HEALTH AND SAFETY

America's Weight Problem

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Almost one-third of children and two-thirds of adults in the U.S. are overweight or obese, conditions that have been linked to chronic medical problems such as diabetes, hypertension, and cardiovascular disease. Nearly 21 percent of U.S. annual medical spending is directed to obesity-related diseases; childhood obesity alone accounts for than $14 billion in direct medical costs.

America has been too slow in arresting its obesity epidemic, says Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation. Addressing this complex, stubborn problem requires a comprehensive set of solutions that work together to spur across-the-board societal changes.

The report focuses on five critical goals for preventing obesity: integrating physical activity into people's daily lives, making healthy food and beverage options available everywhere, transforming marketing and messages about nutrition and activity, making schools a national focal point for obesity prevention, and galvanizing employers and health care professionals to support healthy lifestyles. More than 800 obesity prevention recommendations were assessed to identify those that could work together most effectively, reinforce one another's impact, and accelerate obesity prevention.

Strategies are identified with the greatest potential to speed success by making healthy foods and beverages and opportunities for physical activity easy, routine, and appealing aspects of daily life. For example, the report says, 60 minutes per day of physical activity in schools and increased availability of lower-calorie, healthier options for children in restaurants are two important ways to accelerate change.

The Institute of Medicine study was funded by the Robert Wood Johnson Foundation.

More Bang for Health Care Dollars

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The U.S. spends considerably more on health care than other industrialized nations. However, about 30 percent of U.S. health spending in 2009 -- roughly $750 billion -- was wasted on unnecessary services, excessive administrative costs, fraud, and other problems. Moreover, inefficiencies cause needless suffering. By one estimate, roughly 75,000 deaths in 2005 might have been avoided if every state had delivered care at the quality level of the best performing state.

The fact is, the nation's health care system has become too complex and costly to continue business as usual, says Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Achieving better, more affordable care will require system-wide changes that marshal advances in science and technology to help transform the U.S. health system into a "learning" system -- one that improves through transferring knowledge from every care experience and new research discovery.

Better use of data is a critical element of a continuously improving health system, the report says. The health care system needs to embrace new technologies to collect and tap clinical data at the point of care and engage patients and their families as partners. Mobile technologies and electronic health records offer significant potential to capture and share health data better.

In addition, health economists, researchers, professional societies, and insurance providers should work together on ways to measure quality performance and design new payment models and incentives that reward high-value care. Increased transparency about the costs and outcomes of care also boosts opportunities to learn and improve and should be a hallmark of institutions' organizational cultures.

The Institute of Medicine study was funded by Blue Shield of California Foundation, Charina Endowment Fund, and Robert Wood Johnson Foundation.

Treating PTSD in the Military

U.S. Army photo by Spc. Angelica Golindano

Blast injuries and posttraumatic stress disorder have been called the "signature injuries" of the wars in Iraq and Afghanistan, with recent estimates of PTSD among deployed service members at around 13 percent to 20 percent. Congress asked the Institute of Medicine to examine the military's ongoing efforts in treating PTSD.

The U.S. departments of Defense and Veterans Affairs offer many programs and services for PTSD, but treatment isn't reaching everyone who needs it, concludes Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Initial Assessment. DOD and VA should ensure that service members and veterans who have PTSD have timely access to evidence-based care.

Of the U.S. service members and veterans who have served in Iraq and Afghanistan and screened positive for PTSD symptoms, about 40 percent have received a referral for additional evaluation or treatment, and of those referred, about 65 percent go on to receive treatment, the report notes. Although DOD and VA are making efforts to reduce barriers to care, many obstacles remain. For example, patients may not seek care because of concerns that doing so will adversely affect their military career or because they need to travel long distances to reach a mental health provider. And providers might find it difficult to treat patients because of lack of training or time or location issues.

DOD and VA should track better the treatments that are given to patients as well as their outcomes. The departments should also institute research to evaluate the effectiveness of their PTSD programs and services and disseminate the findings widely. The report adds that PTSD screening should be conducted at least once a year for service members and veterans.

A second phase of the study, due in 2014, will evaluate the success of specific programs and services used to treat PTSD.

The Institute of Medicine study is being funded by U.S. Department of Defense.

Substance Abuse and Mental Health

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Many Americans find it difficult to receive proper treatment for substance abuse and mental health disorders. Two reports by the Institute of Medicine examine the scope of these conditions among two segments of the population: older Americans and military service members.

The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? says that unless there is a major effort to significantly boost the number of health professionals and other service providers able to supply care for mental health and substance misuse or abuse, millions of baby boomers will likely face difficulties getting diagnoses and treatment as the population ages. Nearly one in five older Americans has one or more of these conditions, which, left untreated, can result in higher medical costs and poorer health outcomes.

The U.S. Department of Health and Human Services leadership needs to promote national attention to building a sufficient, well-trained work force to meet the growing demand, the report says. Organizations that accredit health and social service professional schools and license providers should ensure that all who see older patients -- including primary care physicians, nurses, and social workers -- are able to recognize signs and symptoms of mental health conditions, neglect, and substance misuse and abuse and provide at least basic care.

The report calls for a redesign of Medicare and Medicaid to guarantee coverage of counseling, care management, and other types of services crucial for treating mental health conditions and substance use problems.

A similar situation hampers care for military service members dealing with problems related to misuse or abuse of alcohol and other drugs, according to Substance Use Disorders in the U.S. Armed Forces.

Although data show prescription drug misuse and binge drinking among military members are on the rise, TRICARE -- the military's health insurance provider -- does not cover several evidence-based treatments that are now standard practice, including long-term use of certain medications for the treatment of addiction. It also does not cover treatment delivered in settings other than specialized rehabilitation facilities. TRICARE's benefits should be revised to cover maintenance medications and treatment in office-based outpatient settings delivered by a range of qualified providers.

Military health care professionals at all levels need training to recognize patterns of substance abuse and misuse as well as clear guidelines for referring patients to specialists, the report says. The U.S. Department of Defense should promote care provided by a multidisciplinary team with carefully prescribed roles and training, to include office-based outpatient providers. This approach could help alleviate the provider shortage created by the military's reliance on specialty clinics.

The armed forces should promote more effective prevention strategies, moving away from a permissive attitude toward alcohol by enforcing regulations on underage drinking and reducing the availability of alcohol on bases. They should also work to ease the stigma that deters service members from seeking care. Including screening and intervention services within primary care would help achieve this goal and increase the number of places where service members and families can receive basic care for these problems.

Both studies were funded by the U.S. Department of Health and Human Services; Substance Use Disorders in the U.S. Armed Forces was also funded by the U.S. Department of Defense.

Geographic Adjustments to Medicare Payments

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Medicare is the largest payer of health care services in the U.S., spending about $525 billion annually. Although Medicare is a national program, it adjusts payments to hospitals and health care practitioners according to the geographic location in which they provide service, acknowledging that the cost of doing business varies around the country. Federal law requires geographic adjustments to be budget neutral, meaning any increase in the amount paid to one hospital or practitioner must be offset by a decrease to others so that national payment remains level. In 2011 an Institute of Medicine report recommended changing the way that Medicare payments are adjusted to account for these regional differences.

A second report, Geographic Adjustment in Medicare Payment, Phase II: Implications for Access, Quality, and Efficiency, says that the proposed recommendations would also improve the technical accuracy of Medicare payments, which would increase or decrease by less than 5 percent on average for the majority of hospitals and most physicians. However, those seemingly small percentages could make significant differences to certain providers and organizations, the report adds.

Given the relatively modest payment changes that would occur in many regions and given that geographic adjustments are only one factor in setting Medicare reimbursements, revising these calculations may not have a significant overall impact on the distribution of providers and on improving care access and quality in medically underserved areas, the report says. It offered several strategies that would be more effective at boosting access to care than geographic payment adjustments.

The Institute of Medicine study was funded by the Centers for Medicare and Medicaid Services, U.S. Department of Health and Human Services.