Can treating past trauma lead to big US health savings?

For two decades, there's been evidence that people who suffered childhood trauma — violence, sexual abuse or family dysfunction — are much more likely to have a chronic health problems and engage in risky behavior.

Doctor and patient
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Now, 14 community health centers around the U.S. are acting as laboratories for an experiment to see if screening and then treating people for trauma can improve the results from treatment they get for their diabetes, heart disease, pulmonary disease or other ailments.

While the main goal of that project is to get participants leading healthier, happier and longer lives, there's also a potential positive financial side effect. If the project works — and the lessons learned are expanded on a large scale — it may help create savings of billions of dollars for the health-care system by reducing overall medical spending.

"This is a great opportunity here," said Dr. Winston Wong, medical director of community benefit at Kaiser Permanente, the nation's largest managed health-care organization, when asked about the possible financial savings.

Kaiser Permanente is backing the Trauma Informed Primary Care project, which is being conducted by the National Council for Behavioral Health, a group of about 2,500 mental health and treatment organizations. Kaiser Permanente operates a health insurance plan with nearly 10 million members, and as such has an interest in strategies that could hold down medical costs.

Since last spring, the centers participating in the project have been screening groups of clients: Each center decides what physical conditions to focus on, and what level of trauma to use as a cut-off point. Patients who meet those criteria are given the option of receiving help to deal with their trauma along with their chronic condition.

Asked how much the project could save in medical costs if expanded more broadly, Wong said, "I don't think anybody actually has calculated" that figure. That said, the medical costs associated with trauma are often very high.

The federal Centers for Disease Control and Prevention said in 2012 that "the total lifetime financial costs associated with just one year of confirmed cases of child maltreatment ... is approximately $124 billion." And "the lifetime cost for each victim of child maltreatment who lived was $210,012" — comparable to the costs for patients who had strokes or type 2 diabetes, CDC said.

The woman who is overseeing the trauma project, Cheryl Sharp, noted that chronically ill people who have past trauma can quickly rack up large hospital bills as they cycle in and out of emergency rooms, with costs often borne by public programs like Medicaid.

"I am one of those people," said Sharp, who is senior adviser of trauma informed services at the National Council for Behavioral Health. Sharp, 58, said she grew up in "in a home with a mother who was in and out of psychiatric institutions" and also had medical trauma herself from "being very sick as a child" and undergoing invasive treatment over multiple hospital stays.

Her childhood experience, she said "created a firestorm within me" that led to years of self-destructive behavior, she said. Sharp had multiple stays in mental hospitals, abused substances and attempted suicide nine times, she said.

But Sharp got help to address her trauma when she was in her early 30s.

Others haven't been so fortunate.

A major study conducted by Kaiser Permanente and the CDC from 1995 to 199 evaluated more than 17,000 people for childhood trauma. The Adverse Childhood Experiences [ACE] Study asked participants if they had experienced 10 different kinds of trauma, including physical, sexual and emotional abuse. The answers were tallied to give a participant an "ACE Score."

Two-thirds of the participants ended up having at least one ACE. Nearly 90 percent of participants had at lease one additional ACE. And more than half of the participants had three or more ACEs, the study found.

In a published report, the study's author noted that people who have an ACE score of four or more also had much higher rates of alcoholism, drug abuse, suicide attempts and numerous sexual partners than the general population. There was also between a 1.4-to-1.6-fold increase in physical inactivity and severe obesity.

While the findings were dramatic, and have fueled ongoing, related research, Wong of Kaiser Permanente and others said the health-care system still tends to treat trauma-related psychological conditions and physical illness as separate issues.

Wong also said that there is a "long track record" of primary care physicians and behavioral health specialists "not integrating very well."

Sharp, the trauma project's manager, said that even as primary care doctors were aware of the role trauma might play in chronic health conditions, "they didn't know what to do" about it.

That lack of knowledge spurred Trauma Informed Primary Care project.

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"There was this core problem," said Jennifer Perlman, a doctor of psychology who is coordinating the Trauma Informed Care project at the Colorado Coalition for the Homeless. "Our clients have very, very high rates of exposure to trauma. Early life trauma and later life trauma."

"We wanted to find a way to help our clients address the core issues," Perlman said.

Despite that desire, there was some concern among providers participating in the project about the reaction patients would have when given the ACE questionnaire.

"Providers have fears that when we ask questions about their life history, people are just going to collapse," Perlman said.

But in fact, she said, since the project began, clients were relieved to be able to share their experiences, she said, adding that "no one declined the screening."

So far, about 25 people with diabetes and ACE scores of 8 or higher are being treated through the Colorado Coalition for the Homeless, she said.

Based upon the coalition's experience to date with the project, "I would like to be screening all our our population," Perlman said, noting that the group has about 10,000 clients.

The Baltimore-based Chase Brexton Health Care Services center, another project participant, also is "aiming for universal screening," said Suzanne Linkroum, the center's behavioral medicine manager.

"In fact, I'm going to be doing a training for our entire staff" about the ACE study and "some of the strategies that we've learned through this initiative that everyone could be doing, so we can provide trauma-informed care to our patients," Linkroum said.

Linkroum said that "probably at least 75 percent [of the center's clientele] have had some kind of trauma background."

The center, whose clientele overwhelmingly is poor, is focusing on people who have multiple, poorly managed chronic conditions, such as HIV, heart disease, renal failure and diabetes, to screen for the project. Chase Brexton used an ACE score of just 1 as the cutoff.

About 100 patients are participating and getting treatment for their trauma, along with addressing their chronic conditions, she said.

So far, the results have been "wonderful," Linkroum said. "It's more than we could have hoped for."

Specifically, she said, there's been an increase in "patient engagement" among the clients participating in the project, with those people being more apt to show up for scheduled appointments, and check in with their health providers.

"We've had success in reducing HIV viral loads" in some patients, Linkroum said, referring to the amount of HIV that's detectable in the bloodstream. Some patients' "loads are [now] undetectable."

Patients are "doing better, they're feeling better, they are felling more engaged, more supported," Linkroum said. "They feel like they have a team that cares about them."