How behavioral health can advance a better model

American healthcare has received heavy criticism in recent decades due to its cost/outcome profile. The sources of poor performance in the United States are many, to be sure, and yet one source rarely gets mentioned, namely, primary care. 

Anyone following healthcare trends in the United States over the past decade will find few critiques of the deficiencies of primary care. In fact, the press clippings for primary care highlight the positive:  a desire for more primary care providers (PCPs); a call for more coordination of care by PCPs; and the development of supportive structures around PCPs called “medical homes” and “accountable care organizations.” 

One would assume that primary care is working well and that we just need to expand it in various ways. Yet, there is a body of information, both vast and well-known, if not well understood, that would suggest otherwise. Why then is everyone eager for more of the same?

The first answer to this question is that there is nothing wrong with primary care practitioners. They work hard, for less money than other medical specialists, and help their patients in many ways. To be clear, PCPs are not the problem with primary care. 

Instead, primary care is underfunded and is not structured with the right players and the right practice leaders.  Another way of saying this is that the problem lies within the primary care setting, and I will argue that current proposals for medical homes and accountable care organizations will not fix this clinical delivery dysfunction.  I will propose an alternative structure that delivers better care.

We know that 70 percent of primary care visits stem from psychosocial issues¹.  Are PCPs equipped to understand and effectively address these issues? In general, PCPs have not been selected for clinical practice due to their temperament or desire to deal with psychosocial issues, and they receive very limited training to do so.  It can be said then, with some exceptions, that they are not equipped to be effective in this regard. 

What about the lifestyle issues and health behaviors that drive over 50 percent of our health status? How are PCPs at helping people with their diet, exercise, stress, sleep, social isolation, and feelings of loneliness, all of which are significant health risk factors? Again, it can be said that PCPs are not effective, and yet, to be fair, no one has a formula for success, not even behavioral health professionals.

While these facts should lead us to question the adequacy of the primary care model today, it appears fully ripe for dismantling when we recognize that behavioral health disorders are the number one source of disability today.  Depression leads this group by far, with anxiety and substance use disorders contributing significant impairment.  This is not just a U.S. phenomenon – the World Health Organization notes that depression is the leading cause of disability worldwide.  In terms of healthcare costs in the United States, people with depression and anxiety have costs that are 70 percent higher than those without a mental health diagnosis, and people with depression are four times more likely to have a heart attack.

There are numerous troublesome facts like these, but even more worrisome is the reality that 80 percent of the people with behavioral health conditions get no treatment for these disorders.  When PCPs identify them for treatment, they typically only get psychotropic medications, even though psychotherapy is remarkable effective and produces no side effects².

While these facts challenge the rationale for the primary care model, they would be mitigated somewhat if we could point to a primary care workforce that is deeply satisfied, growing in numbers, and eager to meet these clinical challenges. The unfortunate reality is that a shortage of PCPs is projected for the future – by conservative estimates, 45,000 too few by 2020 – and physicians generally view primary care as less desirable than other specialties due to lower income and increased time demand. Choose your image, either the elephant in the room or the emperor with no clothes, but how can we not simply state that the primary care model is irreparably broken and in need of replacement?

Team-based care

Let’s start with a key element of the medical home model, namely, team-based care, and then let us reorient the model by replacing the primary care physician with a behavioral health specialist as the team leader. In so doing, we might excel at:  detecting the psychosocial issues that are motivating office visits; addressing strategies for changing critical health behaviors; and finally, diagnosing and treating unrecognized conditions like depression, anxiety and substance use disorder.  These issues require a team rather than a single behavioral health clinician. 

We still need nurse practitioners to be on the front line for treating infections and injuries – more or less, the acute conditions – and we need PCPs to be the senior physicians addressing the chronic medical conditions that drive more than half of medical costs. Coordination of care must occur not just among the members of the primary care team, but across all the medical specialties that impact a given patient.

This proposed shift in our healthcare delivery paradigm is not just driven by data from the bottom up, but it is also conceptualized top down from a different understanding of the term, “behavioral health.”  In recent decades we have developed an appreciation for health behaviors (eating, exercising, sleeping, etc.) as promoting or impairing health, and there is no single profession owning this vast domain. While we have nutritionists, trainers, health coaches and the like, this fragmented approach is not tapping the enormity of the potential for health improvement by changing critical health behaviors. 

Who should own heath behavior as the path to improved health? Behavioral healthcare professionals make the most sense, given that their training prepared them to get depressed people more active and hopeful, addicted people less compulsive, and anxious people less fearful. 

If behavioral health is understood as this broad commitment to changing the thoughts, feelings and behaviors that drive our health status – or more specifically, focusing on traditional behavioral health disorders like depression, as well as everyday health behaviors related to lifestyle and medical treatment compliance – then we are describing more than another narrow healthcare specialty.  Behavioral health in this more expanded view is “the glue” that holds all of the elements of our health together.  We need psychiatrists, psychologists, social workers and counselors leading our primary care teams with this comprehensive view of health promotion and disease prevention.  This might be called the primacy of behavioral health. 

In closing, it would be negligent to not call attention to the status quo. The proposals put forth in this article constitute an effort to imagine what the best healthcare delivery system might be for this country. It is more common to find proposals for a better system, and those proposals generally include the term, “integration.”  It is as if the answer to the fragmented system of care in the United States (surely one of its more negative features) is to save it with integration. I mistrust the simplicity of this argument that we essentially need to link the existing pieces into a more integrated whole. 

However, many experts, including behavioral health specialists, accept some variation of this.  For example, behavioral healthcare researchers have shown that they can improve primary care results by including behavioral healthcare clinicians within a “collaborative care” model3.  I reject this as a better model that fails to imagine the best model.

Primary care is fundamentally flawed because we need behavioral health to lead the assessment of the patient – leading with the “head first,” so to speak. We need to shift from an illness model to a wellness model, from an acute care model to a chronic care model, from a physician-centered model to a patient-centered model. 

There is a rich literature on these important shifts in clinical paradigms, but the primacy of behavioral health is generally not included in the discussion in any way.  This is the shift that I am suggesting which upends many current recommendations, not just those extolling the virtues of integration. I am proposing the primacy of behavioral health as the basis for transforming primary care in the United States. While I can accept that there are many ways to organize health care delivery once the primacy of behavioral health is recognized – healthcare operations are complicated and there are many ways to operationalize core values – I do not believe we can achieve the best results unless we start with the primacy of behavioral health.

1. Evolving Models of Behavioral Health Integration in Primary Care, Milbank Memorial Fund, 2010.
2.  Wampold, B.E. and Imel, Z.E., The Great Psychotherapy Debate, Second Edition, Routledge, 2015.
3. Unutzer, J., Harbin, H., Schoenbaum, M., and Druss, B., “The Collaborative Care Model:  An Approach for Integrating Physical and Mental Health Cae in Medicaid Health Homes,”  CMS Brief, May 2013.