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Should we aim for cured, doing better or still working on it?
Behavioral healthcare professionals are taught a variety of ways to help people, and yet there is little instruction on how to talk to clients about the level of clinical success they should expect. Addiction treatment has been quite distinct from mental healthcare in this regard, offering some of the boldest and the most tepid claims. An expensive residential treatment program in Malibu has been promising a cure for addiction for many years, which is quite a departure from the typical 12-Step promise that “the program works if you work it.”
Is this an important problem? We can start to assess this by looking to the broader healthcare arena.
Let’s start with the extreme: many people with chronic pain have hoped for an end to their suffering and instead found that they became dependent on opiates, with occasionally deadly outcomes. Let’s move to the banal: most people expect little from physician recommendations about lifestyle eating and exercise changes. Yet many people are transformed into “thriving” states of health and wellbeing that they never expected when they changed their lifestyle.
In many ways the question is how much benefit can a specific treatment provide, and how much benefit is dependent on the behavior of the patient. Does that settle it? Can we offer nothing more specific? Isn’t it reasonable for patients to ask their healthcare providers: Will I be cured, or just do better, or still be working on my health status years from now?
Let’s be honest, we want a cure. We are living in a high tech world with big expectations for solutions. In healthcare this generally means curative medications or surgeries. “Please eliminate the source of my suffering, doctor, and the burden on me is to merely follow some limited instructions to enjoy my recovery.” Many diseases fit this mold and many do not. Some people may need to deal with the reality that better is all you get, or ongoing self-management is as good as it gets.
Physicians are trained to start with diagnoses and work along a chain of possible treatments for that condition. Patients are told to be attentive and obedient, yet rarely are either. Physicians will often say that if this medication does not work, we will try this one instead, and if that does not work, we will try this more invasive procedure.
The percentages of likely positive outcomes for each stage of treatment are outlined, with the overall message being that we will pursue the best outcome based on the results at each stage of treatment. It is both honest and confusing.
What is the behavioral healthcare corollary? As an industry, we are allergic to outcomes. We have spent most of our history—let’s just say starting with Freud—proclaiming how unique our work is and how difficult it is to measure our results, or we just proclaim our excellence based on case studies. This is rapidly coming to an end thanks to the tremendous strides taken by the federal government with the federal parity law and the Affordable Care Act (ACA).
What we measure
In physical medicine we have been measuring basics such as cholesterol, blood pressure and hemoglobin A1c for some time. In behavioral health we have been derelict, with many excuses, but payers were not so concerned, until now. Federal parity created far richer insurance benefits for behavioral health conditions, and the ACA has created incentives for integrated, value-based care.
We now have hundreds of accountable care organizations (ACOs) around the country, launched by the ACA, that are attempting to improve the quality and experience of care while lowering costs. This means that there is yet another awakening (yes, this is old news to many) to the fact that behavioral healthcare costs are enormous.
How can we best express those costs? I would offer the mnemonic of 1-20-50. Health Affairs1 recently published an article that shows “mental disorders” to be the most costly conditions—that is, number one—in the United States. MIlliman2 showed years ago that over 20% of total healthcare costs are driven by depression and anxiety since they escalate total healthcare costs for people with chronic medical conditions. The Centers for Disease Control and Prevention reports an even more chilling statistic: the average U.S. citizen has a 50% chance of experiencing a behavioral healthcare disorder in his or her lifetime.
That’s the 1-20-50 wake-up call for behavioral health.
Now that behavioral health is gaining attention and there is a growing chorus for coordinated, integrated care, along with a push for value-based reimbursement, what can we expect to change in the delivery of behavioral healthcare services? While the services themselves may change little in the near term—for example, the highly efficacious services such as psychotherapy and motivational interviewing—our systems for measuring real world clinical outcomes will evolve, and our healthcare silos will increasingly be torn down.
Yet the 50 in our 1-20-50 will drive another shift in services. Face-to-face services are not possible, nor necessary, for all of the people who will encounter behavioral health difficulties. We are seeing the emergence of telephonic, video, web, and mobile services in behavioral healthcare today, and this will transform the delivery of services in the years to come. The reality is that cognitive behavioral therapy delivered over the internet is as effective as face-to face services3.
How does all of this come together? As more behavioral healthcare services are offered to meet demand, and as expectations rise for positive clinical outcomes and a reduction in healthcare costs, this will of necessity lead to measurement—of access, outcome and cost. Measurement is the basis of management, and this will be the next transformation of the behavioral healthcare industry.
This means that payers, consumers, and family members will increasingly be asking one question. Can we expect that your services will result in a cure, just doing better, or the need to still be working on issues years from now?
The answer to this question should be quantitative, much like the physician who lays out the path from one treatment option to the next based on treatment responsiveness. We will need to show people with depression, anxiety, and addiction that we are monitoring their progress and we are tailoring their treatment based on their progress. We need not burden clinicians with the expectations of cure, nor expect patients to move themselves into a state of wellbeing through self-care activities, but rather provide a playing field with a way to determine who is improving and who is not, tailored with a path to the optimal outcome for each individual.
The reality is that the optimal outcome is not universal, but highly individualized, and we need to calibrate every individual path with meaningful metrics. People with schizophrenia achieve recovery and resiliency. People with addiction achieve sobriety and outstanding achievement. These are surely outcomes to be studied and applauded, but there are also people who die from suicide and overdose daily, and many of them are in treatment. We should only promise our best therapeutic methods, with our best measures, along with our humility as caregivers.
Show effectiveness
What is new today? We can be proud of the treatments that have been developed for mental health and substance use disorders. We can lament our lack of business savvy since the dawn of insurance coverage for mental health and substance use disorders. We now must be focused on both as if our survival depends upon it. In fact, it does. We need to show we are effective, and we need to become serious business people, given the significant dollars at risk to win or lose.
Many people became behavioral healthcare clinicians with the motivation to help people in the shadows. They have been helping people navigate the terrain of healthcare conditions with a stigma. There was no real pressure to demonstrate the value of the services offered. In many cases, the treatment providers just offered what they had found to be personally helpful—for example, 12-Step meetings, behavioral activation, journaling, dream analysis, whatever. There is nothing wrong with this. But when the stigma is lifted, and the reality of 50% is recognized, we will, and must, expect more. We expect measurement, coordination, and accountability. This represents a cure to second-class citizenship.
Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management
Roehrig, C., “Mental disorders top the list of the most costly conditions in the United States: $201 billion,” Health Affairs, June, 2016, 35:6.
Melek, S. and Norris, D., “Chronic conditions and comorbid psychological disorders,” Milliman Research Report, July 2008.
Titov, et al., “Computer-delivered cognitive behavioral therapy: effective and getting ready for dissemination,” F1000 Medicine Reports 2010, 2:49.
