Our Best Executives Must Lead Medical-Behavioral Integration

Business experts tell us that we cannot manage what we do not measure. It is also clear that we will misunderstand what we mismeasure. Behavioral healthcare is a stepchild in the medical world, always needing to prove its worth. Dubious measures of ROI and medical cost offset have been used to test this worthiness. It is time to offer medical systems a new value proposition highlighted by new metrics.

A simple value proposition might be that our services are core to effective primary care. As such, asking if our work gives investors a good financial return or cuts total healthcare costs is both premature—let’s first figure out how to maximize our involvement in primary care—and hocus pocus based more on estimating than measuring. Our initial focus should be if the right services are being delivered well.

The Affordable Care Act deemed behavioral healthcare services as essential, but some medical systems still demand estimates of financial returns for choosing to fund behavioral products and services. As medical organizations increasingly buy behavioral systems, such requests for financial justification are likely to continue. This is best described as a ruse where few actually believe the numbers.

Calculations like ROI and cost offset have been provided for behavioral products and services, and some are so rosy as to be absurd. Medical leaders are grateful for participation in these financial exercises, but they are a distraction. The main question today should be whether our value proposition is strong conceptually. The core element is strong, but innovation is needed for a full realization of the concept.

The Value Proposition

Here is a new approach to value. The NNT for psychotherapy is 3, which suggests greater efficacy than for many other medical services. Furthermore, the need for these services in primary care now seems beyond debate. Behavior change in primary care is essential, based on both high rates of comorbidity with chronic medical conditions and the impact of health behaviors. We can fill critical unmet needs.

A big problem must still be acknowledged. While the need may be great and psychotherapy may be remarkably efficacious, we need variations of formal therapy for many. The overall need is too great for everyone to get full sessions, and some people need very brief interventions. In addition, PCPs must embrace a focus on behavior change as pervasive and essential. We must be aligned.

What is the current state of affairs with medical-behavioral integration? Therapists are working in the primary care setting in small numbers. PCPs request their services as they see the need. No one is impressed that this limited activity is highly valuable. We need more therapists working with more patients in brief encounters. This brings more value but needs both clinical innovation and PCP buy-in.

Behavioral Executives Needed

These problems must be tackled by behavioral healthcare executives. While it is clear that innovative clinicians must develop brief new services, it seems likely that solutions will only emerge when the best business and clinical minds are jointly focused on finding them. Executives must lead the coming integration, push for clinical innovation, and collaborate with PCPs to develop this new model.

What should we be tracking? As new primary care practices with strong capabilities in behavior change are built, we must track the work of primary care therapists (PCTs). This work includes their direct contact with patients and their work with external resources like digital therapeutic platforms and community-based therapists and psychiatrists. This should all be coordinated and tracked.

We cannot know at this point the minimum, maximum, or optimal amount of time for such work in a typical primary care practice. Meaningful calculations of value need this variable to be precise. Also, there are other medical settings needing behavioral expertise –e.g., pediatric settings, pain clinics—and they too should monitor activities to enable us to establish operational norms and budgetary estimates.

The Evolving Funding Picture

Funding for integration has long been the major barrier to success. While the details are unclear today, this issue rests on the same general solution as most financial problems in primary care. That is to say, fee-for-service reimbursement must be replaced by population funding for comprehensive services. Most experts expect this in the near future. Some health plans have already done pilot testing.

There is reason to believe that the total cost of care for patients with chronic medical conditions will decrease as comorbid behavioral health conditions and health behaviors are better managed. Many other cost drivers may improve as well—for example, patient adherence with recommended dietary and pharmacological treatments—but these costs should be tracked and not assumed to improve.

The current challenges are clinical and operational. How do we get vast numbers of patients in primary care the needed services to change behavior, stabilize psychologically, and follow recommendations? In addition to providing brief new services, we need workflows and tracking processes to support this infrastructure. We then must understand financial realities since financial ruses only cloud the picture.

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

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.