Primary Care Needs More Funding and the Right Behavioral Health Focus

Many behavioral healthcare clinicians want to integrate with medical care. This generally means bringing behavioral health expertise to primary care. I prefer a new, broader strategy. It challenges the status quo by asking PCPs and therapists to reconsider how they think and act as clinicians. This new foundation for primary care starts from a single orienting principle, a commitment to behavior change.

Under this principle, PCPs learn that every diagnosis they make includes behaviors that either fuel illness or promote recovery. Therapists learn that a focus on mental disorders and unhealthy behaviors covers only a fraction of the behavior change universe. Therapists will become part of the team, working in the exam room, not consultants awaiting referrals. They drive the behavioral focus for the practice.

Is this a good time to be contemplating structural changes in healthcare? The time seems ripe for primary care. It has been in decline for years, and it contracted further during the pandemic. It is widely believed that the U.S. has not been investing sufficiently in primary care. Beyond the issue of funding, many think that mediocre healthcare results in the U.S. call for reforms in primary care.

What are the latest alarm bells from experts? A 2021 government report focuses on the need to rebuild primary care. It notes that U.S. funding lags other wealthy countries. Primary care has 35% of healthcare visits but accounts for only 5% of healthcare expenditures. This “underinvestment” is contributing to the ongoing demise of primary care.

This call for investment is backed by clinical results. The government’s report follows one in December 2020 by the Primary Care Collaborative that showed states with higher spending on primary care had better clinical outcomes. This was evident in lower ER visits, hospital admissions and preventable hospitalizations. While these findings are robust, they are only a partial view of outcomes and costs.

Increased funding seems appropriate, but do we just fund the existing system? Here are a couple of the red flags calling out for reform. Low-cost retail clinics are proliferating since many patients do not see the value of primary care today. Many PCPs regret their career choice, and new physicians increasingly agree. A consensus grows that therapists add value in primary care, but debate on their role continues.

Payers are willing to fund reform if they believe a viable new model can improve outcomes and decrease costs. Which payers are well positioned to take a risk? Health plans. They have experience investing in changes to healthcare delivery, especially primary care. They know how to track the value of such investments. Their primary care groups include some that are ready to test new ideas.

Questions about return on investment (ROI) will need concrete answers at some point, but our field’s behavioral strategy is fundamentally appealing. Healthcare costs have been steadily escalating (now at 18% of GDP), and costs for chronic medical conditions account for at least 75% of the total. Chronicity is fueled by behavioral comorbidities and unhealthy behaviors. A behavior change plan seems essential.

A new primary care model infused with behavioral healthcare gets to the root problem. Behavior change hastens clinical improvement and decreases healthcare costs in many ways. Behavior change is not an ancillary service. It is rightly a core capability in primary care, a psychosocial intervention on par with medical interventions. This involves more than adding therapists to the team. It changes the work.

Some PCPs will struggle to embrace the primacy of behavior change. They will need external leadership. Behavioral executives are the best candidates to drive this multifaceted clinical-business strategy. Many executives already work with health plans, the ideal funding source for this strategy. Health plans have the resources and perspective, as well as a history of testing innovations in primary care.

Our field will become a priority for health plans and medical leaders only when we present them with solutions to their biggest problems. Primary care is an essential medical service needing a renaissance. While the need for more funding may soon be beyond debate, investors will expect an improved primary care system in return. A renaissance requires a new vision, not just more resources.

As PCP organizations actively push for increased funding, our field can seize this as an opportunity to present a strategy for making primary care both bigger and better. Growing the number of PCPs and team members is a start, but everyone must be rowing in the same direction for primary care to achieve its potential. Behavior change is often the push we need. It gets us on the right path to health.

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