We tend to accept today’s common labels, structures and hierarchies as being durable and historically inevitable, failing to understand the fraught nature of their history, or any history. Primary care had its early formulation in the U.S. in the 1960s, but it became a major institutional force in the 1990s with the advance of managed care. The hope was that primary care would be the hub, the first line of care, for a rejuvenated healthcare system.
Few people look back on the 1990s as the rejuvenation of healthcare, and little energy seems to remain within the primary care juggernaut. Doctors make more money in procedure-based medicine and so the estimated shortfall of PCPs by next year is estimated at 45,000. There is always a conservative force pushing for the current arrangement, but few currents are driving the endurance of primary care medicine – not economics, or culture, or politics.
On the political front, the Affordable Care Act did not reject primary care, but perhaps more importantly, it endorsed the importance of preventive measures. This is the orientation for my discussion here. There is the prevention of illness and there is care for illness. Doctors provide care. Prevention has historically been more the domain of public health. Our focus on prevention must expand more widely to encompass other institutions and to become grounded in the primacy of emotional health.
I should articulate a few key ideas before we get into the details. Primary care as it exists today should not be considered primary. Emotional health is primary, and we need a different prevention model to deal with the breadth of emotional health issues. That model should be shaped by two ideas: Prevention screening should be ongoing, not a consideration for annual exams, and it should be owned by the individual, not the doctor. We should educate and enable people to understand the current state of their emotional health.
The emotional secret of primary care
The Milbank Memorial Fund in 2010 estimated that 70% of visits to primary care “stem from psychosocial issues.” Let’s assume this estimate overstates how many primary care visits are driven by psychology. The actual percentage is probably still quite large. Why are we leaving doctors who have minimal training in understanding or helping people with psychosocial, psychological or emotional issues as the first line of care?
The answer is just history. There was no planning. There was no real understanding during the evolution of primary care about how many people needed help for psychosocial stressors. Now that we know, we must make a change. Primary care must be eliminated as a concept. The new front line must be prevention, not to be staffed primarily by physicians. The PCPs are just fine. These doctors have provided fine medical care, but their role must change as we redesign the care delivery system.
Prevention should be an emotional health check-up; not a blood test. There is a first step to be taken on this path. The term mental health is too negative for a health and wellbeing movement. “Going mental” and being a “mental patient” are not filled with positive associations. This is not the fault of the people involved. It is a marketing issue. We need to drop the phrase mental health and embrace the term emotional health. It is not deeply substantive, but it is a real marketing issue.
Let’s differentiate an office visit from a health checkup. A visit means that you are encountering a healthcare professional in some way, be it in person, by video, or by phone. A health checkup is more distant and confidential. We can get a checkup on our emotional health without talking with anyone. Making it easy and confidential will mean that more people will complete it. Prevention starts with health checkups.
This means that prevention might be largely digital. People can get a sense of their emotional health by checking in on their laptops, tablets, phones or whatever comes next. The current state of emotional health checkups is too diagnostic heavy. For example, you can find many fine screening tools on the Mental Health America website today, but you must commit to completing an assessment of depression, anxiety or some other disorder. This is not the path forward. We need people with no sense of any disorder answering questions that take them to a recommendation.
The under-funding of behavioral healthcare is not going away any time soon. I don’t see this as nefarious. Chronic medical conditions account for roughly half of our medical costs, and doctors have some understanding about how to treat them. They will always advocate moving available resources toward diabetes, hypertension, CAD and so on before they invest in behavioral healthcare. The best test of this is the Accountable Care Organization (ACO) of today: they recognize the prevalence of behavioral healthcare disorders, yet do little about them, and invest largely in chronic medical care. We must change this.
How do we get there? We need to identify the players that can lead us in a new direction. Those players are probably independent, carved-out behavioral healthcare organizations, employers with skin in the game, and government payers with skin in the game. Commercial health plans and healthcare systems will probably follow. While they understand behavioral healthcare, they are most likely to focus on incremental changes that might boost short-term profits.
The fatal flaw of disease management
Rethinking primary care is on a parallel path with rethinking disease management. The core idea for disease management was to have nurses coach patients with diabetes, hypertension and other chronic conditions to follow the recommendations of the primary care doctor. There was some focus on lifestyle changes related to diet and exercise, but most nurses were hardly wellness coaches. While the model expanded to include wellness coaching, most wellness coaches themselves had limited understanding of emotional health.
While health plans and employers still invest in some type of disease management today, no one is excited about the results. The fatal flaw was a failure to understand that our thoughts, feelings and behaviors are critical to the development of chronic conditions, as well as to the management of those conditions once fully developed. We don’t need nurses or wellness coaches on the front lines, but rather behavioral health specialists and coaches trained to understand the path to wellbeing, which is a course that takes people well beyond the path to physical wellness.
Let’s stop wasting time and money. Primary care and disease management are two sides of the same coin. They fail to understand that healthcare starts with the emotional health of an individual, and we need to focus our preventive efforts on this reality. This is a major paradigm change, not a simple one, but we need to start implementing it in every corner of society. It is a public health issue and a system of care issue.
Ed Jones, PhD, is senior vice president of the Institute for Health and Productivity Management.