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Medical Collaboration is Behavioral Healthcare's Defining Challenge
There are reasons to be hopeful about the field of behavioral healthcare. One aspect of hope is knowing what to expect with confidence. While we cannot predict key future decisions for our field, we already know of major parameters shaping its direction. The healthcare industry has been profoundly changed by decades of merger and acquisition (M&A) activity. Our field has been part of that consolidation.
The days of behavioral healthcare being an independent field with separate sources of public and private financing are ending. Few independent behavioral payers remain since health plans have acquired them. Change will not end there. Payers are starting to discuss eliminating separate benefit plans for behavioral health and managing all services under a single defined healthcare benefit.
In certain circles, this has been heralded as the dawn of a new era of integrated care. That is one possibility. It is also possible that behavioral healthcare will get less attention than when it was carved out with unique benefits. What could that mean for the behavioral workforce? It is equally ambiguous. The potential exists for challenging new career paths in healthcare. Efficiency reductions are also possible.
Our field should be grappling with how to integrate people and systems so that medical-behavioral collaboration is a resounding success. Yet technological advances have been a noisy distraction from these issues. Technology has facilitated the emergence of “digital therapeutics,” and virtual therapy sessions by video connection are now common. These tools certainly improve the healthcare experience, but do not transform it.
Another distraction is discussion of “new and improved” provider networks. Yet today’s hybrid companies (digital/virtual/in-person services) have the same core challenges with their networks—clinician compensation and quality control—as the large specialty payer networks first developed in the 1990s.
We should not be distracted by the billions invested in new products. The value of these services will be determined by the health plans and health systems that will adopt and shape them. If you want to know which way the wind is blowing in healthcare, follow the large payers and provider systems.
Biopsychosocial Orientation Can Facilitate Collaboration
Large healthcare systems may be acquiring our field, one component at a time, but the question is how we ultimately fit together. Medical-behavioral collaboration, specifically the diagnostically oriented collaborative care model, is gaining support, especially in primary care, as reflected by the endorsement of 8 of the nation’s leading physician organizations.
This model has strong empirical research support and a history of implementation across varied clinical settings. However, optimizing the use of psychotropic medication is only one element of behavioral expertise to be used in medical settings. It often fails to tap the wide-ranging skills and expertise of psychotherapists. PCPs are concerned about how behavior broadly impacts health and treatment, and therapists are ideal clinicians for addressing behavior change.
The collaboration we need may best be accomplished from a biopsychosocial perspective, a model from the 1970s that for varied reasons, never reached its expected prominence in healthcare. Our current fractured environment may be an opportunity for this comprehensive clinical model to re-emerge. Yet it will achieve practical success only if the clinicians and executives working in primary care fully embrace it.
Primary Care Requires Tailored New Services
A major challenge awaits any approach to medical-behavioral collaboration. How will our chronically poor rates for access to care be improved? Outrage is rising over unconscionable delays in behavioral health appointments (including complaints of “phantom networks”), and pressure thereby builds for less expensive and readily available alternatives like digital and virtual-first services.
These access and availability problems are deeper than they appear. Those frustrated with unavailable services sit atop another group with unrecognized needs. If we include people with maladaptive health behaviors along with those with undetected behavioral conditions, the level of need easily outstrips our available pool of providers. We cannot train enough new clinicians to solve this.
A bright future for our field hinges partly on changing our approach to clinical service offerings. We need interventions tailored to the primary care setting. Psychotropic medications and formal therapy often exceed what many need, while digital services are, at times, insufficient to meet the needs of others. Brief professional contacts (up to 20 minutes) can be targeted and potent when an empathic, skilled, non-judgmental clinician is involved.
There is yet no manual guiding these brief therapeutic interactions, but clinicians often rely on their training and judgment. A bigger issue may be how clinicians with different degrees and backgrounds form integrated, collaborative, cohesive teams. We might also wonder if psychiatrists can and will join these teams as full-time participants. Are they in fact needed? Are they even interested? We will ponder these questions in our next article.
Ed Jones, PhD is currently with ERJ Consulting, LLC and previously served as president at ValueOptions and chief clinical officer at PacifiCare Behavioral Health. Chris Dennis, MD is the chief behavioral health officer for Landmark Health and co-founder of Minded.
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.
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