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Behavioral Health as an Agent of Change, Part III: Primary Care Redesign

April 13, 2020

This article, the third in a series, focuses on necessary changes to the healthcare system to achieve the ends described in the first installment on preventable costs and the second on health improvement. The overriding question is how the behavioral healthcare field can make a substantial contribution to the national crisis.

The impact our field can have in solving this challenge depends on whether it is regarded as a primary or specialty healthcare service. Psychosocial factors are clearly important in determining health status and driving primary care visits. If we are prepared, the primacy of behavior change in health improvement could place our field on the frontlines of healthcare delivery.

We have the clinical tools to significantly improve the health of populations, but we won’t see enough people to make a difference if we wait in our specialty offices. Our services are indeed primary when our efforts in disease prevention and health promotion are appreciated. Helping people work toward wellness and wellbeing generates health benefits on par with treating behavioral health disorders.

The dilemma is not so much the value of our services, but how we might be greeted within the primary care setting. Do primary care physicians see our work as a component of primary care? Are PCPs focused on other pressing issues and not receptive to a greater role for us? We can assert the primacy of our psychosocial services, but it is a practical question whether PCPs welcome greater involvement.

The need for primary care redesign

The primary care setting is increasingly dysfunctional. Physicians trained for that setting are choosing other career paths. One source of dysfunction is the prevalence of behavioral health issues being neglected or inadequately addressed. The setting needs a major redesign with equal attention being given to physical and behavioral health. Focus is needed on health promotion and disease prevention.

A good place to start is with the words of physicians themselves. Two Harvard physicians expressed their frustration last year with a specialty “stretched too thin.” As they finished their residency training, they were choosing to reject primary care as a career option, like 80% of residents in internal medicine. They concluded that “it is time we reimagine the role of the primary care physician.”

There are two problems. The work of the PCP is being treated as a commodity and reduced in price. PCP visits dropped 18% from 2012 to 2016, as nurse practitioners and physician assistants appeared in retail settings. It is also being found inadequate as the frontline of healthcare delivery. Health promotion and disease prevention efforts remain minimal and chronic care costs stay insurmountable.

The primary care concept has only been with us since the 1960s, and it may be time to ask if we need a new formulation. PCPs have not only been on the frontlines for healthcare delivery, but also on the frontlines of efforts to reduce costs. Other specialties enjoyed higher incomes, while the PCP was expected to resolve heightened tensions between quality and cost. Their failings are not personal.

Changes over the last decade have not resolved basic problems in the primary care setting. The growth of NPs and PAs has not fostered a multi-disciplinary workforce. We need expertise in the primary care setting on changing health behaviors, reducing the impact of stress, and addressing the pre-clinical and full-blown impact of depression, anxiety, substance use and other disabling conditions.

The primary care team needs one of our professionals as an equal partner with the PCP, dividing “quarterback” duties according to the burden of physical and behavioral risks. PCPs today acknowledge a role, but not a primary one for our clinicians. The changes described here tackle fundamental problems in primary care today, while most debates are typically stuck on the shortage of PCPs.

Getting started with a shift in existing resources

If redesign is needed, how are staffing and funding secured? We should start with two underutilized and ineffective domains – employee assistance (EAP) and wellness – that could be moved into the primary care setting in order to resuscitate efforts at health promotion and disease prevention. We need these vital services to enhance wellness and wellbeing on the frontlines of healthcare.

EAPs offer free behavioral health visits to resolve problems early, and yet fewer than two sessions on average are typically provided. Wellness programs and chronic care programs are even less successful. Patients are reluctant to accept phone calls from nurses about health improvement activities. These services are primary and should be in person, augmented with a range of virtual services.

Most people with coverage for EAP and wellness services don’t know that they have access to these services. Some discover having coverage when they most need help, while others never do. The idea behind offering these services is quite appropriate. Yet it is wrong to offer them as specialty services on the side. They should be initially offered face-to-face by a trusted professional.

Healthcare reformers often cite the maxim, “the right care at the right time.” Services like EAP and wellness are certainly the right care in that they provide necessary elements in any plan for health promotion and disease prevention. They are offered at the wrong time and place today, and so few people take advantage of them. The right time is when a patient visits the primary care setting.

The primary care team

A key problem in the primary care setting today is being physician-centric rather than team-centric. If many young physicians avoid that setting today for fear of being stretched too thin, a team can help. A behavioral health professional should co-lead the team since behavior change is the missing ingredient for improved health. The PCP can now collaborate with a primary care psychologist or “PC-Psy.”

Doctors feel “stretched too thin” for many reasons, including EMR burdens and common complaints about seeing 25 patients per day. Since research shows most visits are driven by psychosocial issues, behavioral health programming must be developed to meet the needs of primary care patients. Fortunately, EAPs have a legacy of innovation. Having PCPs do more of the same will not solve anything.

Treatment for disease generally occurs in a doctor’s office, but wellness and wellbeing mostly involve self-care behaviors outside the office. Our field has long known people don’t achieve lasting changes in their thoughts, feelings and behaviors in our offices. We can now add virtual, digital resources to the self-care toolkit. Our self-care expertise can be a bedrock for expanding primary care services.

The primary care setting needs to be reconfigured, and the PCP can use our help. Primary care will fail without a substantial focus on wellness, wellbeing and behavioral health. These services can be brought into the primary care setting. They are underutilized on the margins. It is time for health, more than the absence of disease, to become our pursuit. The primary care team can make that happen.

Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.

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