We are bombarded with gloomy predictions every day as the pandemic drags on. Many businesses and social institutions are described as being in crisis, and it is often unclear if their projected failures are temporary or permanent. Which news sources can we trust for those assessments? When it comes to healthcare news, my preference is experts with a history of objectivity.
Business groups on health are one of those trustworthy sources. The Pacific Business Group on Health (PBGH) is a not-for-profit organization whose mission is to improve quality while moderating costs across the U.S. healthcare system. It is dedicated to the needs of public and private employers who purchase healthcare. Its website offers some grim assessments of the impact of the pandemic on healthcare.
The worst case may be primary care. PBGH describes its precarious state:
Primary care is in an acute crisis. What had been a tenuous future for independent and small practices is now in immediate jeopardy as the COVID-19 pandemic has led patients to cancel visits and postpone elective medical procedures, putting an almost immediate stop to physicians’ payments. The COVID-19 crisis is also presenting a potential breaking point for our entire healthcare system and those who rely on it for needed care.
As someone who has followed the state of our healthcare system carefully, I am both surprised and alarmed by this appraisal. My reaction bears scrutiny. It is possible to appreciate all aspects of a problem and still be shocked as it unfolds. How does survival come down to one moment in time? What shapes our views over time? Let us probe that mindset before the state of healthcare.
The formation of social views and opinions is an elusive process. It involves abstract topics subject to interpretation. Views are not derived directly from facts. We might view a social issue from one perspective, and then get a different impression from another perspective. It resembles the old gestalt perception test. The image that we see switches as the figure and the ground shift.
I hold two conflicting opinions of primary care. It is a familiar institution that has survived many challenges over time. Its demise does not seem likely whatever the current issues. However, if you talk with bitter PCPs who are retiring or with internal medicine residents abandoning it for other careers, then the demise of primary care seems likely. Which is it? Is change coming soon?
A related issue is how the established facts of history seem quite predictable in retrospect, while new developments seem highly uncertain and subject to innumerable forces. Consider a social development in our field, like the passage of federal parity. I was first engaged with this cause when one U.S. senator was motivated by having a schizophrenic child. Many years later, it seems like inevitable social justice.
Our viewpoint directly impacts our sense of urgency. The numbing perspective that institutions are immutable gets reinforced by the mistaken idea that they were somehow destined to exist. This fosters complacency rather than a sense of urgency. In fact, social advances like parity are never inevitable. Those not witnessing the transformation might think so. Yet change is always uncertain.
A time to reimagine healthcare
One lesson of the pandemic is the importance of tending to priorities before catastrophe strikes. Do not wait for a crisis to become existential. Options are fewer when the decision is about survival. Market forces prey on weak industries lacking direction, while successful ones navigate those forces by maintaining a strategic direction. Many industries are paying today for failures prior to the pandemic.
How bad is the primary care crisis? Some speculate that retail nursing clinics might replace primary care, leaving us with low-cost basic care and high-cost specialty care. Will some version of urgent care replace primary care? This would be the culmination of a relentless focus on cost-cutting. What if such radical demands were applied to our field? Would low-cost medication management be all that is left?
This specter is being raised for the sake of argument since “what-if” scenarios can help expose real problems. What is the kernel of truth related to psychopharmacology? Our field is divided in an unhealthy way. Psychiatrists sit atop our professional hierarchy, but too many have drifted away into isolated prescribing practices. Should we begin to discuss the isolation of biological psychiatry?
Our professional divide can be explained historically, but not clinically. Both medication and therapy are effective and valuable, but they are provided separately to a very large extent. Should we have more dialogue about the benefits of psychiatrists returning to diversified practices combining psychotherapy and psychopharmacology. Would that not be the quintessential evidence-based practice?
The issue of integrated care is related. This is one of the pressing concerns raised by PBGH. The organization’s CEO has written about this being one of the top 5 critical changes being pursued by America’s largest employers. She notes that nearly 80% of antidepressants are prescribed by PCPs, and she envisions better health and lower costs by integrating behavioral healthcare services into primary care.
There is currently no consensus on a strategy for such integration. A solution is surely needed for psychotropic prescribing in that setting since many patients getting antidepressants do not need them, while many in need remain undetected. Yet psychotherapy of some sort is also needed. Therapy skills are critical for addressing psychosocial issues, health behaviors, and many psychiatric disorders.
Now is the time to reimagine healthcare. PBGH views primary care as “dying” in the midst of this pandemic. Our field can be a life preserver. We can seize this moment of crisis to implement the sort of comprehensive integration that has been discussed as a vague hope for years. We might at the same time realize closer alliances between prescribers and non-prescribers in our field.
PBGH suggests that 20% of primary care visits relate to mental health concerns. Other estimates are much higher. When the role of health behaviors in chronic conditions gets added to the equation, we can see an immediate need for therapists as behavior change experts in primary care. So, let us reconfigure primary care accordingly, and let us have a sense of urgency. Do not wait for disaster to hit.
Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.