Dr. Jeffrey Brenner—MacArthur Foundation genius award winner, founder and executive director of the Camden Coalition of Healthcare Providers, and best known for the “hotspotting” concept—made a powerful assertion (reported on this site by Jane Stevens) in a recent essay: The ACE Study is “the secret to delivering better care at lower cost in America.” Why in the world would we not embrace a tool that holds the secret to solving the thorny and complex problem of rising costs with the added benefit of improved health?
Brenner tackles that question: He describes how the medical community has neglected the ACE Study, which reflects poor training of medical professionals and societal biases on health and healthcare. The reason why is nothing short of a “huge cognitive bias” against discussing early life trauma, addiction, and mental illness across society, which affects medical practice, health care reform and general attitudes toward health and healthcare, according to Brenner.
Even though the ACE Study was conceived and executed in a medical setting by a primary care physician, it remains “hidden away in the medical literature, and barely mentioned among physicians,” according to Brenner. He doesn’t want the ACE Study to be just known to the medical community; he believes that “Ace scores should become a vital sign, as important as height, weight, and blood pressure.”
So how do we get to the place where early life trauma, addiction, and mental illness are freely discussed and recognized for their impact on health?
Brenner suggests that we “need more trauma victims to publicly discuss how their early life experiences have impacted their life and their health…” and lift the stigma surrounding these experiences. Social media, including public sites like AcesTooHigh.com and the social network AcesConnection.com, provide a means for these stories to be told. Public information campaigns such as the one launched by the New York City Chapter of the National Alliance on Mental Illness (NAMI), I will listen, can also be effective ways to dispel myths about mental illness through personal story telling.
Brenner also believes that physicians have a key role to play in bringing adverse childhood experiences out of the shadows and into the sunshine so that healing can take place. He believes that more physicians need to talk publicly about the importance of the issue. There also is a need for research on “ways to bring ACE scores into routine primary care,” notes Brenner. Bringing ACE scores into clinical practice will be challenging, especially because physicians—including Brenner in the early days of his career—don’t want to open a door to issues they don’t have the time or training to deal with.
Physician readiness to incorporate ACE scores into clinical practice is only one, albeit essential, step in the process. The structure of physician practices also will have to change. Healthcare delivery system reforms—encouraged but not mandated in the Affordable Care Act—must be adopted on an accelerated timetable. The expanded use of multi-disciplinary teams to improve healthcare such as those employed by the Camden Coalition of Healthcare Providers is one promising approach. By utilizing the skills of nurse practitioners, community health workers, and social workers, the Camden Coalition is making inroads into reducing the costs and improving outcomes for high-cost complex patients.
As other promising approaches in healthcare such as patient-centered primary care, collaborative care and other holistic approaches gain traction, physicians may be more receptive to the introduction of ACE scores into clinical practice. If the healthcare system provides incentives to improve and measure outcomes, a broader view of caring for the whole person becomes essential.
Further, a real impediment to dealing with early life trauma is how the fields of primary care, mental health, and addiction exist in silos that are difficult to bridge. It is a hopeful sign that Brenner believes that primary care has a lot to learn from behavioral health (the wider use of this term to describe mental health and substance abuse may be a sign that there is growing recognition of the interconnectedness of the two fields.) In a recent interview, he said, “The different tiered interventions provided in behavioral health and ways to engage patients are really remarkable.”
One of those innovative models is Assertive Community Treatment (ACT) teams that bring care to seriously mentally ill people in the community. In a recent letter to the New York Times, the new executive director of NAMI, Mary Giliberti, described the example of an ACT program in Rochester, NY, that led to savings of approximately $40,000 per person compared to hospital or jail costs. Brenner says his community-based team approach for high healthcare utilizers is similar to ACT teams with similar concepts being applied in a different environment. Brenner also strongly recommends the inclusion of “behavioralists” on all healthcare teams.
In a 2011 Frontline interview, Brenner said: “And there are so many ways that illness manifests. It manifests as diabetes and hypertension and headaches and back pain and knee pain, but the common denominator to all that is stress. When people feel like their life is out of balance, when they feel like their life is out control, that they can't change their life circumstance, that's an overwhelming feeling.”
He acknowledges that you can’t solve all the problems people have but if you want to tackle healthcare costs, you have to look beyond the examining table. If a family lives in a rat-infested apartment, it will be difficult, if not impossible, to control asthma. If the family is homeless, healthcare dollars won’t make it a healthy one.
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