May 28, 2018
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A simple way to improve Maine’s health care delivery

Courtesy photo | BDN
Courtesy photo | BDN
Vincent Felitti


Maine officials and health care professionals know of ways to make the delivery of health care more efficient and reduce costs, but political agreement is difficult. One preventive approach, however — where health care providers focus on the underlying reason for an illness instead of only treating the illness — should not be a difficult political lift and deserves greater recognition and implementation in health care circles.

The spending problem could rightfully be called a crisis. Maine is fifth in the nation for health care spending per person. Its health care costs per capita exceed the national average and continue to increase at a faster-than average rate. The Maine Economic Growth Council’s “ Measures of Growth in Focus” 2013 report identifies health care spending as having an “enormous impact on Maine’s economy.” Maine businesses identified the cost of health care as being the top obstacle to investment in a 2010 Maine Development Foundation survey.

The state, unfortunately, does not have a long-term strategy to reduce health care costs, though some good efforts are being carried out in parts of Maine. The “ Accountable Care Organization” model has propelled some doctors, hospitals and other providers to work together to avoid the duplication of services under Medicare, for example, and prevention efforts have expanded under the Affordable Care Act.

Another approach worth pursuing more is trauma-informed care. Studies have shown that when doctors identify a patient’s childhood abuse or emotional trauma and recognize that it contributed to the patient’s health concern, patients end up not needing their doctors as frequently. The approach requires physicians to make a change in the way they practice medicine.

In some cases the correlation between childhood trauma and disease is profound, as Vincent Felitti and Robert Anda learned in their Adverse Childhood Experiences Study, which was carried out in Kaiser Permanente’s Department of Preventive Medicine in San Diego, together with the U.S. Centers for Disease Control and Prevention. They studied 17,000 individuals to record the effect that traumatic childhood experiences had later in life.

Two-thirds of the middle-class population surveyed had experienced at least one adverse childhood experience, such as abuse, neglect or growing up with an alcoholic or drug-addicted parent. The researchers found a proportionate relationship between the number of trauma-related categories that people experienced and the following: self-acknowledged chronic depression, hallucinations, smoking, alcoholism, impaired worker performance, drug use, liver disease and chronic obstructive pulmonary disease — all conditions that require expensive treatments and that are partially responsible for continually rising health care costs.

It turned out what was often presenting as the person’s health problem, such as obesity or an addiction, was, in fact, sometimes the person’s attempted solution for dealing with the long-term effects of trauma. As one study subject, who was beaten as a child and later turned to alcohol, cigarettes and drugs, said, “I found a way to block the emotions and the memories.”

What are the implications for clinical practice? Kaiser Permanente decided to ask patients to answer a number of questions as part of a questionnaire before they arrived at the doctor’s office. A sample of the questions include: Have you been physically abused as a child? Have you ever been raped? Who in your family has been murdered? Who in your family has had a nervous breakdown? Who in your family has been alcoholic or a drug user?

Then, when patients arrived for their appointment, physicians took a couple minutes to ask them how their traumatic experience affected them later in life. “Asking and listening briefly and implicitly accepting … that had an enormous impact on people,” Felitti said at an April 20 seminar at Educare Central Maine in Waterville.

The approach affected health care utilization. After examining more than 100,000 patients who participated in the new medical evaluation, the researchers saw a 35 percent reduction in doctor office visits in the year after the evaluation compared with the year before. They also saw an 11 percent reduction in emergency room visits.

A trauma-oriented approach that focuses on the connection between patients’ biological and psychosocial development seems like a relatively simple idea. But sometimes simple ideas can have a great effect. Of course the larger impact will come when the state and nation can better identify ways to actually prevent the childhood trauma itself.

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