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Our inequitable, inefficient, oftentimes uncaring health care "system," revealed. -- Jeffrey G. Kaplan, M.D., M.S.

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Who's the Keeper of the Commons?

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Recognized as one of their “Top 9 Most Talked About Blogs of 2016,” reports style="font-size: 12px; font-family: verdana, geneva, sans-serif;" target="_blank">Who is ruining the healthcare system?” Medical Economics, 3/26/16. 

"This exploitation is analogous to what happens when incentives are not aligned in healthcare: payers, practitioners and patients at the commons are doing what they feel they must without accountability for equity in access, cost-effectiveness, benefit or cost-utility."

A professor of biology gives us a clue: herders, not out of greed, but out of practical necessity graze more cattle than the finite, common land can support, ruining it for everyone.

This exploitation is analogous to what happens when incentives are not aligned in health care: payers, practitioners and patients are doing what they feel they must without accountability for equity in access, cost-effectiveness, benefit or cost-utility.

Prof. Garrett Hardin (U. of Cal., Santa Barbara): "“The Tragedy of the Commons”." Science 1968;162:1243-1248. [Free Full Text]

Although Professor Hardin was speaking to issues of our fragile planet, his message is apropos as we debate health care reform: the business of medicine is medical business;  It is not insurance business; it is not a shell game by them. It is a right; not a privilege.  If you consider the bio-psycho-social model of health care, then what it is is comprehensive, fully integrated, scientifically-based, experiential and accountable health care. 

Here what I mean by "fully integrated":

"Until the payer, medical provider and behavioral health provider truly collaborate —becoming a team, rather than working in isolation — we won't achieve the Triple Aim of improving patient experience and the health of populations, and reducing costs," said Steve Abell, vice president of Strategic Services for Arkansas Blue Cross and Blue Shield.  "All of us working together – that's what the three of our organizations are stepping out to do."

Jan. 26, 2016 /PRNewswire-USNewswire/ -- "An innovative, 24-month pilot program aimed at integrating behavioral health and primary care is underway at an Arkansas primary care clinic."

SOURCE New Directions Behavioral Health [ - link failed  7/7/2016]

On April 23, 2014, Dr. James Jarvis lectured at the Westchester Medical Center, Maria Fareri Children's Hospital on the topic of "Health Status of Native American Children; Why Every Pediatrician Should Care." In essence, he spoke about social responsibility and how biology, ecology and the environment factor into our health status and perhaps epigenetics.  Let's look at a community of special interest and the work of Dr. Vincent Felitti pertaining to the Native American population: there we, all too often can find, adverse childhood experiences (ACEs as in the CDC) as well as health disparities, including high rates of depression, posttraumatic stress, and resultant substance abuse.

Epigenetic transformations: ACEs have been linked to changes in genes that regulate the stress response, possibly underlying the risk for certain psychiatric tendencies or disorders.

"Reservation-based Native Americans disproportionately experience ACEs and health disparities, significantly impacting long-term physical and psychological health. In addition to these experiences, the persistence of stress associated with discrimination and historical trauma converges to add immeasurably to these challenges. Here we provide evidence to suggest that ACEs result in methylation differences in genes that regulate the stress response and that these changes may contribute to an increased vulnerability* for developing psychiatric disorders, as depicted in Figure 1. Although we postulate these relationships, the lack of prospective studies in this at-risk group prevents us and others from concluding this causality, as well as more studies that include Native Americans. Thus, additional studies are needed to better understand the mechanisms through which ACEs contribute to health and well-being. These studies may inform future interventions to address these serious risks and promote the health and well-being of Native Americans."

Teresa N. Brockie, Morgan Heinzelmann, and Jessica Gill "A Framework to Examine the Role of Epigenetics in Health Disparities among Native Americans." Nursing Research and Practice 2013, article ID 410395. 9 pp

The benefit-cost ratios for Interventional programs with disadvantaged children = $5.70 for every dollar spent on a child by 27 years of age, and $8.70 when projected to later in life. "Cost savings in crime reduction is also notable. Each new developmental stage begins with the skills gained in the previous stage. Costs of later investments are reduced by early investments in younger children

Clearly, families, schools, and other systems play a strong role in human capital development."

Other ACE Responses' Links:

  • The Center for Post-Trauma Wellness provides education and assistance for people who have experienced trauma from abuse, neglect, or other adversities, and for professionals who help them. Using Restorative Integral Support that includes mind/body therapies and embodies research-informed interventions that address adverse childhood experiences and resilience, the Center offers a "whole person approach" to recovery from trauma.
  • The Homelessness Resource Center is offered by the Substance Abuse and Mental Health Services Administration (SAMHSA) to support effective comprehensive service provision to people experiencing homelessness. Restorative Integral Support (RIS) is highlighted as "a flexible model that allows for fluid collaboration among community leaders, service systems, and people receiving supports." RIS includes evidence-based practices in the context of human relationships.
  • The Substance Abuse and Mental Health Services Administration (SAMHSA) provides many helpful resources and supports, including a treatment locator and a National Registry of Evidence-based Programs and Practices.  See SAMHSA's Partners for Recovery.
  • ACESTooHigh houses background, news and information about the Adverse Childhood Experiences Study, developmental neurobiology (how experiences affect a child's developing brain and nervous system), and epigenetics (how our genes turn off and on in response to our experiences and social environment). It covers what communities are doing to reduce the burden of ACEs and is a place where people can tell their personal stories about how child trauma affected their lives and health, and how they have or have not, as the case may be - made peace with the past.
  • The ACE Study [See] is an ongoing collaboration between the Centers for Disease Control and Prevention and Kaiser Permanente. Led by Co-principal Investigators Robert F. Anda, MD, MS, and Vincent J. Felitti, MD, the ACE Study is perhaps the largest scientific research study of its kind, analyzing the relationship between multiple categories of childhood trauma (ACEs), and health and behavioral outcomes later in life.
  • The Centers for Disease Control, Kaiser Permanente and the ACE Study combine to be an on-line source of credible health information.
  • Prevent Child Abuse America has led the way in building awareness, providing education and inspiring hope to everyone involved in the effort to prevent the abuse and neglect of our nation's children. Working with state chapters, the national office provides leadership to promote and implement prevention efforts at both the national and local levels with a focus on valuing children, strengthening families and engaging communities nationwide.
  • The University at Albany School of Social Welfare has provided education, knowledge, and tools to agency, policy, and community leaders who are raising awareness of ACE implications and developing ACE-informed policies and programs.
  • Healthy Families New York–Since 1995, the Research Team (Center for Human Services Research/University at Albany (SUNY)/School of Social Welfare (CHSR) and the New York State Office of Children and Families/ Bureau of Evaluation and Research) have been conducting a variety of studies of Healthy Families New York, a multi-site program designed to prevent child abuse and neglect, increase parental self sufficiency, and enhance child health and development.
  • The Arizona ACE Think Tank and PBS [] speak to Adverse Childhood Experiences (ACE), which can last a lifetime, but don't have to. The ACE Think Tank Arizona has partnered with PBS to raise awareness of ACEs and ACE response strategies. You can also participate in the ACE Consortium blog developed by the Arizona Think tank.
  • The Washington State Family Policy Council–is a state level interagency council that has partnered with community public health and safety networks to support community-driven change in response to ACE knowledge.
  • Healthy People Policy–Healthy People provides science-based, 10-year national objectives for improving the health of all Americans. For 3 decades, Healthy People has established benchmarks and monitored progress over time in order to encourage collaborations across sectors, guide individuals toward making informed health decisions, and measure the impact of prevention activities.
  • The Children's Plan– The New York State Council on Children & Families (NYS CCF) presents this blueprint that helps build an understanding of ways that family engagement, support and youth voice play essential roles in developing the emotional well-being of children. The federal Child and Adolescent Service System Program (CASSP) principles are embraced in the Plan to ensure that every aspect of this Plan is built from a foundation of strengthening and supporting families.
  • The Committee on the Shelterless (COTS)–This award-winning homeless service agency in Petaluma, CA has developed "ACE-informed" programming guided by the RIS model, which draws on evidence-based practices (context: human relationships)
  • Service Outcomes Action Research (SOAR)–A national leader in developing practice-based research, SOAR implements a data-informed practice process that generates knowledge of the direct impact of services provided in support of program development.
  • The National Center on Family Homelessness provides resources that can be adapted for use in various agency settings.
  • National Healthcare for the Homeless Council–Homelessness is often the result of a downward spiral that begins with a person's health problem and escalates into employment, financial, and housing problems. Without homes, people experience illnesses and injuries at three to six times the rates of housed individuals, and they die an average of 30 years earlier. The National Health Care for the Homeless Council works to break this deadly cycle.
  • Low Income Mortgage, Affordable Housing & Homelessness–This guide has been written to help low income earners and the general public to understand the steps and processes required when purchasing affordable housing, as well as inform homeless people about methods and programs to find accommodation.
  • Humane Exposures- Founded in 1997 by photojournalist Susan Madden Lankford, HUMANE EXPOSURES pursues its mission to take a penetrating look at the needs and challenges of society's disenfranchised, encourage public awareness of the causes that underlie the destructive cycles plaguing these populations, and use photography, books, film, education, and advocacy to increase understanding and engender humane response.
  • Healing Neen–Recovery is possible. People can heal from adverse childhood experiences. Neen's story illustrates the consequences that untreated trauma has on individuals and society at-large, including mental health problems, addiction, homelessness and incarceration. Today, she is a nationally renowned speaker and educator on the devastation of trauma and the hope of recovery.
  • Voices Empowered-The mission of this website is to empower survivors of violence and/or trauma by creating a space in which the vulnerable can speak, allowing healing, wellness, and hope.
  • Philanthropists at Work (PAW) [Note: the link, is not accessible, 3/13/15]–Nevertheless, this international body responds to ACEs and seeks to build PE/ACE in Africa. An ACE Think Tank and Action Teams participant collaborating with "" target="blank">Troy Housing Authority," target="blank">Aminata Diaw and colleagues support the development of regional peace processes.
  • The Somatic Experiencing (SE) Trauma Institute [Note: the relevant <> ​link was not working 12/28/15 P.M.; jgk, editor] is an emerging body-awareness approach to trauma being taught throughout the world. The Institute trains practitioners and seeks research partnerships.
  • The Association for Comprehensive Energy Psychology (ACEP)–This international organization supports practitioners and researchers drawing on neuroscience and eastern medicine to inform practice and research on acupressure techniques to help relieve trauma symptoms. Intervention research has begun and this group continues to seek research partnerships.
  • "Child Abuse Information and Resources" [link failed 4/12/15]–A teacher and her students provided this page, which shares information and resources related to child abuse and neglect.
Also, a 1998 ACE study shows that our life stories matter a great deal to our health: Marcelle Pick, Ob-Gyn, N.P. "It's Not in Your Head, It's in Your Body"  Posted 08.24.2013 | Healthy Living

* You cannot have joy without vulnerability / shame.

Courage is borne out of vulnerability, rather than strength; this is a "finding of Brené Brown’s research on shame [which is] inspiring millions to reconsider the way they live, parent, and navigate relations with members of the opposite gender."

For more on this, see:

Krista Tippett, On Being, a podcast featuring Brené Brown, PhD, LMSW — "The Courage to Be Vulnerable."

Upstream Costs and Social and Environmental Determinants of Health
"For decades, experts have described a profound imbalance between public funding of acute medical care and investments in upstream social and environmental determinants of health.1 By some estimates, more than 95% of the trillion dollars spent on health care in the United States each year funds direct medical services, even though 60% of preventable deaths are rooted in modifiable behaviors and exposures that occur in the community.1
[1] McGinnis JMWilliams-Russo PKnickman JR. The case for more active policy attention to health promotion. Health Aff (Millwood)2002;21:78-93
"As health systems are increasingly being held accountable for health outcomes and reducing the cost of care, they need tools and interventions that address patient and community factors contributing to excess utilization. Effective partnerships among medical care, social services, public health, and community-based organizations could improve population health outcomes, but developing sustainable payment models to support such partnerships has proved challenging.4"
[4] Eggleston EMFinkelstein JA. Finding the role of health care in population health. JAMA 2014;311:797-798
Alley DE, Asomugha CN, Conway PH, Sanghavi DM. "Accountable Health Communities — Addressing Social Needs through Medicare and Medicaid." N Engl J Med 2016;374:8-11 | pub. online 1/5/16
Note: Outcomes are "not strictly related to individual specialties or procedures; they reflect the overall care for a patient’s medical condition, in which multiple specialties are usually involved. What generally matters to patients are outcomes that encompass the whole cycle of care — including health status achieved (e.g., survival, functional status, quality of life); the time, complications, and suffering involved in getting care; and the sustainability of benefits achieved (e.g., time until recurrence)." ....
"We predict that a time will soon come when it will be hard to believe that measurement of outcomes that mattered to patients was rare in 2016 — and organizations that measured them each did it in their own way. Universal measurement and reporting of outcomes won’t happen overnight. But we believe that agreeing on and implementing respected standard sets of outcomes for each medical condition is a practical and decisive step in accelerating value improvement in health care. This is an agenda whose time has come."

Porter ME, Larsson S, Lee TH. "Standardizing Patient Outcomes Measurement." N Engl J Med 2016; 374:504-506February 11, 2016 DOI: 10.1056/NEJMp1511701

Improving Access to Home Care

Schimpff, SC. [former CEO of the University of Maryland Medical Center.] "Time for payment models to stop discriminating against in-home care." Medical Economics Nov. 18, 2016