A good debate sometimes needs a contrarian viewpoint. I believe the time has come for such a view in response to proposals for our industry to integrate with primary care. My opinion on this topic is informed by experience in the world of commercial insurance. I have witnessed many degrees of integration between health plans and behavioral healthcare.
We should always coordinate care for people with multiple disorders requiring several clinical specialists. Clinicians from every specialty should be alert to the need for a comprehensive evaluation to ensure there are no unrecognized conditions wreaking havoc. Calls for primary care integration seem to be seeking more than these prudent steps.
The placement of resources within the primary care setting seems to be a big part of this solution, with either care managers or behavioral healthcare clinicians engaging patients there. My concern is not whether we place behavioral health experts there, but the extent to which they are independent. I view behavioral health as a primary health domain, not a secondary resource to be directed by the PCP.
This discussion will be limited to two topics: 1) lessons learned from efforts by health plans and behavioral healthcare entities to implement integrated care; 2) how we might best organize the primary care setting to meet both the physical health and consolidated behavioral health needs of the patient.
The health plan view of integration
The integration of physical and behavioral healthcare has already become a reality inside many health plans. Healthcare does not actually take place in these settings, but they are still laboratories for ideas about healthcare.
It might be helpful to think of coordination and collaboration as the clinical activities that improve care, while integration describes how you structure the terms and formalities of relationships. Many health plans developed or acquired a behavioral health unit rather than contracting with an external entity. Ownership enables direction over the organization’s units.
Health plans sometimes have behavioral units with leaders represented within senior management. Others have leaders with only mid-management authority. In some instances, behavioral healthcare is highly regarded and thriving, while in others it is barely visible.
My experience with health plans leaves me wary of integration. Care managers for physical and behavioral health may sit under the same roof, but this does not guarantee any specific level of care coordination or collaboration. Does integration mean behavioral healthcare is an important focus for innovation? Is its role in overall health promoted? No guarantee exists.
The reality is that innovative programs based on the importance of behavioral health will exist only to the extent a behavioral health unit functions with reasonable levels of independence and investment. Some health plans care little about behavioral health innovation or promotion. Integration within the primary care setting will be no different.
The undifferentiated patient
The American Academy of Family Physicians notes that “primary care practices are organized to meet the needs of patients with undifferentiated problems, with the vast majority of patient concerns and needs being cared for in the primary care practice itself.” The undifferentiated patient presents unanticipated issues to minimally trained doctors.
PCPs have long been unprepared for the breadth and depth of behavioral health problems. Milliman first estimated in 2008 that over 20% of total healthcare costs are driven by behavioral health issues, while a study in 2010 by the Milbank fund estimated that 70% of primary care visits stem from psychosocial issues. The leading cause of disability worldwide is depression.
The most noteworthy response by physicians confronted with these realities has been to prescribe psychotropic medications. Attention has rightly been given to how many people who might need these medications still don’t get them, while many others who don’t need them get prescriptions. Yet this is a distraction from the real problem that our healthcare system is ill equipped to deal with the primacy of behavioral health issues.
Several responses have been tried: screening for depression in primary care; enhanced education for PCPs; co-location of behavioral healthcare clinicians in primary care settings; health homes; chronic care and collaborative care models. These solutions are diagnosis-driven and led by the PCP. Some of these approaches improve care and reduce costs for the most severely ill behavioral health patients.
We need a solution as bold as that of family medicine in the 1960s. It was a response to growing specialization in medicine and the resulting fragmentation of healthcare, and it built an alternative clinical model around the family. We need a new clinical model today built around consolidated behavioral health. We need visionary clinical leaders as family medicine did in the ’60s.
A population health focus
I would argue that there is a large pool of potential leaders – psychiatrists tiring of biological psychiatry; psychologists wondering what differentiates them from other therapists after many more years of education. Where would they lead us? We need a population focus on behavioral health, recognizing the breadth of needs beyond the diagnosis-based case finding we currently pursue.
We then need to reconstitute the idea of collaboration with a broader focus on behavioral health. Let’s replace the analogy of the PCP as the quarterback for care. It is the wrong sport. We need the collaboration seen on the basketball court where plays can start with any player – the point guard is not a quarterback. Collaborative care with a population behavioral health focus needs multi-disciplinary professionals sharing the lead.
This collaborative care team will meet the undifferentiated patient prepared to confront the full range of behavioral health issues, be they diagnosable or not. This team will recognize there is no health without three prerequisites: mental health; safe substance use; robust health-promoting behaviors.
This assessment of consolidated behavioral health is on par with the review of physical health by the PCP. We will need many behavioral health specialists within the primary care setting when behavioral health achieves parity with physical health. This is the topic of the next article in this series.
If we address the 70% of primary care visits driven by psychosocial issues today, we can save healthcare costs tomorrow. Primary care integration is backwards. It is a solution that asks the PCP to drive the behavioral health focus when that focus should be driving the PCP.
Leaders in behavioral healthcare should start problem-solving. Let’s reconfigure how money and power propel our healthcare system today, not just find a comfortable place within the current structure. We need a system built on a new understanding of parity – that between systems of care for physical and behavioral health. Parity means independent leadership and adequate funding for each system.
Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.