ADVERTISEMENT
Beware of Popular Theories in Healthcare
Theories fuel progress in healthcare. They organize our understanding of knowledge and facilitate new ways to structure care delivery. However, some theoretical models may seem positive on the surface and prove deceptive or regressive in practice. Could this be happening in our field? Evidence-based practice, collaborative care, and value-based care are highly esteemed concepts. Are they misleading?
Theories like these are commonly understood in their most superficial sense. This means an innocuous general idea can gain widespread support despite grave limitations and consequences. This is not an academic problem. It is a business problem best managed by executives.
Value-based care (VBC) epitomizes this. We want value as an alternative to volume. We want services that are largely missing under fee-for-service care to be both covered and coordinated. We want outcomes to not only be measured, but also to be taken seriously. It is easy to get consensus on those elements. Yet VBC is a complex model for funding care with high potential for negative consequences.
Executives should not be intimidated by the social consensus around an idea. They should push beyond its appearance to its less visible details. Some ideas become popularized as compelling slogans, and the challenge is to tackle their influence as much as their truth.
It is commonplace for experts to extol evidence-based practices. Advancing beyond tradition, ignorance, or greed is surely a positive step for any science. Yet this does not settle thornier questions. Many in our field continue to promote cognitive behavioral therapy (CBT) as the premier evidence-based practice. This perception has been exploited by the digital therapeutics industry and is gaining ever wider public acceptance.
This common wisdom is wrong. The evidence is equally supportive of therapies that are neither cognitive, behavioral, nor highly structured. Yet many healthcare professionals ignore these comprehensive findings, as do many innovators and business leaders. Where is the accountability?
The CEO is accountable in business. Clinicians help develop products and strategy in our field, but CEOs are accountable for success or failure. If health plans were to preferentially reimburse certain therapies based on misunderstanding the therapy research literature, the CEO is accountable. Academic problems become business problems when sales begin. Business accountability is clear and swift.
What about the highly esteemed concept of collaborative care? Some in our field embrace it based on little more than the evident meaning of the phrase itself. They may have only a vague awareness of the psychiatric consultation model from which it originates. In fact, that model uses psychiatrists to review medication use in primary care, often with unlicensed health coaches as care coordinators.
This model is not dangerous, but it is weak. A key virtue of coaching is low cost. This is not much of an innovation, and it may be time to view coaches as a poor substitute for therapists in primary care. Therapists can provide much more than therapy. Models like collaborative care fail to utilize therapists as broadly focused agents of behavior change. Primary care needs those unique skills.
Behavioral executives can and should resist prevailing wisdom to safeguard patients and staff in their organizations. Changes are coming that may seem attractive, but they could be deeply disappointing. Therapy could be cannibalized by digital products and health coaches. Funding for behavioral services could suffer as it is subsumed into the overall funding and management of healthcare.
Executives can prevent our field from taking the wrong direction. They need not become clinical experts to do so. They simply must be tough leaders who ignore trendy ideas, push beyond vague promises, and question both expected and unforeseen consequences of every decision.
Clinicians are often afraid to challenge clinical authorities without deep knowledge of a subject. Executives just need assurances they are on solid ground to confront a potential business threat. These are some brief rebuttals an executive might use:
- Evidence-based practices are less important than the people using them, and so let us not start rewarding clinicians for the techniques they use or excluding certain therapies from coverage.
- Collaborative care is fine, but we can make much more impact in primary care by making some of our therapists core providers, not remote consultants or clinicians waiting for referrals.
- VBC needs to show better success on the medical side, and until then we should not place budgets for behavioral services in the hands of those tasked with juggling total healthcare costs.
Our leaders must not be seduced by superficially agreeable theories or by social pressures for consensus. Our field is being absorbed into the larger healthcare industry from the payer to the clinic level, and we will be encouraged to accept many changes in the coming years. We should separate the good fights from those where serenity is the best alternative.
Ed Jones, PhD is currently with ERJ Consulting, LLC and previously served as president at ValueOptions and chief clinical officer at PacifiCare Behavioral Health.
The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.
References
