Our New Rallying Cry: 'No Primary Care Without Behavioral Care'

In 1999, the surgeon general argued that there is “no health without mental health.” The importance of mental health had become obvious to most experts, and integrated care was on the rise. He might have imagined more progress by now. Yet we will maintain a sluggish pace until our field adopts some basic structural changes. We now need a call to action, not a call to insight. Here is a suggested refrain:

No primary care without behavioral care.

This maxim distills a direction for formulating clinical care, organizing healthcare delivery, and ending stigma. Clinical care changes when primary care physicians (PCPs) and therapists come together to realize a simple fact. Behavior is ubiquitous, and it plays a role in either exacerbating or ameliorating every diagnosis in primary care. This knowledge calls for changing healthcare delivery, which then sets the stage for stigma’s demise.

The social stigma damaging our patients is longstanding. Treating it as a moral view or lack of empathy misses its structural reinforcement. It persists due to how healthcare is organized. Stigma is sustained by our field’s isolation as a specialty. When behavioral health becomes core to the nonjudgmental routines of primary care, when our patients and services are no longer isolated, stigma will begin to die.

The phrase “behavioral care” refers to behavior broadly, and it includes health behaviors. While PCPs regularly see mental and substance use disorders, they are more familiar with how health behaviors drive chronic conditions like diabetes. They are on the frontlines of the obesity epidemic, and they witness how stigma impacts obesity as it does mental illness and addiction. They see its complexity.

Behavioral care can be understood as focusing on behavior change. Our field broadly focuses on thoughts, feelings, and behaviors for change, but we can accept behavior as representing the whole. Behavior also represents our field in a basic way. Just as we literally do not understand a person’s health unless we know their mental health, care is in no way primary if behavioral health is missing.

PCPs have long struggled to impact health behaviors, and they also acknowledge having few tools beyond medication for psychiatric disorders. Psychotherapists are behavior change experts, an expertise long missing from primary care. Primary care without behavioral care should cease to exist. Behavior change (or behavioral care) is a glaring deficit in primary care that can be rectified.

The solution is to move psychotherapists into primary care to address the population’s diverse needs. Upon becoming core primary care providers, therapists would not follow current protocols of waiting for referrals from PCPs. They would work independently, follow new workflows for coordinating their activities with PCPs, and use the exam room rather than the private office as their new workstation.

This new maxim is action-oriented. It is geared to activate our field, much as insurance parity once did. We remain on the same mission started with parity. The treatment gap for our field, between those needing and getting care, is still larger than for other healthcare areas. Insurance parity was one step, and now a reorganization into primary care is the next major step to achieve this mission.

Unlike the parity battle, we must avoid the minutiae of insurance. Struggles involving fee-for-service healthcare are yesterday’s focus. The economic future of healthcare involves things like global budgets, capitation for populations, and struggles among clinical providers for a piece of the pie. Economic reform probably involves containing escalating costs by managing the total size of the healthcare pie.

Our field must start to lobby for its share, with primary care funding a key focus apart from facility-based care. Several specialties compete for funding within primary care. Note the history of accountable care organizations (ACOs). Primary care groups that secured ACO funding often allocated inadequate behavioral health resources, even while recognizing the prevalence and impact of behavioral problems.

We will not advance on clinical arguments alone. Behavioral executives must build connections, trust, and open dialogue with medical leaders. The message is simple. No primary care without behavioral care means this: primary care cannot reach its maximum potential without behavioral care. Executives must convey our unique ability to impact chronic care where 75% of total healthcare costs reside.

We are more ambitious than in 1999. We plan to end stigma. We seek a medical platform for clinical practice, along with long-term, stable funding for our growing field. Our new maxim is intended to carry us through political battles not seen since parity. The stakes of winning or losing are much greater. The larger healthcare environment is changing, and our future depends on finding a mutually beneficial fit.

Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.