Practitioners Hold a Healthy Dose of Skepticism Before Crossing Into the Medical World

Many colleagues view my passion about working with medical systems of care as naïve or dangerous. Therapists complain of never finding a warm welcome from primary care physicians, and specialty programs in mental health and substance use disorders report a lack of understanding or respect for their work. How does this skepticism presage efforts to bring our worlds together?

The best place to start is clarifying how we got here. Our isolation from medical care is a big part of the problem, and this was never by request of the medical system. Our services evolved independently and got codified as isolated services with distinct payment and management structures. Behavioral healthcare organizations created for this “carve out” purpose are now gone. Is it time for a change?

Another aspect of our isolation rests with psychiatry. Many psychiatrists have long enjoyed comfortable independence from both medical and behavioral financing systems. Psychiatrists might well sustain private pay practices longer than most, changing only with pressure from healthcare reform. Until then, psychiatry seems happy to collaborate with medicine only with firm specialty barriers in place.

What is lost by having separate worlds for medical and behavioral healthcare? We miss the potential help each might give the other. Primary care especially needs our therapeutic skills for modifying the impact of unhealthy behaviors and addressing behavioral health disorders. Our field needs better access to care, and the routine, normalizing aspects of primary care provide an excellent path for access.

Any such move toward integration is hard for many in our field to welcome because 1) we are not in crisis today and 2) we face ambivalent medical leaders. Primary care is especially distracted by other big problems. This does not change the fact that the economic realities pushing integration are gaining steam. Consolidation is progressing, like it or not. The ever-growing medical world is absorbing us.

How do we address the reasonable skepticism that many have about physician attitudes and medical systems? Start by realizing we are rich with opportunities today, and tomorrow will provide a declining range of options. Healthcare is fragmented and exorbitantly expensive by any measure. External pressures will progressively force consolidation for the economies of scale. Choices are time-limited.

It seems clear that doctors and medical systems welcome our expertise in the abstract. Can they accept our actual needs and preferences? Everyone is reeling from mega-mergers. Doctors are increasingly salaried employees. Many in our field rightly worry about what type of second-class status awaits our integration, but we need assertive behavioral executives to guide us and educate potential partners.

Executives can start by encouraging people in our field to not get stuck on old resentments or new anxieties. Our leaders will need broad support when the time comes to forge new alliances. Resistance to change could thwart those new alliances, and so the workforce must become educated on these issues today. It is the dual role of executives to see the needs of their field as well as their companies.

Executives are ever alert to a core maxim of business. Identify needs and fill them with new ventures. Yet will the environment be ready for their solutions? Let us be honest. Most people in our field will not focus on our acquisition by big medicine until it personally touches them. Yet successful negotiations with medicine will hinge on wide and vocal support, not just actions by an enlightened few.

It is reasonable to caution about getting too optimistic that we can negotiate a mutually beneficial relationship with medicine. Oddly, we should be especially wary now that behavioral health problems are gaining increasing recognition in the media based on disclosures by prominent athletes and celebrities. We may be at risk of assuming too much clout for our field due to having greater visibility.

Visibility is not power. Whenever healthcare reform arrives, decisions will be driven more by power than merit. The healthcare industry must one day learn to better economize. Which fields will offer to get by with less? Which clinics and jobs will stay or go? We need executives with vision like Wayne Gretzky, the hockey legend who famously skated to where the puck was going. How many are skating to where it is now?

We need not scare people working in our field about the future. No one can gauge the size or nature of future crises. It makes more sense to build motivation for a better future. Let us find a comfortable seat at the table being set by our large and wealthy healthcare industry. We must endeavor to preserve our people, programs and clinical models as we engage with medical systems. Let us visualize success.

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