New Thinking Is a Prerequisite to Fixing Primary Care’s Therapist Shortage
Behavioral health services are failing to meet the scale and variety of needs found in primary care. While this perception is widely shared in healthcare, little urgency is evident to get to the root of the problem.
The leading approach to integration, the Collaborative Care Model (CCM), started with a medication focus and expanded to include therapy. Yet it epitomizes the shortcomings of care integration today. A new clinical model that better resolves the pervasive behavioral needs in primary care is needed.
The Limitations of Collaborative Care
CCM’s approach to primary care integration is insufficient for 2 reasons. It is a consulting model with low staffing levels, and it is clinically grounded in the medical model. Primary care needs an influx of full-time therapists who function as essential care providers. They must leverage their psychotherapy training to provide brief interventions, relying on a psychosocial rather than medical orientation.
Today’s behavioral clinicians advise primary care physicians (PCPs) as non-essential consulting staff, and therapists typically see few patients because they provide traditional therapy. A medical orientation to therapy often means a preference for diagnosis-specific therapies—a bias not supported by the evidence. Psychosocial thinking does not start with the diagnosis but rather with the problems and goals presented by the client.
The medical model is not flawed. However, it is insufficient in that it cannot solve many problems found in primary care. We need psychosocial services as urgently as medical ones. While the medical model stresses validated interventions and therapies, psychosocial services depend more on the therapist’s training and judgment—engagement and listening skills are more critical than techniques for therapists.
The Executive Challenge for Structural Change
This is not fundamentally a clinical debate. The goal should not be to convince clinicians about clinical solutions. This is a care delivery problem that executives must solve by organizing their delivery systems as needed. The required prescription comes not from a physician but from a healthcare administrator. Neither primary care executives nor behavioral executives can solve this alone.
The siloed nature of healthcare is a problem regardless of the clinical model for solutions. PCPs are the professional owners of the primary care setting, and other specialists enter as consultants. If this were not so, prevalence rates alone might dictate having as many therapists as PCPs in primary care. Consider the major behavioral categories that disrupt lives. Vast unmet needs wait in each one:
- Behavioral disorders like depression, anxiety, and SUDs
- Non-diagnostic behavioral issues like loneliness and social isolation
- Critical health behaviors like eating, exercise, and sleep
- Psychosomatic disorders like some types of headaches and ulcers
- Coping skills to manage everyday stressors
Executives must assure all parties that a psychosocial orientation is neither anti-medical nor anti-psychiatry. The goal is simply to achieve parity among these clinical models. Yet achieving this goal will require some physician leadership.
The Imperative of Psychosocial Thinking
The medical model reaches its limits in domains other than primary care integration. Consider the medical limitations found in the treatment of serious mental illnesses. Former National Institute of Mental Health Director Tom Insel stresses this in a recent interview:
We’ve been trying to mimic infectious disease medicine, where a simple drug kills a simple bug. With mental health, this medical model is necessary but completely insufficient. We also need a recovery model that requires a lot more than medication. It is not just about reducing acute symptoms but also making sure somebody actually recovers to lead a full and independent life.
Dr Insel knows the power of psychosocial interventions in treating mental illness and argues that over-emphasizing biomedical solutions can distract us from goals like recovery and resiliency. His point rises above specific interventions. He warns of devaluing a class of services—psychosocial—that is on par with medical services in being necessary yet often insufficient. Each clinical model has a vital role.
Show Me the Money
The prevalence of behavioral problems in primary care calls for action. Very different responses are generated by the medical and psychosocial models. Our healthcare system follows the medical model, awaiting validated interventions for specific problems and diagnoses. The psychosocial model prioritizes the need for healers. A PCP is one type of healer, and a therapist is another. Both are necessary.
Different solutions appear once an executive starts thinking in organizational terms, but those solutions will require funding. Fee-for-service reimbursement (e.g., CPT codes for partial sessions) cannot fully support such reconfigurations. How will these high-minded, fundamental changes be funded?
This is the great irony of paradigm change. Where are the needed funds? They are locked up in the medical model, of course. This is not to say medical funds must be raided, but rather, the dominance of the medical model keeps all funding tied to its terms, definitions, and solutions—we must unlock funding for psychosocial solutions by breaking the hold on funding maintained by all things medical.
The funding model of the future appears to be value-based care, but nothing will change under that model unless our thinking about solutions changes first. Executives must be our thought leaders.
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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