BACKGROUND:Federal policy impact analyses in the United States do not incorporate the potential economic benefits of adolescent mental health policies. Understanding the extent to which economic benefits may offset policy costs would support more effective policymaking. This study estimates the relationship between adolescent psychological distress and later health and economic outcomes and uses these estimates to determine the potential economic effects of a hypothetical policy. METHODS AND FINDINGS:This analysis estimated the relationship between psychological distress in those aged 15 to 17 years in 2000 and economic and health outcomes approximately 10 years later, accounting for an array of explanatory variables using machine learning-enabled methods. The cohort was from the National Longitudinal Study of Youth 1997 and nationally representative of those aged 12 to 18 years in 1997. The cohort included 3,343 individuals under age 18 years in round 4 who completed the Mental Health Inventory-5 (MHI-5). Round 1 captured 50 explanatory variables that covered domains of potential confounders, including basic demographics, neighborhood environment, family resources, family processes, physical health, school quality, and academic skills. The exposure included a binary variable of clinically significant psychological distress (MHI-5 score of less than or equal to 3) and a categorical variable of symptom severity on the MHI-5. Outcomes covered domains of employment, income, total assets at age 30 years, education, and health approximately 10 years later. Forty-seven percent of the cohort were black and Hispanic, and 4.4% had past-month clinically significant psychological distress. Past-month clinically significant psychological distress in adolescence led to a 6-percentage-point (95% confidence interval [CI] [-0.08, -0.03]) reduction in past-year labor force participation 10 years later and $5,658 (95% CI [-6,772, -4,545]) USD fewer past-year wages earned. We used these results to model the labor market impacts of a hypothetical policy that expanded access to mental health preventive care and reached 10% of youth who would have otherwise developed clinically significant psychological distress. We found that the hypothetical policy could lead to $52 (95% credible interval [51,54]) billion USD in federal budget benefits over 10 years from labor supply impacts alone. This study faced limitations, including potential unmeasured confounding, missing data, and challenges to generalizability. CONCLUSIONS:Our findings showed the impacts of adolescent mental health policies on the federal budget and found potentially large effects on the economy if policies achieve population-level change.

OBJECTIVE:The author examined whether a large language model (LLM) can help identify noncompliance with the Mental Health Parity and Addiction Equity Act (MHPAEA) in health insurance plan documents. METHODS:Using Anthropic's Claude 3.5 Sonnet between December 1, 2024, and January 31, 2025, the author analyzed primary documentation for the Essential Health Benefits benchmark plans for 2026. An LLM prompt was first validated, and the author assessed the LLM's positive predictive value (PPV) in applying that prompt to identify areas of potential MHPAEA noncompliance. The LLM then prioritized the top 10 areas of noncompliance among those accurately identified. RESULTS:The LLM identified on average 3.8 areas of potential noncompliance per document, with an average PPV of 49%. CONCLUSIONS:The findings indicate that LLMs currently have a relatively poor PPV in regulatory oversight tasks but may help improve efficiency by enabling rapid identification of potential MHPAEA noncompliance to prioritize areas for further review.

BACKGROUND:Alzheimer's disease and other dementias (ADODs) severely threaten the wellbeing of older people, their families, and communities, especially with projected exponential growth. Understanding the macroeconomic implications of ADODs for policy making is essential but under-researched. METHODS:We used a health-augmented macroeconomic model to calculate the macroeconomic burden of ADODs for 152 countries or territories, accounting for: the effect on labour supply of reduced working hours of informal caregivers; the effect on labour supply of ADODs-related mortality and morbidity; age-sex-specific differences in education, work experience, labour market participations, and informal caregivers; and treatment and formal care costs diverting from savings and investments. FINDINGS:ADODs will cost the world economy 14 513 billion international dollars (INT$, measured in the base year 2020; 95% uncertainty interval [UI] 12 106-17 778) from 2020 to 2050, equivalent to 0·421% (95% UI 0·351-0·515) of annual global GDP. Japan incurs the largest annual GDP loss at 1·463% (1·225-1·790). China (INT$2961 billion [2507-3564]), the USA (INT$2331 billion [1989-2829]), and Japan (INT$1758 billion [1471-2150]) face the largest absolute economic burdens. The economic burden of informal care ranges from 60·97% in high-income countries to 85·45% in lower-middle-income countries, and treatment and formal care costs range from 10·50% in lower-middle-income countries to 30·80% in high-income countries. INTERPRETATION:The macroeconomic burden of ADODs is substantial and unequally distributed across countries and regions. Global efforts to reduce the burden, especially with regard to informal care, are urgently needed. FUNDING:National Institute on Aging, National Institutes of Health; Chinese Academy of Engineering; Chinese Academy of Medical Sciences; Bill & Melinda Gates Foundation; Davos Alzheimer's Collaborative through Data for Decisions.

This Viewpoint proposes the creation of a Kids Progress Administration housed under the US Department of the Treasury to address children’s long-term health and well-being.

Medical and long-term care for Alzheimer’s disease and related dementias (ADRDs) can impose a large economic burden on individuals and societies. We estimated the per capita cost of ADRDs care in the in the United States in 2016 and projected future aggregate care costs during 2020–2060. Based on a previously published methodology, we used U.S. Health and Retirement Survey (2010–2016) longitudinal data to estimate formal and informal care costs. In 2016, the estimated per patient cost of formal care was $28,078 (95% confidence interval [CI]: $25,893–$30,433), and informal care cost valued in terms of replacement cost and forgone wages was $36,667 ($34,025–$39,473) and $15,792 ($12,980–$18,713), respectively. Aggregate formal care cost and formal plus informal care cost using replacement cost and forgone wage methods were $196 billion (95% uncertainty range [UR]: $179–$213 billion), $450 billion ($424–$478 billion), and $305 billion ($278–$333 billion), respectively, in 2020. These were projected to increase to $1.4 trillion ($837 billion–$2.2 trillion), $3.3 trillion ($1.9–$5.1 trillion), and $2.2 trillion ($1.3–$3.5 trillion), respectively, in 2060.

Mental health and substance use parity provides a rhetorical device and policy strategy for achieving more equitable financing of mental health and substance use services, which the U.S. has pursued as a lead policy approach for improving access to mental healthcare. Parity implementation in the U.S. has improved access to care for children, but implementation challenges remain, leading to persistent treatment gaps and disparities, workforce shortages, and variable care quality. In the U.S., a recent policy change required health insurers to make available all of the data on their coverage and reimbursement practices for all health conditions. This new data enables a more detailed conceptualization of what parity means in children’s mental health and how it should be implemented and overseen. Researchers, clinicians, and advocates across the globe can use this data to build the case and the policy approach for parity, supporting more equitable financing of children’s mental health and substance use care and promoting families’ access to evidence-based care.

In 1538, Swiss physician and philosopher Paracelsus put forth the toxicology maxim that the dose makes the poison. 1 Bus JS "The dose makes the poison": key implications for mode of action (mechanistic) research in a 21st century toxicology paradigm. Curr Opin Toxicol. 2017; 3: 87-91 Crossref Scopus (26) Google Scholar In public health, this concept guides efforts to protect the population from environmental exposures where they live, work, and play through regulation and control. Today, a new toxin has emerged in the digital environment: unfettered access to unsafe social media platforms, with concerning adverse effects on children's and adolescent's mental health. 2 Kickbusch I Piselli D Agrawal A et al. The Lancet and Financial Times Commission on governing health futures 2030: growing up in a digital world. Lancet. 2021; 398: 1727-1776 Summary Full Text Full Text PDF PubMed Google Scholar

This Viewpoint proposes the creation of a Kids Progress Administration housed under the US Department of the Treasury to address children’s long-term health and well-being.

OBJECTIVE: To describe adolescent and young adult (AYA) perspectives on defining quality and value in health care and to gain understanding of their knowledge of value-based payment. METHODS: A text message-based survey was sent to a conve-nience sample of AYAs aged 14 to 24 in 2019. Participants were asked 4 open-ended questions: 1) how they would define "good health care," 2) what factors to consider in rating doc-tors, 3) whose opinions should matter most when rating doc-tors, and 4) the best ways to collect AYA opinions on doctors, and one yes/no question on their awareness of value-based payment. Analyses included descriptive demographic statistics and an inductive thematic approach with multivariable models comparing adolescent (14-18) and young adult (19-24) responses.RESULTS: Response rate was 61.0% (782/1283). Most partici-pants were White (63.3%), female (53.3%), and adolescents (55.6%). Common themes from the first 2 questions included accessibility (specifically affordability), coverage benefits, and care experience (including compassion, respect, and clinical competence). Young adults more commonly mentioned affordability than adolescents (54.4% vs 43.3%, P = .001) and more commonly felt their opinion should matter more than their parents when rating doctors (80.6% vs 62.0%, P < .001). Only 21.0% of AYAs were familiar with the potential value-based link between physician payment and care quality.CONCLUSIONS: When considering quality and value in health care, AYAs expressed their desired agency in rating the quality of their care and clinicians. AYAs' perspectives on health care quality, including the importance of care accessibility and affordability, should be considered when designing youth-cen-tered care delivery and value-based payment models.

The Affordable Care Act established Medicaid health homes to provide care management and coordination for high-need individuals, including many with serious mental illness. The authors used data from the Medicaid Data Warehouse to examine health care utilization over 3 years among 10,193 individuals who enrolled in a New York State health home and had at least one outpatient mental health visit during the year prior to enrollment. Results for postenrollment year 2 indicated a 43% decrease in inpatient mental health discharges, a 38% decrease in substance use discharges, and a 7% reduction in general medical discharges, whereas mental health outpatient treatment and behavioral and nonbehavioral medication utilization increased. Further research is needed to determine the effectiveness of health home care management for individuals with serious mental illness.

This chapter examines the effects of lobbying to influence the political demand for health care. The chapter proceeds with a discussion of the main features of lobbying models, their application in the realm of healthcare policymaking including the consideration of stakeholders, and then provides a summary of findings. Readers are pointed to data for future research and data sources that can be used to do research in the field of healthcare policy lobbying. Finally, the chapter discusses the role that lobbying might have in policymaking aimed at promoting health equity and other important health-related policy objectives.

Budget analysis entities often cannot capture the full downstream impacts of investments in prevention services, programs, and interventions. This study describes and applies an approach to synthesizing existing literature to more fully account for these effects. This study reviewed meta-analyses in PubMed published between Jan 1, 2010 and Dec 31, 2019. The initial search included meta-analyses on the association between health risk factors, including maternal behavioral health, intimate partner violence, child maltreatment, depression, and obesity, with a later health condition. Through a snowball sampling-type approach, the endpoints of the meta-analyses identified became search terms for a subsequent search, until each health risk was connected to one of the ten costliest health conditions. These results were synthesized to create a path model connecting the health risks to the high-cost health conditions in a cascade. Thirty-seven meta-analyses were included. They connected early-life health risk factors with six high-cost health conditions: hypertension, diabetes, asthma and chronic obstructive pulmonary disorder, mental disorders, heart conditions, and trauma-related disorders. If confounders could be controlled for and causality inferred, the cascading associations could be used to more fully account for downstream impacts of preventive interventions. This would support budget analysis entities to better include potential savings from investments in chronic disease prevention and promote greater implementation at scale.

During the first two decades of the twenty-first century, the USA experienced a crisis of increasing psychological distress that was associated with rising morbidity and mortality, especially among young people. The increasing distress probably arose from changing economic, social, technological and political conditions that, unabated, may continue to progress in coming years. The increasing psychological distress may lead to cascading social and economic consequences that further compound suffering, analogous to the spreading impacts of climate change. To address climate change, the USA is beginning to pursue a multisectoral set of policy interventions that include several novel economic strategies. Learning from climate policy, the USA can further address rising psychological distress through: (1) the building of planning, data and regulatory capabilities across agencies; (2) investing in solutions that target root causes and mitigate effects; (3) requiring relevant public disclosures from corporations; and (4) updating policies to reflect potential impacts from psychological distress. In this Perspective the authors detail the potentially parallel systemic economic risk of psychological distress and climate change, and argue for the adoption of a similar set of policy interventions, including bolstering cross-agency capability and capacity and increased investment in targeting root causes and solutions.

This Viewpoint shares New York City's rationale, process, and challenges in addressing mental health, focusing on 1 of 3 pillars of the plan-overdose-as a case study to inform the work of other governments across the nation.

Advances in developmental psychology, child psychiatry, and allied disciplines have pointed to events and experiences in the early years as the origin of many adult mental health challenges. Yet, children's mental health services still largely lack a developmental or prevention-focused orientation, with most referrals to mental health professionals occurring late, once problems are well established. An early childhood mental health system rooted in the principles of life-course health development would take a very different approach to designing, testing, and implementing prevention and intervention strategies directed toward early child mental health. Priorities for such a system include supporting healthy family environments, parent-child and family relationships, parents' emotional/behavioral health, and family routines as a means of providing the best possible neurobiological foundation for mental health across the life span. The system would include proactive, trauma-informed, multidisciplinary care, with integrated mental health and social services support embedded in pediatric primary care settings. Novel intervention approaches in need of further research include 2-generational dyadic interventions designed to improve the mental health of parents and children, mental health-oriented telemedicine, and contingency management (CM) strategies. Integral to this Life Course Health Development reformulation is a commitment by all organizations supporting children to primordial and primary prevention strategies to reduce racial and socioeconomic disparities in all settings. We contend that it is the family, not the individual child, that ought to be the identified target of these redesigned approaches, delivered through a transformed pediatric system with anticipated benefits for multiple health outcomes across the life course.

Key Points Question Do value-based payment (VBP) models that share 50% of the 5-year expected health care savings estimated by reduced postpartum depression incidence offer larger incentives for clinicians to prevent postpartum depression than traditional VBP models that share 100% of 1-year actual savings? Findings In this decision analytical model with a simulated cohort of 1000 pregnant individuals enrolled in Medicaid, sharing estimated savings offered more than double the financial incentives for clinicians to prevent postpartum depression than traditional VBP models, assuming continuous health insurance coverage (ie, no churn). This incentive decreased as rates of annual health insurance churn increased. Meaning These findings suggest that VBP models that share expected future savings may offer greater incentives for implementing interventions that prevent postpartum depression, but additional policy action is needed to address challenges posed by health insurance churn.

Healthcare payment reform has not produced incentives for investing in place-based, or population-level, upstream preventive interventions. This article uses economic modeling to estimate the long-term benefits to different sectors associated with improvements in population health indicators in childhood. This information can motivate policymakers to invest in prevention and provide guidance for cross-sector contracting to align incentives for implementing place-based preventive interventions. A benefit-cost model developed by the Washington State Institute for Public Policy was used to estimate total and sector-specific benefits expected from improvements to nine different population health indicators at ages 17 and 18. The magnitudes of improvement used in the model were comparable to those that could be achieved by high-quality implementation of evidence-based population-level preventive interventions. Benefits accruing throughout the lifecycle and over a ten-year time horizon were modelled. Intervention effect sizes of 0.10 and 0.20 demonstrated substantial long-term benefits for eight of the nine outcomes measured. At an effect size of 0.10, the median lifecycle benefit per participant across the ten indicators was $3080 (ranged: $93 to $14,220). The median over a 10-year time horizon was $242 (range: $14 to $1357). Benefits at effect sizes of 0.20 were approximately double. Policymakers may be able to build will for additional investment based on these cross-sector returns and communities may be able to capture these cross-sector benefits through contracting to better align incentives for implementing and sustaining place-based preventive interventions.

Background The burden of Alzheimer's disease and related dementias (ADRDs) is expected to grow rapidly with population aging, especially in low- and middle-income countries, in the next few decades. We used a willingness-to-pay approach to project the global, regional, and national economic burden of ADRDs from 2019 to 2050 under status quo. Methods We projected age group and country-specific disability-adjusted life years (DALYs) lost to ADRDs in future years based on historical growth in disease burden and available population projections. We used country-specific extrapolations of the value of a statistical life (VSL) year and its future projections based on historical income growth to estimate the economic burden - measured in terms of the value of lost DALYs - of ADRDs. A probabilistic uncertainty analysis was used to calculate point estimates and 95% uncertainty bounds of the economic burden. Findings In 2019, the global VSL-based economic burden of ADRDs was an estimated $2.8 trillion. The burden was projected to increase to $4.7 trillion (95% uncertainty bound: $4 trillion-$5.5 trillion) in 2030, $8.5 trillion ($6.8 trillion-$10.8 trillion) in 2040, and $16.9 trillion ($11.3 trillion-$27.3 trillion) in 2050. Low- and middle-income countries (LMICs) would account for 65% of the global VSL-based economic burden in 2050, as compared with only 18% in 2019. Within LMICs, upper-middle income countries would carry the largest VSL-based economic burden by 2050 (92% of LMICs burden and 60% of global burden). Interpretation ADRDs have a large and inequitable projected future VSL-based economic burden. Copyright (C) 2022 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)

The coronavirus disease 2019 (COVID-19) pandemic exacerbated a growing children's mental health crisis in the U.S. Mental health–related emergency department visits rose by 31% during COVID-19 onset compared with the same 7-month time period in 2019.1 This sudden increase built on a pre-existing trend of worsening mental health issues among children, as children experienced a 329% increase in visits for deliberate self-harm between 2007 and 2016.2 Absent intervention, these childhood mental health challenges will have long-term health and economic consequences that propagate disparities.

Value-based payment reform is gaining momentum as health care stakeholders seek to reduce costs and improve quality. Reforms have not been evenly distributed, with most alternative payment models (APMs) being focused on adults. The relative lack of child-focused APMs represents a missed opportunity. Early life interventions can improve children's cognitive and behavioral development, resulting in reduced costs over a lifetime; however, such interventions require new financing models to be sustainable.1The Center for Medicare and Medicaid Innovation's recent Integrated Care for Kids (InCK) Model, which requires APM development to support the integration of health care and other family-serving sectors, offers new momentum for child-focused payment reform.2 To capitalize on the reform opportunities, new cost measures for APMs are needed that better capture the value of children's healthy development and promote greater investment for preventive interventions during this critical life stage.Cost measures play a vital role alongside quality measures in shaping the incentives within an APM. Cost-of-care measures capture the total spending on health care services for a specific duration of time, population, or care setting. APMs use cost measures to ensure that the total amount paid out is not more than what would otherwise be spent absent the APM. For example, the total cost of care (TCOC) captures the total spending for a patient population over a certain duration (typically ≤1 year) relative to a benchmark of expected costs. TCOC is used in APMs to calculate the amount that was saved, which is paid out as shared savings. Other cost measures used today are variations on TCOC or are focused on specific conditions (eg, heart failure) or specific sites of care (eg, hospitals).Interventions that promote healthy development in childhood can produce cost savings but not necessarily in ways that today's cost measures best capture. Savings in child health are, often, realized over more than a single year and across sectors and include whole families.3 Cost measures will need to better reflect these unique opportunities in child health to maximize value and move away from restrictive cost-of-care measures toward cost-of-health measures.More comprehensive cost-of-health measures could finance child health interventions that are typically unsustainable in TCOC payment models and, instead, rely on grant funding. For example, although Healthy Steps for Young Children or Triple P Positive Parenting Program support children's mental health and healthy development, these programs often produce insufficient annual child health care savings to offset their costs as measured by today's TCOC measures. However, by implementing new cost measures capturing time horizon, cross-sector, and whole-family value, APMs could finance and sustain these and other childhood interventions that offer substantial impacts on well-being and costs over the life course. Opportunities for new cost measure are explored below and in Fig 1.Intervening in childhood can save costs related to behavioral health, injuries and maltreatment, and physical health conditions but may take a number of years to realize health care savings. Net present value is a common concept in business used to account for both current and future value. Applied to health, a net present value of care measure could include the actual savings as well as the predicted future savings over a specified future set of years on the basis of intermediate health outcomes achieved.4For example, as communities implement initiatives like InCK, they will begin to collect novel well-being outcomes, such as improvements in kindergarten readiness and school connectedness at the age of 14. Communities could measure the impact of child health interventions on these shorter-term outcomes and savings over the next 2, 3, or 5 years, which could then inform a new net present value of care measure. Initially, the cost measure will be a rough prediction of future savings. If sites use relatively conservative estimates initially or payers are committed enough to child health to accept a slight loss, the cost-measure accuracy can be iteratively improved over time. Using a measure of net present value of care to determine shared savings in an APM could serve as the basis for a community's long-term reinvestment strategy to sustainably finance the enhanced child health interventions on the basis of the longer-term benefits.A key challenge to a longer time horizon cost measurement is churn, in which members switch between health insurance plans or lose coverage completely, limiting a health insurer's opportunities for long-term savings. Multipayer alignment around common terms for net present value of care would mitigate churn between plans through average reciprocity.Many of the largest savings from children's healthy development accrue to non–health care sectors, such as reduced need for special education or fewer children entering the child welfare system.5 As more communities pursue more integrated collective impact approaches to child health, such as InCK or other evolving models, child-serving systems will work together to improve coordination of care, share data across systems, and align cost and quality outcomes between sectors. For example, health care and child welfare stakeholders may target a measure of reduced out-of-home placements and associated cost savings. Communities can use these collaborative opportunities to establish cost benchmarks across health care and other sectors, such as child welfare, in preparation for a braided APM contract. Such braided APM contracts between health care payers and other state and local agencies would allow savings to be shared by multiple sectors and, potentially, finance more comprehensive behavioral health interventions that prevent child welfare involvement.Some savings from childhood intervention may also accrue across the family unit because parents and other caregivers experience less stress, more support, and better health. Multigeneration focused initiatives, including InCK, are often focused on linking data to better risk stratify children and coordinate care for the family unit. These data linkages also create opportunities to set cost benchmarks for whole families, enabling APMs that can share savings and sustain new models of care with more comprehensive family-focused delivery approaches that would otherwise be hard to finance under standard fee-for-service payments.Although we outline 3 cost-of-health value opportunities that we propose as the next areas to explore as new cost measures are developed, improved child health offers other positive externalities beyond these areas. Examples include improved caregiver labor productivity in the short-term and even greater longer-term returns, as children grow into healthier and more socioeconomically stable adults. These other sources of value also deserve further exploration in future stages of APM development for children.New cost measures will need to capture when and where childhood interventions produce health value: over longer time horizons, across sectors, and among families. Public and private investments in cost-measure development will be necessary to fully specify and validate measures, to mirror what the Pediatric Quality Measures Program has achieved for child-focused quality measures.6,7 Policy reforms and technical guidance on contracting will also be needed to better align incentives across payers and sectors and overcome any statutory barriers to sharing savings in these new ways. Payment reform is underway, and new cost-of-health measures are urgently needed for APMs to drive investments in children's healthy development and fully realize the best well-being outcomes for children and families.