Sexual harassment in science, engineering, and medicine diminishes the integrity of the U.S. research enterprise. The National Academies of Sciences, Engineering, and Medicine take this issue very seriously. We have long been committed to providing a safe workplace free of harassment and intimidation, and our sexual harassment policy applies to anyone who is involved in the work of the Academies, including staff, volunteers, and members of our three Academies. We want to be sure that we are doing everything possible to prevent sexual harassment, to instill a culture of inclusion and respect, and to reinforce that harassment is not tolerated.
The National Academies’ Committee on Women in Science, Engineering, and Medicine has a long history of advocating for increased participation and well-being of women in these disciplines, and in 2016, the committee initiated a study on sexual harassment in academia. We are pleased that the resulting report, Sexual Harassment of Women: Climate, Culture, and Consequences in Academic Sciences, Engineering, and Medicine, will be released next month. The report’s evidence-based recommendations are intended to be a guide for academic institutions and professional societies and will be used to inform a re-examination of our policies and procedures as well.
We recognize that the scientific, engineering, and medical communities and the wider public place much trust in us to advise the nation on a wide range of matters, and we must always ensure that we are deserving of that trust. As a result, the leadership Councils of the National Academy of Sciences, the National Academy of Engineering, and the National Academy of Medicine have begun a dialogue about the standards of professional conduct for membership in our three Academies.
President, National Academy of Sciences
C. D. Mote, Jr.
President, National Academy of Engineering
Victor J. Dzau
President, National Academy of Medicine
The majority of health literacy research focuses on providing support to patients and strengthening individual health literacy skills. The work is much needed and important but places the onus or responsibility to increase health literacy solely on those who are mistreated by a complex system of policies, procedures, and institutions. Instead, as in other market-driven industries, the responsibility should fall on the companies and organizations that sell health care to maintain their margins and profits. Very few other industries could survive by providing poor communication and hard-to-understand information to their clients and consumers.
In Figure 1, we have modified the image to describe how to move from equality to equity and then liberation. The Equality image represents the traditional approach in health care, which turns a blind eye to health literacy and fails to address the differential impact on individuals and populations. The Equity portion of the image represents more equitable care by providing patient and caregiver supports, such as health literacy. Health literacy is a life skill that should be taught in school with reading, writing, and math. For now, it is imperative that we teach health care providers and staff to provide health literate care. It is good business to meet your customers where they are and make their experience as easy and pleasurable as possible. This is at the heart of good customer service.
The health care system must strive to achieve the liberation represented in the third image. With liberation, complex systems and information are broken down to remove the fence blocking patients from getting what they need and truly meet patients where they are. Liberation also involves teaching health care providers to actively listen and build care that is centered around the person’s needs. We need to liberate patients, caregivers, and family members from complex information demands and confounding systems. The responsibility of the health system is to establish health literate organizations and care. That responsibility will become heightened as payment realigns from volume to value and truly incentivizes health deliverers to provide high-quality care. Ineffective communication and inefficient systems of care delivery that do not emphasize listening to and learning about a patient’s life circumstances will become a much rarer sight as the health care industry transforms its business models to thrive under these new reimbursement mechanisms.
Moreover, the case for health literacy grows stronger every day. Those organizations and entities that embrace and adopt health literate principles early will gain a strategic advantage over the competition. Health literacy is still a relatively young field from a research perspective. However, based on the limited studies we have, plenty of preliminary evidence shows that adopting health literacy universal precautions can improve the quality of care and enhance the care experience, while reducing health costs (both for individuals and the system) and strengthening our efforts to achieve health equity .
Returning to the image, there are numerous planks that need to be removed from the fence to liberate patients fully from confusion and frustration, allowing them to make informed decisions about what care to receive, how to receive it, and where and when to receive it. We need to value the knowledge of all involved: the patients as experts in their lives and the providers of care as experts in the field. We will highlight some of these planks/barriers in the remainder of this discussion paper, keeping in mind that this is just a start. Many other barriers need to be addressed before patients, caregivers, and family members will be unshackled from health literacy challenges. The responsibility of those working within the health system is to identify and remove all of these challenges. This is one way we can meet the quadruple aims to provide higher-quality care at a lower cost, while increasing the care experience for both patients and health professionals .
Figure 1 | Equality, Equity, and Liberation | Source: Image by Angus Maguire, Interaction Institute for Social Change, adapted from Craig Froehle.
One systematic change starting to be addressed is the siloed delivery of health care. Many Americans go to outpatient doctors that are outside of the hospital systems to which they are admitted. Others get prescriptions filled at drug and grocery stores that are not connected to any health system. This lack of care coordination across siloes can be a huge barrier to quality care and can lead to further patient confusion. As we move toward more team-based care delivery, we also need to adopt medical home models or move to accountable care organizations that coordinate care across inpatient, outpatient, home care, therapy, and other settings. We cannot leave patients who have little training and understanding of how the health system works on their own to navigate and manage their care across disjointed delivery systems.
With the Centers for Medicare and Medicaid Services ramping up the transition from volume- to value-based reimbursement, a recent survey found that over half of health executives (55 percent) expect value-based purchasing to be the norm by 2020 [3,4,5]. This move will go a long way to freeing up health professionals’ time to communicate with patients in more meaningful ways. Current volume-based reimbursement actually discourages health systems from providing good communication, because if providers do not do a good job and a patient comes back, they make more money. We have already seen a change with the implementation of reimbursement penalties around readmissions. Since hospitals may not get reimbursed if they fail to adequately provide support to patients, new measures call for hospitals to make discharge information easier for patients to understand. New practices also require hospitals to provide clinical, social, and community supports to patients after they have left the hospital, to ensure they are not readmitted due to further complications.
A remaining and systemic barrier in the health care system is the lack of transparency in terms of cost and quality of care. When a car needs repairs, a mechanic usually provides a detailed estimate of the costs for the parts and labor. In fact, a customer will often want to know the estimated costs for the repairs and, in some cases, attempt to negotiate a lower price. Even before going to see a mechanic, a consumer can use various resources to determine which mechanics provide high-quality services for a fair price. If the customer cannot or is unwilling to pay the repair costs, the customer can and will take their car to a different mechanic. In short, the customer possesses the power to choose and negotiate. If a vehicle’s constant-velocity joint, for example, needs to be replaced, the customer will more than likely ask what it is and what it does. However, the health care industry lacks the same level of transparency, as a patient rarely receives an estimate of the costs for a procedure and there is no room for the patient to negotiate a lower price.
Medical terms are often listed on an insurance explanation of benefits or clinical notes without definitions. Patients, family members, and caregivers are more likely to understand “the part of the jaw bone that acts like a hinge” compared to the medical term “temporomandibular joint.” Reaching equity, and ultimately liberation requires complete transparency across the health care industry.
Banks depend on technology systems to make electronic deposits and withdrawals for customers each day. The electronic transfer of money from one bank account to another, either within a bank or across different banks, takes place automatically. If a bank’s technology system cannot communicate with other banks’, it is very likely that bank may go out of business. In this context of interoperability, different software and computer systems communicate, exchange, and use information without any restrictions. Health care systems and providers who accept Medicare payments are required to install electronic health record systems and provide evidence that the EHR system is in use. EHR systems are meant to promote health information exchange and improve patient outcomes . However, numerous private companies have developed different EHR hardware and software systems that are not interoperable, and they fear that doing so would expose proprietary information that might make them lose their share of the market. As a result, instead of liberating patients by breaking down information exchange barriers, the lack of EHR interoperability increases the demands placed on patients. Consequently, patients must ensure that information exchange takes place and that all the places they receive care from have their complete health record.
Proposing health literacy as a key component to transition the health care industry from equality to liberation may appear radical at first. However, as we point out, the changing structure of reimbursement requires that the health care industry implement a liberation business model focused on meeting patients and family members where they are as they describe their needs. We realize that changing business models is disruptive and may introduce market instability. Yet a period of disruption may signal a period of future innovation. Given the current research, we are confident that health literacy is essential to tearing down planks such as siloed delivery, volume-based reimbursement, lack of transparency, and interoperability challenges. Health care organizations and providers who are early health literate adopters will possess a significant market advantage, lower costs, increase satisfaction, improve the care experience for patients and providers, and ultimately improve the population health of the nation. Let us move forward to liberation as equal partners.
Tweet this! Supporting health literacy for all will improve quality of health and medical care, enhance the care experience, and may even lead to reducing health costs. Read a new NAM Perspectives commentary by @rv_rikard and @socialjusticesh: http://ow.ly/3nED30k4cqv
Tweet this! “We need to value the knowledge of all involved: the patients as experts in their lives and the providers of care as experts in the field.” Promoting health literacy will improve the health care experience for all involved: http://ow.ly/3nED30k4cqv
Tweet this! In our newest NAM Perspectives commentary, @rv_rikard and @socialjusticesh advocate for teaching health care providers to actively listen and build care that is centered around the needs of the patient rather than the provider: http://ow.ly/3nED30k4cqv
On January 18, 2018, the Department of Health and Human Services (HHS) announced the creation of a Conscience and Religious Freedom Division within its Office of Civil Rights. The purpose of the new division is to better enforce 25 existing federal statutes that allow health care workers to refuse to provide care that they believe conflicts with their religious beliefs or moral convictions. HHS cited tubal-ligation sterilization and abortion among examples of services that some health care providers may find objectionable . Notably, these protections apply to corporations and institutions as well as individuals, meaning that a health care employer with a religious objection to certain reproductive services can legally prohibit employees from providing those services, regardless of employees’ personal beliefs. For health professionals who do not share their employer’s religious objection and believe they have a duty to provide care, this presents an ethical quandary.
Unfortunately, the new HHS office does not grant equivalent deference to individuals whose religion or moral code provides a “conscience motivation” to ensure that essential and compassionate care is provided. Nor does it honor the deeply held beliefs of patients who have a conscience motivation to undergo a certain procedure (e.g., sterilization or abortion) or to make a medical choice (e.g., contraception). Against the backdrop of an expanding number of institutions with religious restrictions, this oversight may exacerbate an imbalance of power among institutions, employees, and patients and hinder the delivery of essential reproductive health services.
Religious hospitals operate one in five hospital beds in the United States . As with most hospitals, care from religious institutions is funded through public and private dollars. But these organizations are allowed to restrict certain health care services despite the public funding. In many cases, they are allowed to do so due, in part, to their founding as charitable institutions – even though, at present, religious hospitals do not provide more charity or Medicaid care than other nonprofit hospitals [2,3].
While religious hospitals can be of many faiths, 70 percent are Catholic affiliated – a number that has grown significantly in the past 15 years . Catholic institutions are required to follow the Ethical and Religious Directives for Catholic Health Care Services (ERDs), written by the US Conference of Catholic Bishops . The ERDs prohibit clinicians from providing contraception, male and female sterilization, abortion for any reason, most fertility treatment, and, in some cases, treatment during miscarriage, among other things. And while more varied in their permitted practices, non-Catholic religious hospital policies also often include restrictions. These tend to center on which abortions, if any, can be provided. Some Baptist hospitals, for example, allow abortions for fatal fetal anomalies, but not for other indications .
Despite these significant restrictions on services, from a patient’s point of view, religious hospitals are often indistinguishable from secular hospitals. Religious hospitals may not have names that convey their affiliation; nor do they always disclose religiously motivated care limitations to patients. Therefore, patients may not be aware that they have entered a facility that does not provide all forms of care.
Religious hospitals employ and serve diverse individuals. The health professionals employed by them often want to provide the care their employers prohibit , and patients can find themselves surprised and hampered by institutional doctrinal limits on care they want and need . Nonetheless, in communities where the only hospital is religious, or where there is a high level of religious health care saturation, there may be no other options for health care employment or services . As publicly funded entities that control a significant portion of the health care market and resources, religious hospitals, we believe, have a duty to offer comprehensive care. Failing that, we believe they have a duty to communicate relevant limitations clearly in advance.
One way to begin to do this, and to do it in the least controversial and burdensome way, is to focus on transparency, information delivery, and referrals (see Table 1).
Transparency is essential because patients often have no idea that their medical and surgical options are limited due to a religiously motivated hospital policy. At a minimum, patients should not have their ability to exercise their own consciences – and make their own health choices – limited by a failure to properly inform them before they consent to treatment at a religious facility or before they purchase insurance usable only at such a facility. Clinicians of all types should be prepared to communicate which care is limited by institutional policy to help patients navigate the most direct path toward the care they want and need. While the law protects institutions’ right to restrict care according to religion, the individuals working in those institutions should be prepared to address patients’ potential ignorance of those care restrictions by taking extra measures to teach their patients where to find the care they cannot provide.
Regardless of religious affiliation, institutions are not entitled to interfere with an individual’s decision-making process. Information delivery is an essential element of providers’ professional duty to ensure that patients can make their autonomous decisions before giving informed consent. This is an obligation in common law, in state law governing medical practice, and in codes of practice, and it applies as much to institutions as to individual providers. Adequate information includes identifying all available options and clarifying whether they are available at that particular facility. It also includes information from insurers, so that patients can choose a plan that includes an institution willing to offer care they think they might want or need in the future.
These principles – the duty to fully and accurately explain options, to respect patients’ decisions, and to help patients get the services they’ve chosen – are currently at the center of a case before the Supreme Court of the United States. The court is considering whether a 2015 California law, known as the Reproductive FACT Act, violates the First Amendment right to free speech. The law requires that all licensed and covered health care facilities – including pregnancy crisis centers that do not provide abortion for religious reasons – inform patients that the state of California “has public programs that provide immediate free or low-cost access to comprehensive family planning services, prenatal care, and abortion, for eligible women” . The Supreme Court decision, which could have significant ramifications for both patients and providers, is due in June 2018.
We maintain that referral is critical in cases involving health care workers who have a conscience motivation to provide care but are unable to offer those services themselves due to institutional restrictions. Referral allows these providers to fulfill the duty they feel they have to help patients access care sought under their own consciences and medical circumstances. Indeed, it may be difficult for patients to appreciate in real time the interplay between their preference and religious strictures without the guidance of interpretation of the clinician.
The challenges of differing religious beliefs can be mediated at times by ensuring that both patients and clinicians are able to pursue their own preferences. Institutions must be transparent, and clinicians must be allowed – even encouraged – to provide adequate information and referrals so that patients’ needs are not dismissed or deflected. Professional codes have long included a duty to provide patients with information and, in many cases, referrals. The American Medical Association’s Code of Medical Ethics, for example, states that even in the exercise of conscience-based objections, physicians must “uphold standards of informed consent and inform the patient about all relevant options for treatment, including options to which the physician morally objects” .
Our modest proposal doesn’t even go this far. We argue that employers and institutions should not be allowed to prevent providers from following their own religious beliefs and moral convictions when those beliefs lead providers to want to provide information and referrals. Nor should institutions be allowed to place obstacles in the way of patients who seek information and referrals they need to make decisions that accord with their own moral dictates. We must take the handcuffs off those whose consciences tell them to provide care. As President John F. Kennedy said, “If we cannot now end our differences, at least we can help make the world safe for diversity” .
Tweet this! Patients may not realize they are at a religious hospital that won’t provide certain care. Authors of this Commentary state that employers should not be allowed to stop clinicians from providing information on and referrals to all healthcare options: http://ow.ly/s09p30jHpPn
Tweet this! Health professionals that work at religious hospitals but don’t share their institution’s religious objections to certain forms of care can still provide their patients all available information about care options and referrals to other institutions: http://ow.ly/s09p30jHpPn
Tweet this! Authors of our newest NAM Perspectives Commentary encourage health professionals to focus on transparency, information delivery, and referrals when operating within a hospital that has religious objections to certain forms of care: http://ow.ly/s09p30jHpPn
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On May 2, 2018, the National Academy of Medicine (NAM) will host a pop-up art exhibition that collects insights from around the country on clinician burnout and well-being. Clinician burnout can have serious, wide-ranging consequences, from reduced job performance and high turnover rates to – in the most extreme cases – medical error and clinician suicide. On the other hand, clinician well-being supports improved patient-clinician relationships, a high-functioning care team, and an engaged and effective workforce. Supporting clinician well-being requires diverse, collective action and the experiences and voices of many – a focus of the NAM’s Action Collaborative on Clinician Well-Being and Resilience (Action Collaborative).
This winter, the NAM put out a nationwide call for artists of all skills and abilities to submit artwork that expresses how clinicians, their loved ones, patients, and organizations experience and are affected by clinician burnout and well-being. Artists were asked to answer the question: What does clinician well-being look, feel, and sound like to you?
A panel of reviewers drawn from the Action Collaborative selected artwork for the pop-up exhibition. Three artists will present their artwork during the Action Collaborative’s May 2 meeting in Washington, DC. These three artists are Anacristina Chapa (University of Texas School of Dentistry, Houston, TX), Cleavon Gilman (New-York Presbyterian, New York, NY), and Cheryl O’Malley (University of Arizona College of Medicine-Phoenix, Phoenix, AZ).
The thirty pieces of art selected for the pop-up exhibition were chosen based on the insight each piece brings to the subject of clinician burnout and well-being, as well as artistic impact. Pieces include visual and nonvisual art, such as music, creative writing, paintings, drawings, and spoken word. The following artists are featured in the show:
“These talented artists have added invaluable insights to our work on clinician burnout and well-being,” said Charlee Alexander, Director of the Action Collaborative. “We hope the stories told through these pieces of art will shed light on the joys and challenges experienced by so many and will illustrate not only the serious impact that burnout has, but also the solutions that allow our clinicians to thrive.”
In addition to the pop-up exhibition, 100 submissions have been selected to appear in a permanent online gallery. The online gallery, launching May 2, will be found at nam.edu/ExpressClinicianWellBeing. This gallery aims to promote greater awareness and understanding of barriers to clinician well-being and to highlight potential solutions to protect and promote the well-being of clinicians of all kinds, including doctors, nurses, pharmacists, dentists, and others. The NAM hopes these pieces of art will offer an entry point for conversations about burnout that can be difficult to have and will help alleviate the stigma that surrounds the mental health of clinicians.
Artwork from Expressions of Clinician Well-Being will begin a traveling show in summer 2018. If you are interested in hosting the exhibit at your organization, please email ClinicianWellBeing@nas.edu.
To learn more, please visit nam.edu/ClinicianWellBeing.
ABSTRACT | Cognitive, affective, and behavioral health (CAB) conditions are among the costliest and fastest growing in the United States. An array of interventions is demonstrated to be effective in preventing or mitigating these conditions and offers the possibility of lower costs and improved lifelong health. These effective interventions have not been widely integrated into health care, and current health care reform efforts have spurred limited additional uptake. Redesigning incentives to maximize life course CAB health is critical to reducing health costs and improving population health. Future health care reform efforts will need to redesign incentives by developing quality measures of CAB developmental outcomes for accountability, creating payment methodologies based on the expected value of changes in these outcomes, and ensuring sufficient reimbursement. These three changes would allow for timely incentives for effectively promoting life course CAB health and potentially reducing future health system spending. Health care reforms will also need to engage other sectors that contribute to and help optimize CAB health, including child care and education.
Policy makers, administrators, and clinicians face increasing demands to achieve the triple aim by reducing health care costs while improving quality and population health outcomes. A growing body of research indicates that achieving sustainable gains in health and lowering costs will require more effective “upstream” preventive and population-based interventions, which interrupt causal pathways to chronic long-term health conditions and optimize healthy development across the lifespan . To produce greater long-term savings and better health, U.S. health care systems will need to accelerate the implementation of effective prevention and population health improvement strategies.
One useful way to characterize and inform this transformative shift is through the 3.0 Transformation Framework (TF) . The 3.0 TF describes the drivers contributing to the intermittent evolution of U.S. health care delivery systems over the past century. The progression began with a 1.0 medical care system that focused on rescue care for those with acute conditions and infectious diseases, and evolved to the current 2.0 health care system, largely focused on creating networks initially like managed care and moving to accountable health care organizations that manage ever-increasing rates of chronic disease (see Figure 1). This shift from the first-era system to the second-era system was driven by epidemiologic changes in mortality and morbidity (from communicable to noncommunicable diseases); scientific advances that helped to replace simple, linear biomedical models with a more complex and nuanced biopsychosocial framework for understanding health; a bevy of new technologies, strategies, and organizational advances; and growing financial constraints and demands for fiscal accountability.
Figure 1 | The Transformation Framework | Source: Counts et al., “Redesigning provider payments to reduce long-term costs by promoting healthy development,” National Academy of Medicine.
Today, the evolutionary pressures fueling a shift to a third-era 3.0 health system are already underway. Life course health science is transforming how we understand the epigenetic and developmental origins of many lifelong conditions, and we are witnessing a dramatic shift in the salience of conditions such as obesity, behavioral and mental health conditions, and substance use, which have complex, multilevel ecological, social, behavioral, and developmental determinants . With a focus on optimizing lifelong health and achieving equity from the start, 3.0 transformative innovations are already prioritizing strategies that advance upstream prevention and health promotion at the individual, population, and community levels . We see these first stages in cross-sector health improvement strategies that address truly upstream socioeconomic drivers of health and health care costs, such as built environment and poverty , as well as in health care models such as the Accountable Health Communities Model , the Diabetes Prevention Program , and the Vermont All-Payer Accountable Care Organization Model , which lay the foundation for integrating life course and health equity perspectives into future payment and delivery models. Note that while the current movement represents a new, system-wide effort to address population health in payment systems, innovative providers have been implementing effective prevention and promotion interventions for decades. Unfortunately, the 1.0 and 2.0 health payment systems did not foster these efforts, and many of the most innovative interventions that one might expect in a 3.0 system have been largely grant-funded, making system-wide progress impractical until incentive structures are redesigned and larger payment reforms are underway.
While initial results of payment reforms have been promising, most of these initiatives have failed to meaningfully address some of the nation’s largest cost drivers: cognitive, affective, and behavioral (CAB) health problems, such as behavioral and mental health conditions, self-injury and suicide, substance use disorders and overdoses, obesity and chronic diseases, risky driving and accidental injuries, unintended pregnancies and sexually transmitted infections, autism spectrum disorders, and premature births . CAB health conditions have become the costliest in the United States . These conditions are also leading causes of disability in the United States and are frequently interrelated with other chronic physical health conditions, including heart disease, hypertension, and diabetes . Many CAB symptoms and disorders emerge during childhood, often from the impact of adverse experiences, social inequities, and environmental stressors. These early experiences can impact the trajectory of brain development and increase rates of CAB health conditions and interrelated chronic diseases later in life . Interventions to promote CAB health, especially in childhood and adolescence, offer the possibility of substantial savings across the course of an individual’s life.
As the burden of chronic conditions related to CAB development increases, we find mounting evidence that it is possible to prevent or mitigate these conditions in individuals, in general populations, and in subpopulations that have experienced historical health disparities. While many preventive interventions are condition specific, some address common risk factors and can prevent multiple CAB-related health conditions by promoting healthy CAB development [13,14]. The specifics of each intervention differ, but they tend to function by helping families, schools, or communities to structure interactions and the environment in ways that meet children’s specific CAB developmental needs, and/or by focusing on the child or children directly to help build core CAB developmental competencies that allow the child or children to successfully manage developmental transitions and environmental challenges in family, school, and community life. A number of these interventions are considered evidence-based, have been successfully implemented at a number of sites, and have appropriate scale-up plans that make them ready for broad implementation . Of the interventions appropriate for scale-up, some have demonstrated health care cost savings over the long-term , and others can be adapted using technology or other strategies to reduce the costs and increase the return-on-investment ratio [17,18,19]. Wide-scale implementation of interventions that promote healthy CAB development—whether directed toward individuals, families, classrooms, or broader communities—has the potential to substantially decrease the cost of health care and improve the health of the population over the long term. As one critical site for near-universal access in a child’s first years of life, the health care system must be configured to provide interventions that promote healthy CAB development.
Unfortunately, the current health care payment structure not only fails to provide appropriate upstream incentives but often does exactly the opposite by creating disincentives for CAB health promotion and risk prevention. Consequently, few of the effective interventions for promoting CAB health have made it beyond research and into clinical practice . For example, in the Quality Payment Program of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), value-based payments may accrue when a provider screens for depression and creates a follow-up plan, or when effective treatment interventions achieve progress toward remission. Incentive payments do not accrue, however, when a provider intervenes to prevent depression or its recurrence [21,22,23]. This dysfunctional misalignment of incentives is systemic throughout health care sectors and runs counter to the strategies that are necessary to achieve transformation to a 3.0 health system. With appropriate incentives in place for CAB health promotion, health systems could offer effective prevention in CAB health, with the potential for reductions in suffering and some of the related health care expenses.
This article (1) examines a possible trajectory of health care reform and the potential of leading health care payment and delivery systems to more strategically leverage the promotion of healthy CAB development; (2) outlines three areas that will need to be addressed to create incentives for promoting CAB health—quality measurement, appropriate incentive payments, and sufficient reimbursement; and (3) reviews other work that will be required to maximize CAB health and progress toward a 3.0 TF.
Although impending policy changes will alter details, the tectonic shift from volume-based payment toward value-based and population-based payment models is expected to continue for the foreseeable future, opening up opportunities to redesign health care payment incentives to promote CAB health .
“Value-based payment” generically refers to arrangements in which payers reimburse health care providers or provider groups based on their performance on different indicators, often a mix of quality and cost measures. Population-based payment is one type of value-based payment arrangement in which payers reimburse health care providers based on the estimated cost of effectively managing the health of a population of individuals, with incentives for quality, rather than reimbursing for each service provided to the population. These payment arrangements could offer a health care system the financial incentives and flexibility to maximize health status across many—if not most—populations.
Efforts toward these types of payment reforms have been, for the most part, bipartisan and have spanned public and private sectors. MACRA, the pivotal legislation on value-based payment and alternative payment models (APMs), received bipartisan support in 2015. While some private sector initiatives toward innovative payment arrangements have occurred in concert with public sector support, other private sector initiatives have been entirely independent. For example, Blue Cross Blue Shield of Michigan began a value-based payment initiative in 2004, years before most federal value-based payment programs, and has since expanded across a number of provider types and settings . Health care delivery system and payment reforms will continue to evolve over the coming years, guided by value-based and population-based payments goals, given the bipartisan support and substantial private sector buy-in.
In some instances, the proliferation of payment innovations has already enabled the implementation of some interventions that promote CAB health . Unfortunately, despite these scattered successes, health care reform efforts as a whole are not on track to meaningfully incentivize prevention and promotion efforts in CAB health at the provider level. Provider-level financing for CAB development is challenged by at least three issues: (1) better quality measurement to link to incentives, (2) appropriate incentive payments, and (3) sufficient reimbursement. Better quality measures that are aligned with CAB payment and outcome strategies will be needed to document the effectiveness of CAB interventions in diverse populations and settings. Health systems will need to offer appropriate incentive payments for achieving CAB quality outcomes. Finally, providers will need sufficient reimbursement to perform the interventions that affect the agreed upon quality measures.
Both population-level and provider-level measures will be necessary to advance incentives for CAB health promotion. Population-level outcome measures allow stakeholders to assess the well-being of a large group of people using representative indicators, whereas provider-level outcome measures track the short-term health of individuals receiving care using indicators relevant to the provider. The provider-level measures drive changes in a provider’s practice (e.g., whether they deliver interventions to promote CAB health), while population-level measures drive changes at the system level (e.g., whether communities build systems of support for early childhood, which is especially important for addressing health equity across a community). While some strong population-level measures for CAB development have been created and used for community-wide intervention efforts [27,28], there has been limited progress toward developing and validating appropriate provider-level outcome measures for CAB health . (Note that, although “provider” often refers to a clinician in health care payment reform, the provider being incentivized need not be a clinician. “Provider,” as used here, refers to any individual compensated by a health care payer to deliver any part of an intervention to improve health, and so the term could include community health workers, peer support specialists, or other types of practitioners.)
In determining what measures might be most appropriate, the literature makes a useful distinction among three types of health: health conditions, functioning, and health potential. The latter refers to “the development of health assets that indicate positive aspects—competence, capacity, and developmental potential .” In CAB health, health potential refers to the development of social, emotional, and behavioral competencies, which may be defined as
[A] family of constructs related to the capacity or motivation for, process of, or outcomes of effective adaptation in the environment, often inferred from a track record of effectiveness in age-salient developmental tasks and always embedded in developmental, cultural and historical context .
While all development occurs in relation to others, child development in particular should also be contextualized within the caregiver(s)-child interactions in the family and educational systems that build these developmental competencies. Thus, developmental competencies in the child, the dynamics with caregivers as they relate to the child, and the functioning of health supportive systems such as communities and schools together constitute health potential for the child’s CAB health. Health potential related to CAB development could be measured in health care at both the population and provider levels to predict some types of changes in health conditions and functioning that will manifest years later, far beyond the time frame in which incentive payments are typically offered.
Beyond this conceptual framework, there is little consensus around which measurable constructs capture developmental competencies or how these competencies should be measured . To ensure that appropriate measures are used in value-based or population-based health care systems, two strategies must be employed. First, health care systems must experiment with existing measures in value-based and population-based payment frameworks to determine if they effectively incentivize CAB prevention and promotion. Second, over the next decade, clinically appropriate measures must be developed for public use to evaluate the impact of CAB prevention and promotion services, and determine how best to effectively integrate CAB prevention and promotion into different clinical and community contexts.
Experimentation with existing measures in emerging value-based and population-based payment frameworks can drive stronger incentives for prevention and promotion in the near future. Existing CAB developmental measurement tools should be tested for use as quantitative scales. In such testing, healthy development and the effectiveness of interventions would be evaluated by changes in the score on the measurement tool. Some measurement tools have been tested as quantitative scales in this way , but none have been used in the high-stakes context of value-based and population-based payments, where payments are tied to risk-adjusted improvements or maintenance of high scores on the measurement tool. In addition, in keeping with the emerging movement toward a two-generation approach to health, appropriate measures for parents will also be needed . The measures used for parents should be expanded beyond current efforts to screen for maternal depression, as so much of healthy CAB development involves engaging parents in addressing an array of CAB needs. Providers could look at both parental risk factors (such as parental stress or maladaptive coping behaviors [e.g., parental substance use])  and parental competencies and functioning associated with healthy CAB development (such as good parent-child communication) . Those measures that prove helpful in directing and evaluating interventions in health and health care could then be used in value-based payment.
While existing measures offer the possibility of some progress, the measure development pipeline should prioritize measures of healthy CAB development to ensure that health systems use the most effective measures for incentivizing prevention and promotion. The Centers for Medicare and Medicaid Services and the National Quality Forum should propose child and parent CAB measures for each stage of development as priority gaps to be addressed and as an area of focus for the Pediatric Quality Measures Program of the Children’s Health Insurance Program Reauthorization Act of 2009. There are many clinical research measurement initiatives that could lay the foundation for building a clinical quality measure set, such as the National Institutes of Health (NIH) Toolbox , the NIH Patient Reported Outcome Measurement Information System (PROMIS) measure set and the multivariate computerized adaptive tests , the NIH’s PhenX initiative , and the National Institute of Mental Health’s Research Domain Criteria (RDoC) . Fewer initiatives have focused on individual- and community-level risk and protective factors for use in health care (with a notable exception in Vital Signs, from the National Academy of Medicine, which proposes population markers of developmental progress, such as kindergarten readiness, teen pregnancy, and high school graduation [40,41]) or relational health, such as in a child-caregiver dyad in the first few years of life through adolescence). The ultimate measures of CAB health potential may include a combination of the psychometrically valid person-reported outcome measure sets, such as the PROMIS set (which has constructs like “Depression” and “Applied Cognitive Abilities”), and the neuroscience-derived measure sets, such as the RDoC set (which has domains like “Frustrative Non-Reward” and “Declarative Memory”), along with individual- and community-level risk and protective factors and relational measures—the latter of which may be as necessary to understanding developmental trajectory as any individual-level measure. All of this measure development will need to consider the overall measurement burden and the opportunities afforded by technologically efficient data collection systems (such as computerized adaptive testing ) and/or remote reporting through active or passive systems .
Clinical and community measurement development initiatives could fuel research on efficient measures that can be tracked over the near term but effectively predict the impacts of prevention and promotion over the longer term—and eventually fuel practice.
With quality measures in place to track CAB development, value-based payments can be provided for achieving improvements in individual-level measures over time, in much the same way that MACRA and many APMs currently offer provider incentives. However, MACRA and existing APM incentive structures represent a partial transition from volume to value—they pay for value in the context of the specific health need but not for the value to overall life course health. To promote the most efficient allocation of resources for population health, incentives should be tied to the amount of value the intervention confers across the individual’s life course. Note that benefits also accrue to sectors outside of health care, such as juvenile justice, so that value under this framework would not be fully captured by a financing model that engaged the health sector alone. This “wrong pocket problem,” where interventions delivered in one sector lead to savings in another, is addressed later in this paper.
MACRA and APMs do include incentives for the efficient allocation of resources, usually in the form of total cost of care (TCOC) over the time frame under evaluation. TCOC is designed to ensure that health care systems are achieving health outcomes at the lowest costs. TCOC could be improved as a measure of efficient allocation of resources if it included forward-looking elements that incorporate how the health care system’s present allocations of resources affect future health outcomes and costs of care. Incentives that consider the net present value of care would favor the implementation of interventions that are most cost-effective to Americans, such as prevention, children’s health promotion services, and other population health investments. This would shift the current distribution of spending away from adult chronic disease management and rescue care, and toward those services and supports in childhood that are most likely to mitigate later needs. Note that, as the wrong pocket problem discussed later in this paper indicates, TCOC should be expanded as appropriate to include the costs from other health-producing systems.
Longitudinal studies of mediating factors associated with later health outcomes can provide a compelling starting point for redesigning TCOC. For example, social-emotional kindergarten readiness significantly predicts reduced psychiatric medication usage by age 25 . This research allows the expected value of improvements in kindergarten readiness to be determined from anticipated savings in health service utilization, and used to begin to calculate net present value-based payment amounts for a life course TCOC incentive . Over time, as all-payer claims databases are increasingly implemented and data from other sectors can be integrated, actuarial science can provide more robust estimates of life course TCOC using large sets of life course socioeconomic and health data to more accurately predict changes in future costs of care. Although these robust predictions may take some time to evolve, payment pilots can begin immediately in places where local payer and provider capacities align.
An incentive system that rewards positive changes in the trajectory of CAB development and reduction of life course TCOC would also inherently adjust for risk, promoting equity. By paying for dimensional improvements in CAB health potential and expected reductions in health service utilization over time, providers could receive the largest incentive payments for the highest risk children and much lower incentive payments for low-risk children. Throughout implementation, incentives should be further structured to address the fundamental goal of achieving health equity, with services organized to reduce disparities in health, health services, and the social determinants, and to overcome historical inequities that underlie many of these disparities.
Policy changes will be necessary to implement a life course TCOC incentive framework. Health plans have several financial disincentives to pay for the preventive care of individuals at risk. The most notable disincentive is that the current TCOC configuration mirrors the incentives that health plans face: individuals are free to and often do leave a given health plan after a few years. If the savings accrue outside of that time frame, the benefits accrue to another health plan, removing any financial incentive to invest in prevention. This presents a classic collective action problem: health plans benefit if they all pay for preventive interventions, but a health plan loses if it is the only one that pays. Legislation that mandates preventive services, such as those identified by the US Preventive Services Task Force; contract terms in all-payer arrangements; or some payer-provider collaborations could require the use of a common life course TCOC incentive structure to address this issue and establish value-based payment rates for performance on quality measures of promoting healthy CAB development .
Health systems will need to do more than apply new incentives to usual care to effectively promote CAB health and reduce costs.
Fee-for-service (including managed care), as currently structured, is generally not conducive to the provision of CAB prevention and promotion interventions. In fee-for-service settings, providers currently have limited opportunity to take advantage of value-based incentive payments, as there are limited billing codes for such health promotive services, and providers face competing professional accreditation and site certification requirements. Even in many current population-based payment frameworks, the case rate is often based on the current fee-for-service framework and so will be insufficient for providers to promote CAB health. Appropriate base reimbursement will be required for providers to implement effective interventions, receive the associated incentive payments for promoting CAB health, and produce the associated downstream savings.
To recalibrate the base reimbursement rate and test new incentive models, health systems should begin by implementing family-focused preventive interventions in the context of an integrated (behavioral, developmental, and physical health) and interdisciplinary care setting . Family-focused preventive interventions are evidence-based interventions that engage parents, sometimes in groups, to improve their children’s healthy CAB development. Some family-focused interventions are offered universally to promote health, whereas others are offered selectively to address specific risk factors. There is a large body of research demonstrating these interventions’ long-term effectiveness and impact on health equity, as well as the cost-effectiveness of a number of different family-focused interventions in nonmedical settings. There is also growing momentum around their widespread implementation, including in primary health care . Most recently, Washington State created billing codes for a short course of one of these interventions, the Triple P Positive Parenting Program, and allowed certified providers in a number of pilot sites to bill for it . If reimbursable codes for family-focused interventions were created for use—both universally and selectively, as appropriate—in an integrated behavioral health and primary care practice, providers would have a strong starting point to promote healthy CAB development and receive corresponding incentive payments for decreasing long-term costs.
By expanding these types of models, and pairing those with the incentive systems outlined above, health systems can begin to experiment with the most effective financing systems to promote CAB health and achieve larger reductions in overall health care costs. To ensure that the additional upfront expenditures in implementing these models ultimately result in downstream savings, payers and providers can work together to ensure that enhanced reimbursements do not exceed the expected value of the services provided, as calculated by the life course TCOC. When providers scale CAB promotion models, they will need to experiment with different provider types offering services, simplifying interventions, and employing technology and telehealth as appropriate to achieve desired outcomes within the financial constraints of health care systems.
To transition to a 3.0 health optimizing system, incentive realignment must look beyond health care and take an ecological perspective across all systems that produce health. This “360 degree view” would align across institutions, including child care, education, juvenile justice, faith-based groups, employers, social services, community organizations, home visitation programs, and others, with each of these stakeholders sharing common outcomes and planning processes . Cross-sector integration and alignment is especially important for CAB health, as other sectors beyond health care spend an appreciable amount of time with children and families and have the opportunity to reinforce and amplify interventions to promote healthy CAB development [49, 50]. CAB health is also important for other sectors, as effective CAB promotion interventions demonstrate effects on academic achievement, juvenile justice involvement, and social service use. We anticipate that the ideal incentives for such cross-sector integration will need to track improvements in population-level CAB and major milestones (e.g., school readiness, third grade reading competency).
Financing and incentive structures will need to reinforce this cross-sector alignment. Many of the benefits of healthy CAB development accrue to sectors outside of health care—such as reduced spending on criminal justice, special education, and child welfare, and increased tax revenue from increased worker productivity. This reduces a health plan’s incentive to invest in prevention and promotion because it sees less of the benefit, an issue commonly referred to disparagingly as the wrong pocket problem. Policies should begin to experiment with ways to allow health care systems to share in cross-sector savings, providing stronger incentives for the health care sector to invest in healthy CAB development. Similarly, community partners should receive incentives for their contributions toward healthy CAB development. Early care and education, schools, and community programs all have the capacity to positively impact CAB health and should receive financial incentives to do so, including appropriate reimbursement for the value they add.
As health care systems adopt 3.0 integration strategies that lead to co-development and co-design of services with other sectors and systems, federal, state, and local policies should implement braided and blended funding models with shared accountability systems to provide fair rewards for cooperation and co-investment. Appropriately balanced incentives should ensure that the health care system plays a support role to other sectors where appropriate and does not subsume them, building an ecosystem where different community stakeholders are empowered as co-producers of CAB health. Ideally, the additional resources made available from cross-sector savings should be fairly distributed across the entities that contributed to their production.
Under mounting pressure to reduce the costs of health care to Americans, leaders in health and health care must accelerate current progress in the fundamental transformation of how services are organized, integrated, and compensated. Reductions in the burden of the costliest health conditions are possible by using 3.0 design strategies for transforming health care systems so they can more effectively promote population and individual CAB health. To realize the potential impact of optimizing CAB health as part of emerging health care reform strategies, quality measures of CAB health in value-based payment must be tested. Simultaneously, strategies to redesign total cost of care to include future health care costs must be advanced to justify sufficient reimbursement and incentive payments for interventions that promote CAB health. Redesigning incentives in health care and across sectors to maximize healthy CAB development across the life course and reduce health inequities is a crucial step in reducing the costs of health care and promoting the health of the American population .
Tweet this! Cognitive, affective, and behavioral health issues are now the costliest in the United States. Focusing on treatment and prevention strategies will require thoughtful health care payment and delivery reform: http://ow.ly/TuJn30jxrSr #investinkids #childrenshealthforum
Tweet this! Health care systems already calculate the cost of healthcare over a patient’s lifetime to study health care delivery – what if they considered how much the prevention of an illness saves? http://ow.ly/TuJn30jxrSr #investinkids #childrenshealthforum
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The National Academy of Medicine (NAM) honors the life and work of Beatrix Hamburg, a pioneering child and adolescent psychiatrist and NAM member who passed away on April 16, 2018, at the age of 94. Dr. Hamburg is survived by her husband, David A. Hamburg, who was president of the Institute of Medicine from 1975 to 1980; her daughter, Margaret Hamburg, who currently serves as NAM Foreign Secretary; her son, Eric Hamburg, a writer and filmmaker; and three grandchildren.
Dr. Hamburg was the first openly black student to attend Vassar College and in 1948 became the first black woman to graduate with a medical degree from Yale University School of Medicine. She went on to build a trailblazing career in both research and clinical practice, focusing on early adolescence, youth peer-to-peer counseling, violence prevention, and biobehavioral aspects of diabetes in children and adolescents. Throughout her career, Dr. Hamburg held professorships at Stanford, Harvard, Mt. Sinai, and, most recently, Weill Cornell Medical College. She served as Executive Director of the President’s Commission on Mental Health under President Jimmy Carter and later as president of the William T. Grant Foundation, a philanthropic organization dedicated to research on children’s issues. In addition to her NAM membership, she was a fellow of the American Association for the Advancement of Science and the Royal Society of Medicine.
Dr. Hamburg was deeply involved in the work of the NAM and the National Academies over four decades. From 1985 to 1990, she served as chair of the Panel on the Health Status and Demography of Black Americans, which documented racial disparities in access to health care as well as employment opportunities in the health care industry. She also served as vice chair of the defining consensus report Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research and was a member of the Board on Neuroscience and Behavioral Health for more than 10 years.
“Betty was among the first to call attention to the important influence of childhood experiences in shaping lifelong health and well-being. It is hard to imagine a more foundational contribution to the field,” said Victor Dzau, president of the NAM. “She was an instrumental leader within our organization, and we will continue to benefit from her vision and dedication for decades to come.”
To learn more about Dr. Beatrix Hamburg, please visit her obituary in the Washington Post.
ABSTRACT | Children’s development of cognitive, affective, and behavioral capacities is best promoted when the contexts that surround them are strong and healthy. Children are embedded in families, who are, in turn, embedded in communities. Policies or programs that strengthen families and communities by addressing the social determinants of health also promote children’s healthy development, and ultimately national prosperity. We provide examples of housing, education, and income policies that address the social determinants of health. We suggest that their potency is augmented when they also strengthen the collective efficacy of families and communities, thus laying the foundation for children’s long-term, healthy development. We urge a concerted focus on these broad social policies as a key component of any children’s health policy.
Federal and state policies that invest in families and strengthen communities create the enabling conditions for child development and, by extension, our nation’s prosperity. These policies can directly target children (for example, the Children’s Health Insurance Program [CHIP] and the Early and Periodic Screening, Diagnosis, and Treatment benefits under Medicaid), or they can indirectly support families and communities (for example, through income support programs or housing policies). Child-focused policies such as CHIP raised the standard for children’s health care coverage, and consequently 95 percent of children nationally now have public or private health insurance . Yet, critical as these policies are, we argue in this paper that children’s development of cognitive, affective, and behavioral capacities requires more than investment in programs directly targeting children’s health.
Children’s development is best promoted when, in addition to these direct investments, policies and programs that strengthen families and communities are supported. Children are embedded in families, who are, in turn, embedded in neighborhoods and communities. Consequently, policies or programs that strengthen the ecologies of children—i.e., their families and their communities—also promote children’s healthy development. Policies and programs investing in family and community are often more cost-effective than services provided only to children, because they affect a broader population of children and the adults in their lives, and are more likely to have longer-term effects. Strengthened family and community contexts increase the capacity for community cohesiveness, thus activating a sense of meaning and purpose. This process, called collective efficacy, can be a lens through which to assess the contributions of federal and state policy investments, even when those policies do not directly target children. We use this lens to review major federal and state policies targeting social determinants of health, and the evidence regarding their effect, and describe how these policies and programs can strengthen family and community agency or purpose, and therefore can influence children’s development.
The social determinants of health (SDOH) model has become a powerful explanatory construct, a meta-explanation for how certain conditions and circumstances that surround individual growth and development are influenced by the distribution of wealth and resources at local, national, and even global levels. This construct has become a cornerstone for Healthy People 2020, and accords with the World Health Organization’s (WHO) Commission on Social Determinants of Health. A growing body of research identifies social factors as being at the root of many of the nation’s and the world’s health inequalities [2,3]. Because social determinants are relevant to all forms of disease, health status should be of concern to policy makers in every sector (such as housing, income, and education), and not only to those involved in health policy . There are other national and global calls for attention to inequalities in health and the need to strengthen health systems and relieve poverty by taking concerted action directly on the social determinants of health [3,4,5].
The SDOH model is important in its focus on global health for all individuals. We focus here specifically on children’s healthy development, and have selected one framework that is compatible with and builds on the SDOH literature—the Framework for Children’s Health Promotion, developed by Mistry et al. . The work of Mistry, concordant with Bronfenbremmer and others who looked at the relationship of social contexts to individual behavior [2,7,8,9], arises from the premise that early childhood has the potential to have long-term effects; therefore a crucial factor in optimizing health in this developmental period is building the capacities of families and communities, which includes access to community-based early childhood enrichment services (for example, early care and education, home visiting, and parent support programs) [10,11]. These capacities, in turn, build the foundations for lifelong health in early childhood, a premise promoted strongly by the Institute of Medicine in the Neurons to Neighborhoods report . The Mistry et al. framework (see Figure 1) explicitly links policies to their intended health outcomes by showing how the capacities of families and communities provide the foundation for ensuring optimal environments and experiences for children. Policies, such as those requiring seat belts, lead-free housing, minimum wages, and smoke-free environments, promote better health outcomes for children and families. This framework, which draws on the work of many others, including Chamberlin [13,14] and Shonkoff, Boyce, and McEwen , illustrates the importance of acknowledging that children exist within a system that is affected by multiple levels of influence [6,16].
Collective efficacy refers to the way in which social cohesion among families, communities, and/or neighborhoods activates a sense of purpose in intervening for a common social good . Rather than viewing neighborhoods as simply collections of individual attributes of specific people, collective efficacy suggests that social learning and self-efficacy activate a sense of purpose that strengthens the contexts in which individuals grow and thrive. For families with children, this social cohesion can be a very influential factor in children’s healthy development , because social cohesion creates safer environments.
Many health problems cluster together at the neighborhood and community level, as documented in studies by Sampson and others . These include child maltreatment, infant mortality, low birth weight, violence, and the risk of premature adult death. Concentrated poverty, family disruption, poor-quality housing, racial segregation, and residential instability are related to poor health outcomes; many of these are a result of decades-long federal policies and social injustices that still persist today . Experimental studies have found a direct association between social contexts and children’s physical and mental health [2,20,21,22]. The quality of these social contexts, when there is a sense of community agency or purpose, is collective efficacy. It provides a useful and intuitive way to think about how policies that target children’s ecologies may influence children directly, that is, how policies targeting social determinants may actually have their intended effect.
Practically speaking, collective efficacy asks the question, Can individuals work together to accomplish their shared goals? This question contains three components for consideration: (1) whether people want to work together and trust one another; (2) whether they have the shared knowledge of how to achieve their goals; and (3) whether they have access to the resources, both in time and money, to accomplish their goals. To the extent that communities are made up of families raising children, the answers to these questions affect the health and well-being of those children.
The concept of collective efficacy can be used to evaluate the potential for federal or state policies to affect children’s health, even when those policies do not directly address children’s health. This approach is consistent with the public health emphasis on the aforementioned social determinants of health framework adopted by the World Health Organization, as outlined in the United States Department of Health and Human Services’ Healthy People 2020 and the Centers for Disease Control’s Essentials for Childhood, and the work of the Maternal and Child Health Bureau and Health Resources and Services Administration’s Infant Mortality Collaborative Improvement and Innovation Network [3,23,24].
Because the Mistry framework and the explanatory idea of collective efficacy are based upon decades of empirical research, using this lens for assessing policies can help communities make empirically informed decisions about what investments will promote community prosperity and children’s health. In other words, policies and programs directed at adults can also benefit children, and thus improve the economic future of the country as a whole.
In the remainder of this paper, we provide examples of specific housing, social, and income policies and programs that have the potential to strengthen the
collective efficacy of families and communities, and thus strengthen the foundations of health for children and for the nation. These are (1) federal housing programs and policies that increase community capacity to provide improved housing conditions and strengthen family housing security through reduced-cost housing—specifically, the Moving to Opportunity for Fair Housing (MTO) demonstration program; (2) federal tax credit programs, such as the Earned Income Tax Credit program, a federal tax benefit for working people with low to moderate incomes; (3) federal and state income-supplementation programs aimed at lifting families out of poverty and employment benefits policies (for example, maternal and paternal leave) that strengthen family contexts; (4) block grants supporting maternal health, child care, and parenting; and (5) federal and state programs supporting two-generation social policies.
HUD sponsors a number of programs that provide housing assistance to low-income households: vouchers (i.e., housing vouchers for the private market), project-based rental assistance (i.e., subsidized rent in privately owned buildings), and public housing (i.e., subsidized rent in publicly owned buildings). There are also several HUD programs that seek to increase community capacity to provide improved housing conditions, and strengthen family housing security through reduced-cost housing. For example, neighborhood revitalization programs, such as the Choice Neighborhoods program, fund locally driven strategies to address struggling neighborhoods through a comprehensive approach to neighborhood transformation. The Choice Neighborhoods program addresses not only housing, but also people (for example, employment) and neighborhoods, via collaborative partnerships among local leaders, residents, and other stakeholders, such as business owners, city agencies, nonprofit organizations, private developers, public housing authorities, schools, and police . This type of comprehensive, collaborative program may be ideal for promoting healthy development in children because it reinforces the collective work that adults within neighborhoods can do, in a shared way, to improve the living conditions for the entire population.
Another program aimed at strengthening family housing security and capacity is the Moving to Opportunity for Fair Housing (MTO) demonstration program. Research findings from the 10-year demonstration provide data on how improving families’ socioeconomic environment has a direct and substantial effect on their health (for example, fewer asthma attacks and injuries) and behavioral outcomes (such as lower levels of violent offending among juveniles), including improvement in the general health status and mental health of household heads [21,26,27,28], as well as increased earnings later in life for children moving to these less-impoverished neighborhoods before the age of 13 . Interestingly, some negative effects of MTO were reported by sex (relocation to a more stable environment had negative effects on boys, owing to differences in social adaptability) . With respect to educational outcomes, some studies have shown that housing policies that increase access to already high-performing, low-poverty schools (rather than investing in high-poverty schools to bring them up to low-poverty levels) can help boost children’s educational outcomes .
Programs such as the MTO demonstration program can be seen not just as a way to improve the availability of safe and affordable housing—one of the building blocks of healthy child development—but also as contributing to future prosperity because of the documented effects on both child development and education. For underresourced communities in particular, the private sector has little incentive to take responsibility for community development, thus leaving families, as well as entire neighborhoods, without access to safe and affordable housing, and promoting an individualistic response (i.e., everyone for themselves). Programs such as MTO enhance the capacity for collective action and instill a sense of community purpose, thus potentially mobilizing collective efficacy.
The Earned Income Tax Credit (EITC) is a federal benefit for working people with low to moderate incomes; 26 states and the District of Columbia also have state-level EITC programs. Income and family size determines the amount of the EITC. (See https://www.eitc.irs.gov/eitc-central/about-eitc/income-limits-and-range-of-eitc/income-limits-and-range-of-eitc for income limits and ranges of earned income tax credits.) The goal of the program is to encourage and reward work, offset federal payroll and income taxes, and raise living standards. EITC is one of the largest antipoverty government programs: in tax year 2015, more than 27 million people received about $67 billion in EITC , and the average amount of EITC paid out (for tax year 2015) was more than $2,455 per claim. The program has a high participation rate; four of five people eligible for the EITC claim it .
Recent research shows that EITC and the Child Tax Credit, another IRS program, greatly reduce poverty for working families. Combined, these working family credits lifted nearly 10 million people out of poverty—including 5 million children (2013 data), and made more than 20 million other people less poor . The EITC expansions of the 1990s appear to be the leading single factor explaining female family heads’ increased employment between 1993 and 1999, lifting families out of poverty . For children raised in families receiving the higher levels of EITC under the 1990s expansions, birth outcomes, such as premature birth and birth weight, were better, compared with birth outcomes for families receiving the lower levels of EITC . In addition, educational gains have been reported for families receiving higher levels of EITC; studies have found that children in low-income families that received larger state or federal EITCs score better on reading and math tests, compared with children from largely similar families that do not receive large credit expansions. These children are more likely to finish high school and attend college .
These tax credit programs enable families to have sufficient resources to live, work, and engage in their communities in meaningful ways, thus activating a sense of community agency or purpose. This contributes to children’s healthy development and their future possibilities.
Health outcomes are highest in states with minimum wage laws and higher tax credits for the poor . States with more generous levels of Temporary Assistance for Needy Families (TANF) also show better child health outcomes . Income supplementation to parents is associated with decreases in children’s behavior problems . One experimental study showed that an additional $4,000 per year for the poorest households increased educational attainment by age 21 and reduced having ever committed a minor crime at ages 16-17 by 22 percent. Further, evidence suggested that improved parental quality was a likely mechanism for the change [40,41]. Another income supplement
intervention that moved families out of poverty reported major effects on children’s conduct and oppositional disorders, but not anxiety and depression . This income augmentation occurred when a casino was built, affecting some families participating in an ongoing longitudinal study of children’s psychiatric disorders. This naturalistic experiment thus enabled the research team to assess the effect of income supplementation on the developmental course of children’s mental disorders.
Employment benefits to parents in the form of paid or unpaid maternity leave, paternity leave, or family and medical leave allow one or both parents to stay at home with young children during a critical period in their growth and development. This paid leave affects not only children’s physical health and mental health, but the physical health and mental health of their mothers and fathers. Although longitudinal studies have not been conducted on the effect of paid maternal leave on children, a recent research review (including international studies) suggested that paid maternity leave provided maternal health benefits, though these benefits varied, depending on the length of leave . This finding was echoed in a U.S.-based study that showed that policies supporting longer family leave benefit maternal mental health [44,45,46]. Likewise, longer paternity leaves and increased time fathers spend caring for their very young children is associated with their children’s higher cognitive test scores [47,48], and there is some evidence for improved child mental health outcomes as well .
Finally, although research conducted on the effects of unpaid maternity leave taken under provisions of the Family and Medical Leave Act show positive effects on the health of very young children , most low-income, unmarried mothers cannot afford to take this unpaid leave, although TANF can be used as a kind of maternity leave [51,52]. Even in the face of nearly two decades of research and numerous studies showing that dedicated parental time with their young children in the earliest months of life confers significant benefits to child health, the United States is the only first-world country without a formal national policy providing employees paid time off when they become new parents .
Like the tax credit and the housing policies and programs, these income and employment supports reduce some of the social determinants of compromised health and, importantly, improve the opportunities for families and communities to develop a sense of shared meaning and purpose. With a safety net of basic income to meet their immediate needs, communities can thus focus on building neighborhood capacity to handle setbacks and crises when they occur. Thus, these income supplementation and employment benefit policies and programs create the conditions for establishing the shared values that define collective efficacy.
The Title V Maternal and Child Health block grant  supports policies and programs in every state that promote healthy families, positive parenting, and community conditions that improve the health of women, infants, children, and youth. Funded in 1935 as part of the Social Security Act, the Title V block grant requires a statewide needs assessment, family and community engagement, and performance measurement to track program [55,56] and policy implementation and outcomes. Most of the funds in states are spent on systems-level development of programs and policies that support healthy behaviors and community/state programs that promote better health of children and families. Under this federal law, one-third of the funds must be spent on children and youth with special health care needs, and one-third must be spent on preventive and primary care for children . The Title V program has had a legacy of program accomplishments for children and families since its inception in 1935 . In addition, funds from the federal Title V support multidisciplinary training programs, such as the Leadership Education in Neurodevelopmental and Related Disabilities, to improve the health of infants, children, and adolescents with disabilities.
The Child Care and Development Block Grant (CCDBG) allows each state to develop child care programs and policies that best match the needs of the parents in their states, and improve the quality of child care, via federal benchmarks, for low-income families . Importantly, the CCDBG promotes parental choice that empowers working parents to make their own decisions regarding the child care services they choose. Proposed changes to this program would provide low-income parents a choice, via a stay-at-home subsidy, about whether to work or stay home with their child, which promotes the opportunity for them to have meaningful roles in their communities, thus supporting a personal sense of competence that affects their parenting practices .
The Maternal Infant Early Childhood Home Visiting (MIECHV) federal program, which is authorized under Title V of the Social Security Act , along with the Maternal and Child Health block grant, promotes child and family development through its home-visiting program, which includes evidence-based parenting information for new families. MIECHV provides states with funds for identified evidence-based nurse home-visiting models (17 approved in 2017) from which to choose to promote positive outcomes for at-risk families in their states . These programs provide direct in-home services, supports, and resources and referrals to families. Home-visiting programs can improve outcomes for low-income, unmarried mothers for up to 15 years after the birth of the first child, including reductions in the number of subsequent pregnancies, the use of welfare, child abuse and neglect, and criminal behavior . A recent mediation reanalysis of the mechanisms by which nurse home visitation led to reductions in substantiated child maltreatment found that these outcomes can be partly explained by the program’s positive effects on maternal outcomes, including pregnancy planning and economic self-sufficiency .
These block grants focus on strengthening parenting capacities by providing education, training, and services (child care), thus enabling parents to work and to engage in meaningful roles in their communities. Moreover these grants provide special supports for the most vulnerable children (i.e., low-income, developmentally disabled). Families receiving high-quality child care and evidence-based parenting programs are more likely to be able to remain employed, and their children are more likely to be ready for school; new data shows improved school readiness for children of families receiving services through home-visiting programs . Supporting parents thus helps support communities by positively affecting schools, public safety, and neighborhood development.
Research shows that states where the ratio of social service and public health spending to health spending (sum of Medicare and Medicaid spending) is higher have better health outcomes for their population; this includes improved rates of obesity, asthma, mortality, and mentally “unhealthy days” . These findings are compatible with the development of what are called two-generation social policies . This approach is based on research demonstrating how conditions that affect parents, families, and communities also influence children’s development, and that this is a bi-directional influence. For example, since parenting capacities can be reduced by parents’ physical and mental health problems, health insurance for parents affects the well-being of their children. From the other direction, children’s experience of stable, high-quality early care and education supports both children’s early learning and parents’ work effort. This two-generation approach is being debated within state legislatures . Other federal and state health initiatives designed to improve adult health include “place-based” initiatives (such as Promise Neighborhoods and Best Babies Zone). These are designed to create a community environment that promotes and protects the health of adults, and simultaneously create healthier communities [69,70,71].
These programs, along with the examples from housing, tax credit, income supplementation, and parenting supports, exemplify ways in which children’s healthy development is promoted by policies or programs that are not child focused, but rather address the social determinants of health and that by virtue of the assistance provided to families and communities have far broader effects, mobilizing a sense of purpose and engagement, thus strengthening the possibilities for children’s healthy development.
Policy makers, researchers, and program officials concerned about healthy child development, future adult health and productivity, and societal prosperity should focus their attention on policies and programs that support the foundations of children’s health. One way to do so is to pay particular attention to those initiatives that strengthen the contexts for children—their families and their communities. This includes looking closely at policies not typically involved in debates about children’s health issues, such as housing, income supports, and employment benefits, as well as two-generation approaches. Policy makers may want to pursue design-oriented thinking to assess the value of new initiatives, not only in terms of costs and immediate benefits, but also in terms of potential effect on neighborhood and communities’ sense of purpose—in other words, their collective efficacy. This should be considered a component of the Health in All Policies approaches [22,72].
Rebecca Solnit, in Hope in the Dark , says, “[W]e write history with our feet and with our presence and our collective voice and vision.” Although the pace of change—especially for initiatives that operate at larger system levels such as neighborhoods and communities—can be slow, it may be useful to recall that the past three decades of progress in health services occurred less as dramatic transformations and more as small, focused, and incremental steps toward a shared goal. Social progress is often invisible because it proceeds incrementally. National and state policies and programs that enhance community efforts to change social environments, rather than change people, are likely to have the longest-term positive effect on healthy child development with additional downstream improvements in adult health and communities. In a 2001 report, the National Academies of Science, Engineering, and Medicine recommend exactly this broader approach . We urge a concerted focus on broad social policies targeting families and communities that can increase the capacity for collective efficacy and thus promote healthy child development. A concerted focus on broad social policies targeting families and communities should be strongly considered to increase the capacity for collective efficacy and thus promote healthy child development.
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By investing in communities and neighborhoods, we support the health, productivity, and future potential of our children: http://ow.ly/ybPX30jodfD #childrenshealthforum #investinkids #childrensforum
Children’s health is not just about health care. We must also invest in the communities and neighborhoods where they grow up: http://ow.ly/ybPX30jodfD #childrenshealthforum #investinkids #childrensforum
Collective efficacy is how social cohesion among families and communities activates a sense of purpose in intervening for a common social good, and is critical in ensuring children’s health and prosperity: http://ow.ly/ybPX30jodfD #childrenshealthforum #investinkids #childrensforum
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“America, the land of opportunity” has been the historical rallying cry inspiring individuals to work their hardest to succeed. Although today’s children will determine our nation’s future prosperity, scientists have repeatedly demonstrated that individuals are rarely able to fully determine their own destiny—especially in matters of health and well-being. Decades of research have shown that children’s physical health, mental health, and well-being are significantly influenced by the states, communities, neighborhoods, and families in which they live (see Figure 1) , and that reducing investments to these infrastructures may be done at the expense of children’s health. Our nation’s increased investments in health over the last 10 years have resulted in improvements in health and reductions in the prevalence of chronic diseases, obesity, and asthma . These investments have also resulted in positive community-wide shifts in health, resources, opportunities, and norms. Yet there is a call for investments in other domains. Sustained and expanded investments in the contexts that surround and nurture children are needed to promote the health and well-being of children across the United States. Thereby, these investments ensure our nation’s long-term prosperity.
Quite simply, environmental contexts either foster healthy behaviors and relationships or, conversely, increase children’s risk for poor outcomes. For the last 40 years, scientists have repeatedly and rigorously experimented to identify efficacious and cost-effective intervention approaches. Investments in these evidence-based programs and policies support families and communities so that children’s development and lifelong productivity increase. Likewise, policies and programs that directly reduce adverse social risks, such as community violence, improve the health and well-being of children and parents .
At this time, policy makers are challenged to choose how, and in what, to invest for America’s future. With investments that provide access to basic resources, supportive environments, and nurturing interpersonal relationships, children will thrive, and their capacities increase developmentally with age—ultimately leading to healthy families, a vital workforce, and strong communities. However, research has shown that even short-term reductions in foundational investments in children, families, and communities can have broad, sustained, and negative consequences for children’s health and their parents’ productivity and employment . The country has already seen examples of the consequences of such shortsightedness: the children and families of Flint, MI, will spend their lives trying to undo the poisoning conferred from one year of cost-saving on water.
While the benefits of investments in health clearly result in better health, investments in community infrastructure also yield better health outcomes. Epidemiological researchers have demonstrated that when basic structures are missing in a community—for example, affordable housing—there is a significant increase in a community’s homelessness and mental health burden, as well as children’s problematic school behaviors . If housing and case management are provided to homeless families, as was demonstrated in New York City several years ago, these challenges disappear . Investments in affordable housing and supports for homeless families should be considered as we face the fact that 2.5 million families are expected to be homeless this year . Also, factors such as parental unemployment and job instability affect health outcomes for children. Thus, providing employment supports improves children’s outcomes and reduces maternal depression . Even when states merely enact minimum wage laws and provide tax credits for the poor, population health is better than in states without such laws . Therefore, limiting investments in community infrastructure is one example of toxic community stress that sets children on a trajectory of poor health into adulthood, threatening national prosperity.
Similarly, investments in the education system contribute to improved lifelong health and long-term workforce productivity . Toxic stress experienced by children and families—from the daily challenges of poverty, institutional racism, trauma, and community violence—is linked to mental health disorders and poor health outcomes. Investments made in education—including professional learning opportunities for educators, early care and education programs, school mental health clinics and support services, and school/classroom environment—can buffer the stress that many families experience. These investments also help to engage children who are frequently absent from school, thus, increasing graduation rates. An educated workforce leads to stronger workforce engagement and improved health over the life course. Likewise, investments in mental health systems may provide quality care and access to the 55 percent of American communities that lack mental health providers . If there are cuts to education or mental health care, the most affected will be children who face daily stresses—and these are the children for whom we should instead be making the greatest investments.
Thus, current investments in community infrastructure, as well as in health and education systems, forecast a future in which our nation’s prosperity can soar, particularly if we expand these investments in communities that serve low-income families and children. Failing to sustain these investments will result in an unprepared and unhealthy workforce and citizenry, and will lead to unintended consequences for our national prosperity. Now is the time for scientists to inform legislators and policy makers about evidence-based interventions, strategies, and tools that can be integrated in communities and implemented with fidelity to improve children’s physical and mental health outcomes. In addition, policy makers must consider the significant, long-term consequences of community cost-cutting initiatives that may strip away key community infrastructure for children and families, crippling the nation.
Regarding the health and well-being of children and families, the evidence is clear: when basic family supports and community infrastructures are damaged or weakened, the next generation suffers from broad, lifelong, negative consequences. It is critical that policy makers, scientists, and program administrators recognize the lessons of the last 40 years: thoughtful national, statewide, and community-level investments in prevention, health care, housing, education, employment, and anti-poverty programs have paid off for America. The country need to continue and expand scientifically supported investments to ensure future prosperity.
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Investing in the health of our children means not only providing for their medical needs, but their mental health, housing stability, access to food, and feeling of overall safety: http://ow.ly/8cRy30j9E7S #investinkids #childrenshealthforum #childrensforum
“If there are cuts to education or mental health care, the most affected will be children who face daily stresses – and those are the children for whom we should instead be making the greatest investments”: http://ow.ly/8cRy30j9E7S #investinkids #childrenshealthforum
Investments in education, including early and after-care programs and mental health support systems, can counteract long-term and toxic stress that children in unstable communities may face: http://ow.ly/8cRy30j9E7S #investinkids #childrenshealthforum #childrensforum
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The National Academy of Medicine’s President, Victor J. Dzau, has authored three editorial pieces on promoting research as a crucial first step to developing effective policies.
Below are highlights from each of the three editorials.
Good Gun Policy Needs Research – Science
March 16, 2018
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Co-authored with Dr. Alan Leshner, CEO emeritus of the American Association for the Advancement of Science, Drs. Dzau and Leshner state that “It’s time to stop the polarized ‘debates’ that lack a science base and turn our energies toward constructive, informed examination.” They cite the 2013 IOM/NRC report Priorities for Research to Reduce the Threat of Firearm-Related Violence and a 2018 publication by RAND Corporation on The Science of Gun Policy as existing research roadmaps that could be utilized to guide said research. Read the editorial>>
Public Health Research on Gun Violence: Long Overdue – Annals of Internal Medicine
March 20, 2018
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Co-authored with Dr. Alan Leshner, Drs. Dzau and Leshner call for the reinstatement of funding to support research into gun violence. They state, “It is time to bring the full power of science to bear to deal with this issue of such great concern to our country. We need researchers from different disciplines, including public health, social and behavioral sciences, mental health, and law enforcement, to work together to tackle this problem.” Read the editorial>>
Congress hasn’t banned research on gun violence. It just won’t fund it. – The Washington Post
March 21, 2018
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Co-authored with Dr. Mark Rosenberg, the founding director of the National Center for Injury Prevention and Control at the Centers for Disease Control and Prevention, Drs. Dzau and Rosenberg urge Congress to include funding for gun violence research in this year’s federal budget. They state that, “… viewing gun violence as a public-health problem worthy of research has a lot to offer, and can provide a way forward that brings together advocates on both sides of the gun violence debate.” They also note Rep. Jay Dickey’s (R-Ark.) amendment that has effectively curtailed federal funds being made available to support research into gun violence. “After the July 2012 mass shooting at a movie theater in Aurora, Colo., Dickey called for an end to the de facto freeze on federal gun research. … Dickey died in 2017, but we agreed with his call to action six years ago, and we know he would agree with us now that Congress should act to fund research into gun-violence prevention.” Read the entire editorial>>
Additional Resources from the National Academies:
The National Academy of Medicine (NAM) today launched the Clinician Well-Being Knowledge Hub, a comprehensive online repository for health system leaders, clinicians, and trainees that contains resources highlighting promising approaches for combating clinician burnout, such as research and news articles, toolkits, peer-reviewed literature, and reports.
More than half of U.S. physicians experience burnout, a syndrome characterized by a high degree of emotional exhaustion, depersonalization, and a low sense of personal accomplishment at work. Nurses, dentists, pharmacists, and other health care professionals are also experiencing high rates of burnout, putting an unsustainable strain on the health care system.
Improving clinician well-being requires sustained action at the organizational, state, and national levels. This knowledge hub provides a comprehensive overview of the causes of clinician burnout; its consequences for health care professionals, patients, and their families; and innovative approaches that organizations can take to promote well-being.
“While challenges to promote clinician well-being are numerous, progress is possible. The NAM is proud to launch the Clinician Well-Being Knowledge Hub,” said National Academy of Medicine President Victor J. Dzau. “Our hope is that the knowledge hub will facilitate communication and learning, share promising solutions, and will encourage leaders to critically think about how burnout affects their organizations and to implement the solutions that are right for them.”
To explore the knowledge hub, visit nam.edu/ClinicianWellBeing.
Launched in 2017, the Action Collaborative on Clinician Well-Being and Resilience is a network of organizations committed to reversing trends in clinician burnout, with the goals of raising the visibility of clinician burnout, improving understanding of challenges to clinician well-being, and elevating evidence-based, multidisciplinary solutions that will improve patient care by caring for the caregiver. The Action Collaborative will host a public meeting on May 2 in Washington, D.C. The meeting will feature Expressions of Clinician Well-Being, a pop-up art exhibition focused on clinician well-being.
The National Academy of Medicine, established in 1970 as the Institute of Medicine, is an independent organization of eminent professionals from diverse fields including health and medicine; the natural, social, and behavioral sciences; and beyond. It serves alongside the National Academy of Sciences and the National Academy of Engineering as an adviser to the nation and the international community. Through its domestic and global initiatives, the NAM works to address critical issues in health, medicine, and related policy and inspire positive action across sectors. The NAM collaborates closely with its peer academies and other divisions within the National Academies of Sciences, Engineering, and Medicine.