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Minimize the Middlemen and Preserve Therapeutic Relationships
Healthcare systems have many gaps and deficiencies. Businesspeople are trained to see each one of them as a product opportunity, so it is no surprise they often fill unmet needs left by our healthcare system. Many of these products are valuable. Yet it often means that “middlemen” are inserting themselves into patient-doctor/client-clinician relationships. Is this the best route for healthcare?
The CEO of SCAN Health Plan, Sachin Jain, thinks the mushrooming of these products and services is one reason for the bewildering amalgamation we call our healthcare system. He complains, "Patients are not necessarily sure where to go for what, because there are so many different people.” While mostly well-intentioned, he suspects the benefits are far less than promised.
Care managers and disease management nurses are the epitome of these middlemen in modern healthcare. Their programs target patients with higher risk, cost, or complexity, and yet Dr Jain asks an essential question: Should we create “new layers of care” or instead empower the existing care network?
It may sound simple to minimize the middlemen, but it actually gets to the core of our healthcare system. Two examples from different domains of healthcare will be discussed here. They show the difficulties of minimizing middlemen and preserving therapeutic relationships for our clinicians:
- Risk-sharing with payers—a critical financial solution
- Making therapists essential primary care providers—a valuable structural solution
While risk-sharing has a long, rich history, the structural change to be discussed is a new strategy. It treats therapists as necessary caregivers on primary care teams rather than as consultants reporting to the primary care physician (PCP).
Minimizing Middlemen as Third-Party Strangers
The original middleman in US healthcare is the third-party payer. Insurance companies, rebranded as health plans, have long played a role in the exam room. It is too late to bemoan this fact now that nearly 20% of our economy is healthcare-based. However, we have learned some effective ways to manage the intrusiveness of middlemen along the way. One method has persisted through many variations.
Payers have been sharing financial risks (e.g., capitation, case rates) with care providers for decades. This sends the care management middlemen down one level to reside within the provider system. Why is this effective? Inquiries about treatment from a colleague in one’s provider system are more palatable than those of a stranger working for a payer.
I first discovered this in the 1990s when my group practice received annual case rate payments for each person referred for outpatient care, including therapy and medication management. Profit margins were adequate. The experience seemed generally positive for clients and clinicians. Risk-sharing has taken many forms since then, with value-based care being the latest incarnation.
Risk-sharing that satisfies all stakeholders may be a reasonable goal for healthcare financing as long as our system rests on third-party payers. Experts agree that the fee-for-service model is inferior. Networks of individual providers seem unsustainable—consolidation touches every healthcare segment, with clinicians steadily becoming health system employees. Risk-sharing is complicated but workable.
Minimizing Middlemen as Layers of Care
Let us recall Dr Jain’s question. Should we create new layers of care or empower the existing network? Consider primary care, where our field has tried various ways to help PCPs with pervasive behavioral issues. For this discussion, we can contrast 1) adding middlemen as care managers, consultants, and “behavioral counselors” to the team or 2) adding therapists as essential and empowered caregivers.
Our field has created middlemen consultants. The Collaborative Care Model has a consulting psychiatric focus, and the Primary Care Behavioral Health (PCBH) model has a therapeutic focus. These middlemen have low staffing levels and focus on supporting the PCP. They are not essential care providers. Some PCPs value this additional layer of input, but others prefer a non-expert layer of counselors.
Behavioral counselors are being hired in many primary care settings to address behavioral issues that impact health. While called counselors, they lack professional degrees or licenses. This should be seen as devaluing and undermining our field’s expertise. It suggests that many PCPs recognize the need for behavioral interventions but will pursue low-cost options unless our field advances better alternatives.
Those alternatives are in the hands of our executives. We do not need new products or services. Our licensed therapists can provide valuable primary care interventions today. The questions are staffing levels and status. The staffing level should meet the level of need; the status is as an essential care provider. Primary care is where behavioral issues first emerge. Therapists are essential, not ancillary.
Repairing 2 Fundamental Divisions
Our field was founded on 2 major divisions. Third-party payers stand between clients and clinicians; behavioral care is separated from physical care. We may never erase these divisions, but we can diminish their negative impact on our work.
These are executive responsibilities. Funding and care delivery models are core issues that will shape our field. Our leaders should collaborate on a strategy to position us well. Otherwise, powerful healthcare currents will mold us in ways we may not like.
Ed Jones, PhD is currently with ERJ Consulting, LLC and previously served as president at ValueOptions and chief clinical officer at PacifiCare Behavioral Health.
The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.
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