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News and Notes   |    
Poor Scores for U.S. Health and Mental Health Care Systems on New National Scorecard
Psychiatric Services 2006; doi: 10.1176/appi.ps.57.12.1840
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A new report on U.S. health care shows that the system falls far short of what it could achieve. On a national scorecard of 37 indicators, the overall score was 66 out of 100, with wide gaps between the best and worst states. The findings indicate that improved performance in key areas would save an estimated 100,000 to 150,000 lives annually and $50 to $100 billion in health care spending.

"The National Scorecard on U.S. Health System Performance" was developed by the Commonwealth Fund, a private U.S. foundation established in 1918 to promote high-quality health care. In 2005 it created the Commission on a High Performance Health System, which developed a set of 37 quality indicators built in part on measures previously developed by organizations such as the National Committee on Quality Assurance. For each indicator, a benchmark rate was identified from rates achieved by top countries or by the top 10 percent of U.S. states, hospitals, health plans, or other providers. A score of 80 was defined as adequate care. By showing the gaps between national performance and benchmarks, the scorecard provides targets for improvement.

The scorecard includes one indicator specifically targeting mental health care: "Needed mental health care and received treatment." The average U.S. score was 66. Only 47 percent of adults who needed care received treatment in 2003. For children with a current emotional, developmental, or behavioral condition requiring treatment, 59 percent received treatment. Thirty-four percent of children with no insurance received treatment, compared with 63 percent of those with private insurance. Large percentages of adults did not have a follow-up visit within 30 days of discharge from a psychiatric hospitalization—46 percent of Medicaid patients, 39 percent of Medicare patients, and 24 percent of privately insured patients.

Scores on the five overall dimensions of health care examined by the scorecard were as follows: long, healthy, and productive lives, 69; quality, 71; access, 67; efficiency-value, 51; and equity, 71. In the area of long life, the United States ranks 15th among 19 industrialized countries in the prevention of deaths that are "amenable to treatment." Reducing U.S. mortality to the benchmark level would mean 88,000 fewer deaths per year. The U.S. infant mortality rate is the highest of 23 ranked countries; reducing infant mortality to the benchmark rate would mean 17,000 fewer deaths.

In the area of quality of care, although 79 percent of children receive five key vaccines, only 49 percent of adults receive recommended periodic clinical screening tests. Data from the scorecard indicate that lack of hospital discharge planning may be the norm rather than the exception. In the dimension of access to care, lack of insurance led to low scores. The United States is the only industrialized nation that fails to guarantee universal health insurance. According to the scorecard report, 61 million adults aged 19 to 64—or 35 percent of this age group—were uninsured or underinsured in 2003.

The lowest score in any of the five dimensions—51 for efficiency—indicates that Americans are getting a low return on their health dollar investment. Despite devoting far more of its economic resources to health care than other countries, the U.S. ranking on quality-of-care indicators is remarkably low, the report notes. The report cited a recent survey indicating that 23 percent of adults who kept a medical appointment found that their medical records and test results were not available, which often led to repeat tests. Unnecessary use of the emergency department is four times higher than in countries with better access to community care. U.S. costs of administering private health insurance have increased by 75 percent over the past five years. As a portion of national health expenditures, the U.S. devotes 7.3 percent to administration of insurance programs—the highest rate of the 11 countries ranked on the scorecard, about three times the Canadian rate and twice the rate in the United Kingdom.

Describing the overall U.S. health care picture as one of "missed opportunities," the report calls for many changes, including universal coverage, improved prevention and primary care, and national goals for improvement. The 32-page report, Why Not the Best? Results From a National Scorecard on U.S. Health System Performance, is available at the Commonwealth Fund Web site at www.cmwf.org. The findings are also discussed in a Health Affairs Web exclusive at www.healthaffairs.org.

NMHA policy position statements: The National Mental Health Association (NMHA) has released four renewed policy position statements to guide its national network of affiliates in promoting informed policies. The statement on psychiatric advance directives outlines their benefits and offers recommendations to state governments and community stakeholders for developing legislation and programs. The statement on mental health parity in health insurance presents the case for comprehensive parity legislation along with a history and supporting research. The statement on standards for management of and access to consumer information recommends consumer protection standards for managed care and government programs, health care providers, and insurance companies. The statement on the federal role in children's mental health services lays out the disparities in care that put children and families at risk of mental health problems and outlines strategies for increasing federal interagency collaboration, educating the public, and promoting prevention and early intervention services. The full statements are on the NMHA Web site at www.nmha.org.

NAMI's online discussion forum: The National Alliance on Mental Illness (NAMI) is teaming with HOTSOUP.COM as part of an experiment to transform polarized national debate into constructive dialogue. HOTSOUP is designed to bring together "opinion drivers," including well-known figures and "grassroots influencers," in ongoing discussions ("issue loops") on a variety of topics. Former President Bill Clinton, Lance Armstrong, Senator John McCain, and Senator Barack Obama are among those seeking to use advanced technology on the Internet to build a broad, nonpartisan community. NAMI will lead a discussion on mental illness and society. NAMI's "issue loop" can be found at www.nami.org/hotsoup.

APA's Minority Fellowships: Psychiatry residents are invited to apply for the American Psychiatric Association's (APA's) Minority Fellowships Program. The program provides educational opportunities not only to residents from minority groups but also to any resident interested in providing effective services to individuals from minority groups and to underserved populations. Three types of fellowships are available. Some fellowships provide funds for psychiatry residents to experience a specialized educational program geared toward building leaders in psychiatry. Fellowships are also designed to involve fellows in APA's work and give APA the perspective of young psychiatrists. The deadline for applications is January 31, 2007. For more information, contact Marilyn King at 703-907-8653 (e-mail: mking@psych.org) or visit the APA Web site at www.psych.org/edu/other_res/apa_fellowship/cmhs_index.cfm

New interest group for psychiatry students: PsychSIGN—the Psychiatry Student Interest Group Network—is a newly formed working group to foster the creation and involvement of student psychiatry interest groups at individual North American medical schools. The student leaders at PsychSIGN are working to create opportunities for medical students to make connections with each other, residents, and faculty. The group will function as a central hub for the exchange of ideas, information, and resources. It will also promote discourse about psychiatric education in the medical school community and about advocacy and justice in mental health. The group was founded in 2005, with the support of the American Psychiatric Association's Division of Education and had its first annual meeting in May 2006. More information is available at the PsychSIGN Web site at www.psychsign.org.

Video on borderline personality disorder: A documentary-style short film produced for the Borderline Personality Disorder Resource Center, a nonprofit center at New York-Presbyterian Hospital, is designed to educate patients, family members, mental health professionals, and the public. "Back From the Edge" features first-person accounts of people living with and recovering from borderline personality disorder. Leading clinicians and researchers, including Otto Kernberg (clinical director of the center), Marsha Linehan, John Gunderson, Wayne Fenton, and Perry Hoffman, put the first-person stories into a broader social and medical context. The video can be ordered for $20 by contacting info@bpdresourcecenter.org.

Tools for choosing a Medicare drug benefit plan: The National Mental Health Association (NMHA) encourages Medicare beneficiaries, their families, and caregivers to evaluate drug plan options to find the plan that best suits their needs. Open enrollment ends December 31. Recent changes in Medicare Part D will affect treatments that beneficiaries can access in 2007 as well as cost-sharing. "What may have been a good plan for someone in 2006 could be entirely different in 2007," said NMHA president and C.E.O. David Shern, Ph.D. Materials include a summary of changes in Medicaid Part D for special populations, basic resources to examine and compare plans, and tips to save money and find programs offering financial assistance to beneficiaries who fall into the benefit's coverage gap ("donut hole"). A workbook is also available in English and Spanish. Materials are free to individuals and available at the NMHA Web site at www.nmha.org or by calling 800-969-NMHA (6642).

NIMH autism trials: The National Institute of Mental Health (NIMH) has launched three major clinical studies on autism at its research program in Bethesda, Maryland. These studies are the first products of a new, integrated focus on autism generated in response to reported increases in prevalence and valid opportunities for progress. One study will define biological and behavioral differences among autistic children to explore the likelihood of "autisms," that is, multiple disorders that comprise autism. Another study will examine the usefulness of the antibiotic minocycline in treating regressive autism. Past research suggests that autism may be linked with changes in the immune response that cause inflammation in the brain. The third study seeks to address the widespread but unproven theory that autism may be treated successfully by chelation therapy. Many families seek this treatment to try to remove mercury and other metals from their autistic children's blood. This practice is based on the belief that many cases of autism were caused by exposure to thimerosol, a mercury-based preservative previously used in childhood vaccines. Information about these studies and other ongoing studies of autism is available at http://clinicaltrials.gov.

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