I am an enthusiastic supporter of having more behavioral healthcare professionals work within the primary care setting. Like many colleagues, I see the need for primary care physicians to collaborate with us on the care of patients with chronic medical conditions. The high rates of comorbid conditions like depression have historically prevented PCPs from stabilizing their patients’ health or cost of care.
However, this is a secondary rationale for our working with PCPs on the frontlines of healthcare. Our field belongs there because behavior is central to health and illness. I believe colleagues who promote some form of integrated primary care, with the chief goal of improving chronic care, are missing the big picture. Behavioral healthcare is essential to the health of the broader population.
In recent months I have entered a dialogue with PCPs on these issues, and I realize that I too have been missing the big picture. Primary care is weakened and endangered. The possibility of its dissolution into a basic service model staffed by nurses is quite real. Primary care was debased during the 1990s by the HMO gatekeeper model. Today we spend half as much on it as other highly developed world economies.
While I still believe behavioral healthcare belongs in the primary care setting, reaffirmation of the initial rationale for this setting is the first step. Our field can hardly rescue primary care, but we can help it regain its proud tradition by reinforcing the importance of a comprehensive focus on health and illness. We can then contribute to that focus with an expanded scope for behavioral health in this setting.
Reaffirmation of primary care’s roots
The role of deciding who can pass through a gate is a low-level policing function. At one point in the history of American medicine, we asked primary care physicians to provide such a task. The purpose was to narrow the flow of patients into specialty care. The goal was fundamentally financial. It is a failed experiment that demeaned PCPs.
PPOs then flourished with no better financial results. Specialty care has maintained financial clout since procedure-based medicine commands higher rates. Some PCPs today fight to survive as small business owners while others accept salaried employment. Value-based care models may be a necessary next step. Yet fixing the financial arrangements will not completely fix all the care issues that are primary.
The PCP is trained to provide comprehensive care for a wide range of conditions. Behavioral healthcare professionals can expand the focus of these frontline services and address unmet needs. Yet the primary care setting is under attack as PCPs report chronic stress and medical residents abandon this career option. Large corporations either buy practices, replace them with nursing clinics, or both.
Most of what has been described here is widely known. A key statistic about medical students today accentuates the predicament. The percentage of U.S. medical student seniors choosing residency slots is closely tracked. Results from the 2020 residency match process found that only 45% of primary care positions were filled by U.S. students. Of the 45%, many of them leave primary care after residency.
Reaffirmation starts with the recognition that the foundation of our healthcare system should be routine visits with physicians with comprehensive knowledge of medical conditions that can be diagnosed and managed without specialty or facility-based care. Our field has progressed enough to know behavior holds a position of primacy in health and illness, and so we too should be in that setting.
Why is this area of medicine in crisis? My view is its size and history. It is an obvious target with over 50% of the total annual doctor visits, per the CDC. It has been battered as the entry point for reforming our healthcare system, epitomized by failed reforms like our byzantine electronic health records. Let us reaffirm its value as originally conceived and scale its funding according to that value.
Our triple focus: Behavioral health, health behaviors and comorbidities
Behavioral health issues are distinct from behavioral health diagnoses. We all struggle to adjust to stressful, challenging circumstances in life, with stress levels from mild to very severe, and functioning is impacted even when an individual’s moods and behaviors do not coalesce into a formal diagnosis. Our clinicians need to be on the frontlines to prevent these issues from manifesting as somatic disorders.
While it is important to address how global distress impacts health, so too is the timely diagnosis of psychiatric disorders. We need psychotherapists engaging patients to discover and ameliorate the full range of behavioral health problems in this setting, by using brief therapeutic encounters, digital health resources, and referrals to both peer and professional counselors outside the setting.
The second reason for placing psychotherapists in primary care is to impact health behaviors. We know that behavior change is essential for health, and our history with wellness programs shows limited results. These programs tend to rest on a set of cognitive and behavioral techniques for changing health behavior. Our experts know behavior change generally requires personal, idiosyncratic motivations.
The third justification for making behavioral healthcare clinicians an integral part of primary care is the prevalence of comorbidities among patients with chronic conditions like diabetes and heart disease. Healthcare costs for these patients are estimated to approach 75% of the total U.S. spend, and a big reason for this expense is complications caused by depression, anxiety, and other behavioral disorders.
There have been many steps taken to fulfill this third justification, but the solution is often a consulting arrangement with external experts. The potential financial savings for this third category are vast, and this alone might warrant internal behavioral resources. The proposal here recognizes a much greater need due to the primacy of behavior in health status. Behavior is key to comprehensive primary care.
It is time to recommit to the model of comprehensive primary care with an updated awareness that behavioral healthcare is primary, and psychotherapy is a remarkably effective treatment. Clinicians can use their behavioral skills to establish a therapeutic alliance, provide brief interventions, utilize digital resources, and refer to an outside network of peers and professionals.
Operational specifics on this vision will be forthcoming, based on collaboration with PCP thought leaders. Yet clinicians in our field should note well that they will not be joining a contented primary care workforce with stable organizational and financial arrangements. PCPs are embattled, with late stage physicians retiring early and residents abandoning the field.
Let us join them in the good fight.
Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.