National Academy of Sciences to “secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public.”  The National Academy of Sciences was granted a charter by the Congress in 1863 to advise the federal government on scientific and technical matters.

Scaling Up:  David Hawkins, Professor of Social Work at the University of Washington, briefed us on the compelling Discussion Paper he chaired Unleashing the Power of Prevention.  “Every day across America, behavioral health problems in childhood and adolescence, from anxiety to violence, take a heavy toll on millions of lives.  For decades the approach to these problems has been to treat them only after they’ve been identified – at a high and ongoing cost to young people, families, entire communities, and our nation.  Now we have a 30-year body of research and more than 50 programs showing that behavioral health problems can be prevented.  This critical mass of prevention science is converging with growing interest in prevention across health care, education, child psychiatry, child welfare, and juvenile justice.  Together, we stand at the threshold of a new age of prevention.  The challenge now is to mobilize across disciplines and communities to unleash the power of prevention on a nationwide scale….  Within a decade, we can reduce the incidence and prevalence of behavioral health problems in this population by 20 percent from current levels through widespread policies and programs that will serve millions and save billions.  Prevention is the best investment we can make, and the time to make it is now.”

David and his colleagues opined: * When it comes to giving young people a healthy start in life, our nation faces very different challenges than it did just 30 years ago.  And, * Behavioral health problems in childhood and adolescence take a heavy toll over a lifetime, with significant impacts on rates of economic independence, morbidity, and mortality.  Seventy-two percent of all deaths among adolescents are due to motor vehicle crashes, accidents, suicide, violence, and difficulties in pregnancy.  Daily, an average of 1,700 young people are treated in hospital emergency rooms for assault-related injuries.  Smoking, which begins in adolescence for 80 percent of adult smokers, increases the risk of morbidity and mortality through adulthood.  Underage drinking costs society $27 billion per year and delinquent behavior costs society $60 billion annually.  Behavioral health problems reflect and perpetuate social inequities.  Different social groups, characterized by gender, race, ethnicity, citizenship, sexual orientation, and class, experience dramatically different levels of behavioral health.  For example, almost 83 percent of the deaths of American Indians and Alaskan Natives are attributed to behavioral health problems.

A large body of scientific evidence over 30 years shows that behavioral health problems can be prevented.  Prior to 1980, few preventive interventions had been tested and virtually no effective preventive interventions had been identified.  Today, more than 50 programs have been found effective in controlled studies of interventions aimed at preventing behavioral health problems in children, adolescents, and young adults.  These can be categorized as: * Universal programs, which seek to reach all children and youth without regard to level of risk exposure.  * Selective programs, which focus on young people who have been exposed to elevated levels of risk, but who do not yet manifest behavioral health problems.  And, * Indicated programs, which focus on youth who evidence early symptoms of behavioral health problems.

The challenge is to “scale up,” expanding these effective programs in order to achieve population-wide reductions in behavioral health problems.  To accomplish this critical objective it will be necessary to establish interdisciplinary programs and training in evidence-based prevention that involve the full complement of practice settings and, encouraging cross-sector collaboration across today’s vertically organized (“siloed”) agencies.  These efforts will help advance the movement in health care towards integrated primary care, which is a growing public health concern.  We possess the requisite knowledge.  What is needed is the creation of a comprehensive services architecture that provides population-based universal care, including prevention.  Behavioral health problems now surpass communicable diseases as the country’s most pressing concerns for the well-being of our younger people.  Unleashing the power of prevention is a call to action that our nation can’t afford to miss.

The Social Determinants of Health:  Transformative change is evolving.  At the Uniformed Services University of the Health Sciences (USUH), we recently attended several presentations by senior health policy leaders within the Department of Defense (DoD) and the Centers for Medicare and Medicaid Services (CMS) describing how the increasing use of information technology was allowing for the development of quantitative metrics to determine whether, in fact, the clinical services being rendered were effective, on both an individual and population basis.  The former U.S. Army Surgeon General Patricia Horoho has consistently emphasized “the importance of transforming Army Medicine from a healthcare system to a System for Health.  The patient healthcare encounter is an average interaction of 20 minutes, approximately five times a year.  Therefore, the average amount of time spent with each patient is 100 minutes; this represents a very small fraction of one’s life.  It is in between the appointments – in the Lifespace – where health really happens and where we desire a different relationship with Soldiers, Families and Retirees.”

“Dr. Janet Heinrich, Senior Advisor at CMS’s Center for Medicaid and Medicare Innovation (CMMI), described the mission of CMS to promote healthcare that is better and smarter, as well as health care that ultimately leads to healthier persons which was not only insightful, but confirming.  She discussed the various grants and programs that enable clinics across the country to implement infrastructures and technologies that are person-centered, sustainable, incentivize quality of care over quantity of services, and are coordinated across multiple disciplines and providers.  CMMI is pursuing this goal by developing, testing, and implementing new payment and delivery models that not only acknowledge disease symptoms, but also the ‘social determinants of health’ that place individuals at risk for specific diseases and serve to maintain symptomology” (Omni Cassidy, USUHS).

CMMI was established by President Obama’ Patient Protection and Affordable Care Act (ACA).  Its underlying objective is to test innovative models to * reduce expenditures, while * preserving or enhancing the quality of care (i.e., the Triple Aim concept of former CMS Administrator Don Berwick — Better care for individuals, Better care for populations, and Reduced costs).  Historically, our fee-for-service system has been provider-centered, provides incentives for volume, is unsustainable, and results in fragmented care.  The Administration’s vision is patient-centered, providing incentives for outcomes, sustainable, and emphasizing coordinated, team based care.

As of January, 2015 HHS announced its goals for value-based payments within Medicare fee-for-service as having payments tied to quality or value through alternative payment models at 30 percent by the end of 2016 and 50 percent by the end of 2018.  And, fee-for-service payments tied to quality or value at 85 percent by the end of 2016 and 90 percent by the end of 2018.  Medicare growth has fallen below GDP (Gross Domestic Product) growth and national health expenditures since 2010, due, in part, to these efforts.  Currently 477 Accountable Care Organizations (ACOs) – another initiative established under the ACA to foster systems of organized care – have been established across the nation, with 121 new ACOs in 2016, which cover 8.9 million assigned beneficiaries.  Pioneer ACOs were designated for organizations with experience in coordinated care and ACO-like contracts.  These models demonstrated savings for three years in a row of $92, $96, and $120 million.  One concrete example, the Independence at Home demonstration project saved more than $3,000 per beneficiary, with the year one results producing more than $25 million in savings.  Currently there are 14 total practices, including one consortium, participating in this model, with approximately 8,400 patients enrolled in the first year.  All health care is local and CMMI has been working closely with the private insurance sector to transform our nation’s health care system.  The underlying goal — Better care, Smarter spending, and Healthier people, as measured by objective health metrics.  “I don’t know when I’ll be back again.”

Pat DeLeon, former APA President – Division One – March 2016