Keep your eyes on the prize: Thoughts on product development

Not many years ago the owners of mainframe computers and telephone landlines were quite optimistic that their vast economic fortunes would long endure. They did not see personal computers and cellular phones coming. This might be understood in retrospect as successful industries being disrupted by cheaper alternative products, or it might be seen as new products solving problems that the dominant industry did not care to address.

What sorts of problems? In simple terms, there is always a drive to get the job done cheaper, faster or better. This is a useful way to evaluate the job you are doing today. If someone is on the cusp of replacing your job with an approach that is cheaper, faster or better, then you should be thinking about joining them, beating them to the punch or moving onto something else.

Fortunately, jobs and industries are not disrupted overnight. Alternatives begin to pop up well before the seismic shift that leaves you in a dying or dead industry takes place. Also, best-in-class is often not first-in-class, as the iPod and iPhone exemplify. So, what should those of us in the behavioral health field be thinking about next generation products? What is the prize we should have in our sights?

‘Next gen’ behavioral health

We should apply the test of cheaper, faster, better to our current industry, but an inevitable criticism of this exercise should first be addressed. Helping people with mental illnesses and addictions requires an appreciation for the uniqueness of human connection and communication, and applying a business model to it could damage its core. This is quite right – a healing relationship is both powerful and precious – and so any effort to transform the behavioral health product should respect this. However, traditions such as the 50-minute psychotherapy session and the 28-day rehab stay became sacrosanct with little validation behind them. Next gen behavioral health should preserve essential elements and yet transform current practices.

Cheaper

Services provided in person with a helping professional are expensive, and they should be reserved only for problems and circumstances which require them. Cheaper interventions with a professional can be provided by phone or video connection, and even cheaper services can be delivered via web and mobile self-care platforms that direct people to tailored, evidence-based materials. Well-trained peers or para-professionals can support people needing care and help them navigate the complexities of the service delivery system.

Delivery systems need to be developed with these principles as a foundation, and they can compete on value to the extent that we can rank order systems according to the clinical outcomes achieved for the cost expended for each type of service. In other words, the prize is value, and value equals outcomes achieved/cost expended. It is far better to rely on the value equation which incorporates clinical outcomes rather than strictly focus on promoting cheaper services.

Faster

The dimension of speed is best considered in relation to how quickly patients get a needed intervention rather than how much time the intervention takes. Untreated conditions tend to advance and become more complex and disabling. Over time people with chronic conditions tend to experience complications outside their primary condition, thereby developing co-morbidities with multiple medical and behavioral health conditions. The most important challenge related to speed in healthcare is the delay of intervention.

People with chronic medical disorders who develop co-morbid behavioral health conditions are roughly 3 times as expensive to treat on average. More than half of total healthcare costs are devoted to people with chronic conditions. Time is of the essence for halting the advancement of chronicity and comorbidity, and timely services can result in both better outcomes and lower costs.

There are two pathways for quicker interventions: self-care and doctor care. Employers have long funded programs for helping people take charge of their personal wellness and wellbeing. They are well-founded, little utilized and only marginally successful. The stakes are probably too large to give up on them, and so we have to find new ways to reach people with pre-diabetes, subthreshold depression and dangerous substance abuse. It is certainly much faster (and cheaper) to find a way to stabilize people in these early stages rather than have to provide more intensive, ongoing chronic care. We may need to explore linking self-care resources to the site of doctor care rather than leave it in a wellness bubble of telephonic and online tactics.

We have long embraced a primary care model of medicine in which the PCP refers to a specialist when certain needs and conditions are detected. Some PCPs practice in group settings which facilitate specialty referrals for certain conditions, and all systems by design place a high value on communication between primary and specialty care practitioners. The goal is to ensure quick referrals and timely interventions. Only a tiny fraction of healthcare systems in the US meet this goal in terms of referral for specialty behavioral healthcare. This means that the millions of people who might benefit from a quick referral and assessment get ignored until problems are more complex and disabling.

We don’t need another cost-benefit analysis for embedding behavioral health services within the primary care setting.  Behavioral health is a primary care need driving over 20% of total healthcare spending, and so we need to incorporate it in within primary care in some way. We also need primary care to focus more on health care than sick care (or health and wellness, if you like), and so the nexus of primary care will be properly transformed when we realize that wellness and wellbeing are the prize. This will presumably include an awareness of how behavioral health professionals are the best trained specialists to promote wellness and wellbeing from the cradle to the grave.  

Better

It is fundamental to science that we test which healthcare interventions work best. We can then develop a system of care built upon services with the greatest empirical support. This approach is necessary but not sufficient for achieving the best results. It may not even be the most important strategy for best results.

In specialties like behavioral healthcare there are too few interventions with superior outcomes (in the face of a wide range of psychological conditions) and there are disparate results among practitioners using validated approaches. Many studies find differences in outcomes for psychotherapists to be more important than the psychotherapeutic interventions being used. This does not mean clinicians should feel free to intervene in any way they like, but rather that we need to be measuring how each person is responding to the care they are given. This has been called measurement-based care or outcome-informed care.

There is room for debate about the best measures of outcome – symptom rating scales, functional impairment scales, number of days sober – but we need to monitor these preferred measures during treatment and modify the clinical approach based on the response. Let’s be cautious about exhorting colleagues to follow empirically-supported practices, as if they constitute a straight and narrow “royal road” to superior outcomes.

Better clinical outcomes are one of the most highly valued prizes in healthcare. Keep your eyes on the twisting road ahead since better results, especially for the most difficult problems, are likely to be individualized and driven by how people respond to fragile conversations taking place within the context of a healing relationship.  

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