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Perspectives

Equity for Frontline Healthcare: Primary Care Needs a New Start and New Soldiers

October 26, 2020

Many of us in behavioral healthcare should be preparing for a future in primary care. There is an academic basis for this proposal, but it increasingly has political urgency. Many in our field point to primary care as a destination, but for reasons different from mine. Yet we should all agree it is time to join PCPs in demanding equitable frontline healthcare in America. This is best expressed stepwise.

The dualism of mind and body is an old mistake. It has lingered for centuries, and its enduring implications for healthcare are destructive. This historic dichotomy persists in part due to efforts to bridge its false divide. A lasting solution can only be found by redefining the starting point. Let us replace mind-body dualism in healthcare with a new point of orientation, the biopsychosocial model.

The modern embodiment of mind-body dualism in healthcare is the behavioral-medical divide. Endless strategies for integration are discussed today. This is the wrong focus. We should instead orient healthcare in a more holistic way and consider the biopsychosocial dimensions of every health concern. This would include reconstituting every healthcare specialty to ensure multidimensional solutions.

Primary care exemplifies the problem. Psychosocial understanding is a weakness for PCPs. They offer few such solutions. Primary care could be transformed by introducing psychosocial solutions grounded in psychotherapy. Helping PCPs better prescribe psychotropics is fine, yet incidental to their main deficit. PCPs strive for whole person health, but this requires deeper psychosocial knowledge.

Behavioral healthcare is also flawed. Clinical services address multiple dimensions but are splintered. Psychotherapy began with a narrow mental perspective. Freud visualized a complex mind as he sat, oddly, out of view of his patients. Nonetheless, his intentions aside, he created a field grounded in our reality as social animals. Behavioral healthcare needs consolidation around a biopsychosocial model.

Starting from a holistic perspective or working to repair divisions

No one can be faulted for wanting better integrated healthcare delivery. Our fundamental mind-body divide is problematic enough, but it is then compounded by additional fragmentation based on funding, subspecialty and tradition. People from all quarters have been clamoring for integration, and this is not the wrong impulse. However, the proposed solutions are quite limited and preserve basic divisions.

Calls for integration have become mainstream. Afterall, Medicare now has a current procedural terminology (CPT) code for behavioral health integration (BHI). Who can argue with doctors being more attentive to behavioral health needs? Similarly, how can we object to laws like the Affordable Care Act directing behavioral healthcare funding to Federally Qualified Health Centers, the largest primary care network in the country?

Integration often means coordination of care. This is preferrable to isolated care. Collaboration across disciplines can be beneficial for certain patients. Consultation helps too. For example, psychiatric consults, despite a narrow biological focus, improve PCP prescribing for major psychiatric diagnoses. Yet the core problem remains. Integration grows best from a holistic stance, not as reparative work.

Comprehensive primary care

Primary care was initially established as comprehensive in scope. While other doctors specialize, the PCP is ready to help people with diverse, unspecified problems. This comprehensive focus has included attention to behavioral health, but our field’s focus is too unique and extensive for a standard training rotation. PCPs mainly absorb knowledge of psychotropics. Psychosocial domains are largely neglected.

The inadequacies of primary care today are more than its strictly biological approach or its failure to recognize many well-developed behavioral disorders. PCPs neither recognize nor treat the psychological distress driving people to see them for various somatic complaints. They fail to help with behaviors that are the root cause of many chronic medical conditions. They cannot succeed on their own.

PCPs acknowledge deficits. Some find psychotherapists to partner with them. Yet the newly emerging definition of comprehensive is expanding to include virtual visits and interactive digital resources. The early aspiration to be comprehensive will reach new heights. Primary care is getting primed for change. We can and should become a critical part of that change once we reconfigure our own house.

Consolidated behavioral health

Our field has internal fragmentation to resolve. For example, every practitioner should have expertise in the interconnections between mental health and substance use disorders. This should be achievable since we have deep knowledge in both domains, but we are not there yet. Also, health behaviors exist on the fringe of healthcare. They should be core to our field since we are the behavior change experts.

Some of the greatest causes of disability today receive marginal attention from us because they are trivialized as lifestyle problems. Clinicians in our field have developed structured programs for a segment of those in need, but it is time to see behavior change as often needing individualized care. We specialize in psychosocial complexity. Psychotherapy taught us long ago that change can be slow.

Consolidated behavioral health is a term for reconstituting around these key, interconnected domains. For example, we know people jeopardize their health every day. Many need more than education or goal setting exercises since other mental health or substance use problems are interfering. Personalized solutions are needed. Variations on psychotherapy will be a major source for them.

Parity with a new focus

Our industry achieved parity within the arcane rules of insurance in 2008. Lessons from that battle can help us with a new objective, equity for frontline care. We need to prepare our field for migration to the primary care setting. This may be our most critical undertaking for succeeding generations of clinicians. Inequitable funding for primary and specialty care awaits us there. It will not disappear upon our arrival.

The problem is not just that PCPs are paid less than most specialists, but that our primary care funding is half of other industrialized countries. Those countries serve only as a reference point, not an end point. Our aim should be to prevent diabetic and heart patients from needing expensive surgeries. We should transform population health and the total cost of healthcare by improving emotional wellbeing.

The frontlines of care are ringing with panic that primary care is crumbling. PCPs need our support for healthcare reform. A strong primary care system is vital. We must prevent its demise. Let us promote parity in healthcare spending. We need parity with specialty care and with other advanced nations. The biopsychosocial model can be our mutual anchor as we collaborate for equitable frontline care.

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

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