How behavioral health professionals can shape the future of health care teams

Literacy is essential to career success, encompassing the ability to think critically, write coherently, and ultimately develop increasing levels of mastery of an area of knowledge. 

The business world is one of those areas, with its own unique body of knowledge and way of thinking about the world. Nick Cummings cites Henry J. Kaiser, his mentor who built the Kaiser Permanente health care system, as describing the mindset of a successful business person in this way: “find a need and fill it.”¹ For professionals trained in the treatment of mental health and substance abuse issues, this is not a point of view fostered during many years of education. The prevailing view is more in line with this stance: acquire a professional license and wait for your time to be filled with clients.

Thanks to health care reform, many new paths are opening that are well suited to the basic skills of mental health professionals, but following them will require that you have not only additional capabilities but greater business literacy as well. For example, health promotion and illness prevention are not synonymous with psychotherapy, but a skilled psychotherapist has a strong foundation for building additional skills to keep people healthy. Other options for professionals to consider today exist outside the traditional office or clinic, as employers want to hire professionals who can provide effective worksite health and wellness services. And, integrated delivery systems – whether known as patient-centered medical homes (PCMHs) or accountable care organizations (ACOs) – need professionals who can provide team-based care in a primary-care practice office or other medical settings.

Opportunities like these must be understood as supplementing traditional services, not replacing them. For example, psychotherapy should continue to be offered to people with a wide array of psychological disorders since decades of research have shown that “psychotherapy is remarkably efficacious.”² While far too few people are aware of this ironclad conclusion, we cannot let psychotherapy’s effectiveness in known treatments prevent us from leveraging its power to solve other health care problems and expand business opportunities for clinicians.   

Clearly, people with health care risks such as obesity and tobacco use need something other than psychotherapy from mental health professionals, but they also need more than the education, support, and prodding by nurses that has been tried over the past decade. The need to treat these problems is clear, as is the willingness of many employers to pay for treatment services, but clinicians have yet to figure out how to effectively meet this need. The good news is that no one has yet figured this out and health care reform views health and wellness services as a cornerstone of improved health and cost outcomes.

These services can be provided through a variety of modalities: telephonic sessions, secure online sessions, face-to-face sessions at the worksite or in private offices.  The key is to realize that clinicians have not been trained for each of these modalities, and so additional training is needed.  One must also realize that these are not 50-minute psychotherapy sessions.  Successful new models will be developed by skilled clinicians with high business literacy.

Tending to the stressed workforce

A health crisis exists globally, not just in the United States, and one of the greatest concerns world-wide is stress, encompassing everything, depending on who’s describing it, from coping with the everyday challenges of life to clinical depression. Stress reduction is well tailored to the skill set of a mental health clinician, but once again the solution is not traditional psychotherapy. Employers are increasingly willing to pay for “resiliency training,” in the hopes of developing a workforce that is both physically and psychologically fit. The first place to turn for professionals who think they can contribute in this area is the work of Martin Seligman. His positive psychology, as described in his 2011 book, Flourish:  A Visionary New Understanding of Happiness and Well-being³, is the type of solution being sought by employers concerned about a stressed workforce. Clinicians will need training for this new and large opportunity.

There is a specialty within the field of psychology called Industrial and Organizational Psychology. Psychologists with this background provide a wide range of services to employers, but increasingly today’s employers are recognizing a new need. They are realizing that the health and wellness programs implemented for employees cannot succeed if the work environment itself does not support these goals. Accordingly, employers are turning to external consultants who can help them move the company further toward a culture of health. Because there are not enough I&O psychologists to do this work, there are opportunities for mental health clinicians to develop the skills needed for this type of organizational consultation. EAPs are one common pathway. Many employee assistance professionals with experience consulting to organizations on a variety of issues are working today to build their credentials related to a culture of health.

More paths to opportunity await in the development of PCMHs and ACOs, which fundamentally change and integrate care delivery. The principles at the root of these new delivery systems are patient-centered care, holistic care, and team-based care. The most common team model is for the PCP to drive the coordination of care. The PCP may personally lead this coordination or collaborate with care managers, but the essential goal is to ensure that the PCP is aware of all specialty services being provided to the patient. These services would naturally include mental health and substance abuse services and some models call for the clinician to provide these services within the primary care setting.

Although the role of mental health clinicians in new systems of care is yet to be determined, it is clear that innovative approaches for assessing and meeting mental health needs are needed. While there are many types of ACOs emerging, the mental health clinician can begin by studying the local ACOs that have formed, identifying their mental health needs, and filling those needs. While the devil is in the details, and breaking into complex business structures can be challenging, those with a high degree of business literacy will find a way to succeed.

While the ideas presented so far might suggest that the person with the highest level of business literacy will prevail, that is not really my message. In a career that has been split between direct clinical service roles and executive leadership roles, my experience has taught me that leadership and team performance matter too.  

When I suggest that health care reform is providing dramatic opportunities for mental health professionals who choose to seize the moment, I do not recommend the solitary pursuit of business success. The arc of my career went from private practitioner, to co-founder of a group practice, to chief clinical officer of a managed behavioral health care organization (MBHO) with 6 million members, to president of a division of another MBHO with 16 million members. My success after leaving the comforts of private practice was based on the exponential power of a high functioning team. My recommendation is quite simply this: become part of a high functioning team, in whatever role you find most comfortable, and assertively pursue the business opportunities of the 21^st century.

‘Team building is imperative’

Since I have digressed into a discussion of my personal experiences, and since this is my personal appeal to behavioral health clinicians to take steps to advance their own careers, as well as the careers of their colleagues, I will spend a bit more time on the personal. When managed care was changing the landscape of private practice in the 1980s, I joined a group of roughly a dozen behavioral health clinicians who met weekly to discuss how to change their business practices in response to the changing business landscape. These discussions led to my starting a group practice with a partner. We made a good team because he liked discussing clinical issues and I became more interested in the business of health care. The teams that I assembled after that in corporate America were comprised of people with diverse skills, who were empowered by me to take decisive action, and were expected to deliver results without any micro-management by me. I believe that we have entered an era in health care when team building is the imperative.   

Another way of articulating the strategy I am proposing is that thoughtful behavioral health clinicians need to develop teams with high business literacy. The new medical homes and ACOs being established today require the services of more than a single clinician, and the physician leaders of these new delivery systems need to find behavioral health teams that know how to achieve health and cost goals for a covered population. We fortunately have strong arguments to make regarding the positive impact of behavioral health care. 

One of the strongest arguments is economic:  Look at how much total health care costs increase when people with chronic medical conditions (already a high-cost population) also have a comorbid behavioral health condition. A 2011 report sponsored by the Robert Wood Johnson Foundation identified populations with comorbid medical and mental conditions as “at risk for high costs and poor quality of care.” This report indicates that 34 million adults in the U.S., or 17% of the adult population, have such a comorbidity within a 12-month period⁴ and that they often have poor medical outcomes.

Actuaries from Milliman have calculated the impact of comorbid depression and anxiety on total health care costs. They evaluated a claims database to evaluate costs for members in a commercially-insured population with one of 10 chronic medical conditions. Their next step was to identify the health care costs for members in this group with treated depression and anxiety. This comorbid sub-group cost $45 per member per month more in total health care costs than the group without depression or anxiety. However, even more important than this calculation is their estimate of the additional cost impact of members with depression and anxiety who do not get mental health treatment since their condition has not been identified. When total health care costs are calculated for this entire comorbid population, including those treated and untreated for their depression and anxiety, they account for 21% of the health care spending for the entire insured group.⁵

The leaders of ACOs and medical homes need to understand how important this comorbid population will be to their success. A team of behavioral health clinicians should emphasize the impact their work can have economically, and should be prepared to discuss protocols for integrating with the larger health care team to improve the detection and treatment of depression and anxiety. 

Of course, this is only the beginning of the value proposition, the difference that behavioral health professionals can make in a world shaped by health reform. This discussion began with the perspective of how behavioral health clinicians can benefit from being more business literate with the emergence of health care reform, but the more appropriate perspective is how savvy behavioral health clinicians can improve the overall health status of populations, as well as the total cost of health care in the U.S.

Edward R. Jones, Ph.D. is Senior VP for Strategic Planning at the Institute for Health and Productivity Management (Scottsdale, Ariz.) and a member of the Behavioral Healthcare editorial board.

References

1.      Cummings, N.A., Cummings, J.L., and O’Donohue, W.  “We are not a Healthcare Business:  Our Inadvertent Vow of Poverty,” J Contemporary Psychotherapy, 2008.

2.      Wampold, B.E., The Great Psychotherapy Debate:  Models, Methods, and Findings, Lawrence Erlbaum Associates, Mahwah, NJ, 2001, p.71.

3.      Seligman, M.E.P., Flourish:  A Visionary New Understanding of Happiness and Well-being, Free Press, New York, 2011.

4.      Druss, B.G. and Walker E.R., “Mental Disorders and Medical Comorbidity,” Research Synthesis Report No. 21, The Robert Wood Johnson Foundation, February 2011.

5.      Melek, S. and Norris, D., “Chronic Conditions and Comorbid Psychological Disorders,” Milliman Research Report, July 2008.