Health for life

It thought the fundamental purpose of teachers was to teach. Yet, when it considers that the hours that a child spends in school is an opportunity to catch problems that may be missed by parents and docs alike, the idea that schools can be a first line of defense in the early detection of mental illness has some merit.

 For your consideration when youre grappling with your local school taxes:

Tim is the son of Paul Gionfriddo, who is a former Connecticut politician and current mental health advocate.  As the parent of a child with schizophrenia, he knows what hes writing about.

When Mr. Gionfriddo was starting out as a legislator, he was only just becoming aware of Tims difficulties in school. What followed was heartbreaking tale of inflexible school officials arranging for the wrong evaluations, wrong diagnoses, inadequate care and wasted attempts to help a deeply troubled child. Teachers were unable to cope, the parents were often blamed and Tim got shuffled around an unresponsive school system.  Despite "good" insurance, coverage fell short and many services involved onerous co-pays and limitations. And once he reached adulthood, an unwillingness to accept services moved Tim to the margins of society, leading to repeated hospitalizations and incarcerations. He now lives in squalor somewhere in San Francisco.

Tims story is not unique. According to Mr. Gionfriddo, a well meaning policy that moved hundreds of thousands of mentally ill out of decaying inpatient psychiatric hospitals in the 1980s was followed by

1) schools being unable to handle children with mental illness,

2) underfunding of community agencies, and

3) the siloing of the resources that did exist, resulting in little collaboration among physicians, law enforcement, community services or the mental health community.

Among Mr. Gionfriddos recommendations?  In addition to better screening by pediatricians during the well child visit, insurance orm and better housing options, state legislators should support the following:
 
1. The U.S. public school system should be prepared to offer mental health services in addition to basic education;

2. Every teacher should receive training in recognizing mental illness and how to handle it;

4. Once mental illness is  discovered, meaningful support should be included in a childs individualized education planning.

Image from Wikipedia

Your doctor will see you now!

If only the U.S. health care system had the democracy of the French, the efficiency of the Germans, the primary care of the Brits and the common sense of the Swiss. Then wed be able to see our beret-wearing PCPs ad lib, receive care in 9 minute aliquots, mutter "bullocks!" when were told were too old for dialysis and then die old and quietly at home.

Victor Fuchs, writing in the Jan 2 edition of JAMA, has a slightly different perspective.  He notes that American history is dominated by waves of immigrants who came here to escape oppression. We are far more distrustful of government.  We are also less likely to support redistributive public policies. That may be partly due to a more heterogeneous population that is less sympathetic to the less fortunate when they fall outside the right social or demographic class. Last but not least, our system of government is quite inefficient compared, say, to a parliamentary system.

Thats why:

1. Government spending on health care is comparatively lower: 46% in the U.S. vs. 75% in Organization for Economic Co-operation and Development (OECD) countries.  As a result, a) administrative costs are fragmented, and b) there is less ability to negotiate prices with providers and suppliers

2. There is a different mix of services: in the U.S., less top-down control means more high tech, specialists and amenities with relatively less reliance on physicians and hospitals to render health care services.

What is the way forward?  Dr. Fuchs recommends that future health orm efforts not be modeled on Europe.  Instead, Americans should scale back their expectations and focus on what is necessary, not desireable.

If government is to assume a greater share of health care costs beyond the current 46% level, it should probably worry about funding basic care, not all care.  In addition, Americans are less likely to support total equality; they want to preserve the option of "buying up" when they can afford it.  Last but not least, future orm is going to have to find a middle ground between all the advocacy groups, stakeholders and special interests that dominate the mix of services.

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The Department of Health and Human Services (HHS) has launched a "Million Hearts" campaign that is designed to prevent a million heart attacks and strokes in the next 5 years.  You can read about it in the New England Journal here or in Circulation here.  There is also more detail here at the HHS gov web site.

The campaign is crafted to address the "ABCS" a.k.a. aspirin, blood pressure control, cholesterol control and smoking in the U.S. population. The Feds propose to 1) consolidate just how ABCS will be specifically measured in any population, 2) remind and help manufacturers as well as users of EHRs that they can be tasked to addressing ABCS, 3) initiate a "pharmacist-led campaign.... (to) facilitate counseling about hypertension control," 4) launch an anti-tobacco marketing and community-based campaign, 5) push for food labeling in restaurants and 6) increase the measurement of sodium and fat consumption.  Details are in this table.

"Bravo!" says the DMCB.  When it reads about Million Hearts, its clear that the Feds are identifying population-based strategies, basing their interventions on demonstrated needs, increasing awareness of health risks, using patient-friendly education, helping consumers make the right choices and figuring out how to assess outcomes on an ongoing basis with a feedback loop.

If you agree on the DMCBs assessment of what the Feds are up to, you also agree that theyve they have launched a huge population health improvement (PHI) initiative.  The DMCB isnt making that up: if you compare the Care Continuum Alliance description of PHI here with the fundamentals of Million Hearts, youll see that the overlap is almost 100%.

Whats different is that the Feds are also using Million Hearts to 1) further justify the Affordable Care Act and the EHR meaningful use initiative, 2) leverage some potent government entities like AHRQ, CDC, CMS and the FDA, 3) distribute hundreds of millions in community grant money, 4) create a coalition that includes The Y, AHA, Walgreens, some professional pharmacy associations and AHIP, and 5) say some nice stuff about Mrs. Obamas childhood obesity program.  

All that makes perfect sense from a governmental as well as political process, but its still PHI.

"A hearty welcome to the fold!" says the DMCB.  HHS has finally decided to give millions of Americans access to PHI that combats atherosclerotic heart disease.  Better late than never, but based on what we know about the science of PHI in multiple other settings and assuming the government can pull this off, the DMCB is confident that a million lives being saved is within reach.