You know it.  I know it.  The Patient Protection and Affordable Care Act (PPACA) is wounded in Washington and assaulted in the states.  Whether these wounds to this brand of federal reform are fatal or not remains to be seen.

However, the tide of market reform and healthcare consolidation pushes inexorably on, and the momentum gained from the PPACA for reformists is more than enough to continue the needed expansion of digital medicine, systems consolidation and value-based insurance design.

For child healthcare systems, these larger trends translate into specific realities.  More and more child healthcare will be paid for by public payers — Medicaid in particular.  Cost control strategies in states will combine with a demand for accountability to produce more and more provider cost-sharing and outcomes monitoring.

Specific emphases will be placed on medical home strategies, managed care organizations, and accountable care organizations to manage the costs and outcomes of our most expensive children.  Early screening and brief interventions with stepped referral processes will decrease inappropriate specialty care and waiting lists.  Medication algorithms and regional quality collaboratives will decrease emergency department use and increase guideline compliance.

After the neonatal period, mental disorders represent one of the most costly and poorly managed populations of sick children.  Their care will come under increasing scrutiny by those concerned about high costs and poor outcomes who employ strong medical home models, specialty care monitoring, early detection and case management.  Avoidance of inpatient days and early intervention will be the first targets.

As persons interested in mental health and medical integration, these challenges and diverse forces present a rare opportunity to radically alter our rigidly separated mental health and healthcare systems.  Although the mental health clinicians, primary care clinicians, and government panels have all called for greater integration of behavioral services into the medical setting, the impetus for unification has been missing except for the most committed.  Population health management in at risk provider organizations like accountable care organizations will achieve integration between behavioral and other medical services and likely achieve savings through the prevention of inpatient care or perish as a result of the same fragmentation that has crumbled most public mental health systems.

Kelly J. Kelleher, MD, MPH, is Director of the Center for Innovation in Pediatric Practice at the Research Institute at Nationwide Children’s Hospital and Professor of Pediatrics, Public Health and Psychiatry at The Ohio State University College of Medicine.