The phrase, “motherhood and apple pie,” has long been used as an everyday critique of proposals with vaguely positive ideas that no one could generally oppose, but that don’t carry enough content or substance to know how constructive they really might be in practice. I nominate the idea of integrated care to that tradition.
Integrated care is a slogan. It seems like a high principle, but it is really a ruse or gross exaggeration in most cases, especially when behavioral health is on the table.
Prominent thought leaders from many specialty healthcare disciplines have encouraged us to integrate behavioral healthcare solutions into primary care. Many are increasingly recognizing that behavioral health problems are so prevalent as to be considered epidemic. Depression is the number one source of disability, and an escalating opioid crisis in the United States is resulting in overdose deaths unlike anything we have seen before. More people are now overdosing from opioids each year than died annually from AIDS at the peak of that crisis.
Utilization and quality oversight: communication among care managers
It is important to narrow the field of discussion since integrated care is a slogan in many areas of healthcare, from payer levels of quality oversight (health plans and managed behavioral healthcare organizations) to the trenches of healthcare delivery (primary care providers, accountable care organizations, etc.) to newly integrated digital tools (e.g., Health Cloud and myStrength).
Health plans with behavioral health units managing behavioral healthcare (e.g., Anthem, Aetna) and independent managed behavioral healthcare organizations (e.g., organizations like Magellan, Beacon, New Directions) insist that they foster integrated care since they encourage communication between physical health and behavioral healthcare managers. Shall we address the results that validate the existence and the importance of this integration? We can’t. We simply don’t have a body of evidence for integration by any of these entities.
There is no established evidence that health plans effectively integrate their medical and behavioral health services, nor that managed behavioral healthcare organizations do this. Since no payers or quality oversight entities are really asking for serious evidence in this regard, health plans and managed behavioral healthcare organizations can just proclaim their excellence in this area. We really have no idea how well they integrate medical and behavioral health services, and we have no idea whether superior integration at this level would lead to better clinical results.
Clinical delivery integration: communication among specialty clinicians
It would seem reasonable to presume that it is important to get our primary care providers and psychotherapists talking with one another, but again we have no body of evidence that integration of front line clinical providers makes a difference. This sort of communication between clinicians was accepted as essential long ago, even though the lack of such communication was also accepted as the norm. My experience is that this matters little for the vast majority of people (mild to moderate problems), and yet it could make a difference in clinical outcomes for the most severely impaired. Therefore, we should discuss some version of the collaborative care model.
The prevailing idea for collaboration today is to have specialty healthcare providers, like behavioral healthcare clinicians, find an effective way to integrate into the dominant primary care model. I would argue for a different model: Let’s make the specialty of behavioral healthcare first-rate, and then, let the benefits from that transformation flow to primary care and other healthcare specialties. This is not the space for a detailed argument about how we structure our healthcare system, and so I will just articulate one of the main healthcare priorities that I embrace. Our emotional health is primary for our overall health status, and all care should be grounded in an understanding of emotional health.
SUD and mental health integration: perhaps the most desperate case
Integration in this domain may seem like a tangential topic given that only a little more than 10% of those needing substance use disorder treatment in any given year get it. However, we should still address the question of integration since comorbid substance use disorder and mental health conditions are the norm. The reality is that most substance use disorder programs focus exclusively on sobriety, while others provide limited resources for mental conditions. This is a major problem that must be addressed, and the reality is that evidence-based digital tools for depression, anxiety, and the like could be incorporated into substance use disorder programs at low cost. More professional help is needed, but digital tools are a good place to start for people desperate to manage their co-occurring mental health conditions.
Video, phone, digital and text-based integration into care: a new model
These emerging modalities should become standard for what people expect to be available to supplement or replace their face-to-face professional office visits. These services are not weak replacements for traditional services. There are empirical studies for start-up companies today that suggest clinical outcomes are substantial, but the ultimate vision should be to integrate all of the effective modalities for helping people into a comprehensive healthcare delivery system. The goal should be for people to be able to select the modality that best suits their clinical needs and personal preferences.
The clinical professional gap: credentials for para-professionals
While you can teach people to be more empathic, there are people who come by it naturally. This is the first ingredient for a good psychotherapist. An effective psychotherapist should be empathic, and then she needs an orienting model for how to help people1. Yet the data do not support one model over another. Cognitive behavioral therapy is not actually the most successful model for the treatment of any condition, but it is certainly the most persistently promoted model of treatment.
The question becomes quite practical. We have nurse practitioners who help millions of people that are not engaged with a primary care provider, and so why don’t we have “peer therapists” (my term) who might help millions of people with their mental health problems through empathic listening and a generally accepted clinical model? In the public sector we have long had certified peer specialists who have guided people with serious mental illness to recovery and resiliency based on their own personal journey to mental health.
I am suggesting a similar model that would be focused on the vast majority of people without a serious mental illness, yet who suffer from enough psychological distress to merit a helping relationship.
Real integration of healthcare services is hard, and it is only an article of faith today that integration will result in significantly better health outcomes. It seems intuitive that integration is a worthwhile goal, but our healthcare system has a graveyard of structural or process solutions that once seemed worthwhile. Changes to any system are largely controlled by the most powerful parties at the time of reforming the system.
The behavioral healthcare industry is low on the hierarchy of power and influence, and it should be wary of any proposals for integrating with general medical care. Getting a bad deal is certainly a concern. However, a larger objective or goal should be this: We should be trying to build a healthcare system with emotional health as the number one priority. Emotional health drives our overall health. That should be the first principle of any integration model.
Ed Jones, PhD, is senior vice president of the Institute for Health and Productivity Management.
1. Wampold, Bruce (2012), The Great Psychotherapy Debate