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In Pursuit of Inseparable Care and a New Healthcare Culture
Much like mind and body, behavioral and medical care are conceptually inseparable. What we do in one domain impacts the other. Yet our healthcare system is fragmented, and disconnected care misses countless opportunities for health improvement. Inseparable care is an ideal. We should pursue it as a care delivery model and cultural value. Cultural goals matter as part of transforming our institutions.
Inseparable Care: The Pinnacle of Integrated Care
Transforming our healthcare system to embrace inseparability is a tall order. It means changing both institutions and culture. Today, we treat mind and body as disconnected repositories of symptoms and disorders. This is one of the drawbacks of diagnostic categories. Though critical first steps in medical care, diagnostic categories carve up what is essentially inseparable.
Efforts to coordinate care do not undo these divisions. Targeting interactions between common medical and behavioral conditions is important but limited. Inseparable care goes beyond this—it means that everyday thoughts and feelings can impact the body. The reciprocal impacts of mind and body are continuous and pervasive. Separating them conceptually is a basic error. It violates this reciprocity.
Inseparable care does not imply any specific delivery model, but it does argue for substantial behavioral capabilities in general healthcare. Licensed therapists are especially valuable in primary care. Brief visits are most scalable—primary care is best seen as offering brief interventions with trusted professionals over many years. This is a new version of long-term care for behavioral health.
Healthcare today uses screening protocols to compensate for separating behavioral from medical care. PCPs screen for depression, anxiety, etc., focusing on scores above a measure’s cutoff. By contrast, inseparable care is not limited to identifying the most severe behavioral needs since, optimally, nearly as many therapists as physicians should work in the primary care setting.
The issues warranting behavioral attention are endless. A therapist’s intervention need not be elaborate or guideline-driven. Therapists connect with people, listen, and offer guidance as needed. Problems may be simple—e.g., a patient stopping medication—or classic mind-body interactions—e.g., chronic stress erupting in physical complaints—or reflect behavioral disorders like depression or substance use.
Limitations of the Status Quo
Our field has produced two models for adapting to the current state of fragmented care: the collaborative care model and the primary care behavioral health (PCBH) model. Collaborative care is medication-focused, while PCBH is a consultative model in which therapists address a range of medical and behavioral issues. These are spartan models. They hope to achieve much with few clinicians.
Is it realistic to instead pursue a model richly staffed with behavioral clinicians? Can such an investment be justified without definitive evidence of this model’s clinical and financial impact? Yet, this is also a cultural question. We fund pharma and tech products in healthcare with limited evidence of efficacy or ROI. How do we justify different standards? Healthcare leaders like Milbank’s Chris Koller are troubled:
We don’t pay for our new pharmaceuticals based on a demonstrated return on investment. We don’t pay for our new medical technologies with a return on investment. Why should we ask that of our patient-centered medical homes?
Team-based primary care (e.g., medical home) was once seen as game-changing. Koller notes payers became lukewarm due to a weak ROI. Yet, changing a dominant paradigm always meets resistance.
Leaders like Koller and Charlie Baker question our cultural prioritizing of tech and pharma products over talk-based care. ROI questions cannot be dismissed as irrelevant, but neither should they be empowered to reject new ideas. We must consider solutions outside the prevailing paradigm.
Contemplating a New Paradigm
The term is a bit cliched, but paradigm still has meaning, and our financial model is the best example of one undergoing changes in healthcare. Fee-for-service care is slowly being replaced by value-based care. Our volume orientation will hopefully give way to cost and outcomes. This is a paradigm change.
Let us contemplate another paradigm change: inseparable care. It applies specifically to behavioral and medical care and replaces more limited integrated care concepts. Inseparable care rejects misguided divisions that can fragment care and lead to reduced behavioral health access.
Where do we begin? Behavioral executives should host brainstorming meetings with local healthcare leaders to discuss inseparable care. This will advance our thinking and build key relationships. Those personal connections will be helpful as our field consolidates with the rest of the healthcare industry.
Placing therapists in local healthcare organizations on a limited basis is an excellent way to explore inseparable care. A therapist can bring needed clinical detail to these discussions. However, such a paradigm change is fundamental, not just clinical, with every part of a business impacted.
The easiest path is our current one—prioritizing limited solutions with short-term ROIs. We can derail an expansive, new idea like inseparable care with premature questions about operations and finance. Let us first debate it as a cultural value, and if it survives that test, bring it to life inside our institutions.
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.
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