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Overcoming Underfunding Requires Playing the Long Game With Strategic Approach
It will take shrewd long-term planning for our field to escape its chronic underfunding. Playing the long game can require creativity and risk taking, along with some financial investment. It often requires taking new paths and ignoring conventional wisdom. This discussion of integrated care is offered in the spirit of encouraging such a mindset. Integrated care is an emerging specialty that lacks strong business models.
Too often, our field starts from a clinical perspective and then builds a business case on that foundation. For example, our dominant models for integrated care—the Collaborative Care Model (CoCM) and Primary Care Behavioral Health (PCBH)—are built on consulting with physicians, usually primary care physicians (PCPs). Is that a solid business model? Is consulting a stable, long-term goal? Are other funding sources needed?
Behavioral consultants in both integration models advise PCPs in secondary roles rather than as empowered clinical partners. It is challenging to make a business consulting role secure and profitable. CoCM psychiatrists are secure—this is generally a small part of their private practices. Yet CoCM therapists face a common problem—patients are referred but are wary of seeing unknown clinicians.
Therapists can face another form of insecurity—no personal connection with the PCP. For example, primary care companies like One Medical offer virtual behavioral care—however valuable those services might be, they leave therapists disconnected from PCPs and largely unrecognized. More worrisome yet, some settings hire unlicensed staff as “behavioral counselors.” Playing the long game is essential.
The Business Model Is Question One
Care integration must be molded into a business that works well for our field and our clinicians. We need behavioral executives to develop new business models with reliable funding sources. Waiting for primary care companies to present us with mutually beneficial models for care integration is backward—we should present them with business arrangements that serve everyone’s needs.
Two traditional benefits—employee assistance (EAP) and disease management (DM)—are ripe for reconsideration by employers. Might these benefits be better used in the primary care setting with a delivery model combining digital, coaching, and professional services? Existing digital health companies already use such a model. Can we convince employers their benefits will see higher use in this setting?
The Transformation of the EAP Benefit
Employers fund EAP benefits to focus on problems before they progress into disorders, so diagnoses are unnecessary for payment. EAP services began as in-person visits, with telephonic and digital services added secondarily. Digital health companies realized their mobile and online platforms could 1) increase access overall and 2) facilitate more personal, human engagement as needed.
Spring Health and Headspace are successful behavioral companies with products featuring digital therapeutics and work with coaches and licensed therapists. They assert that their programs transform and replace traditional EAPs while boosting utilization. However, like other EAP products, theirs are detached from primary care. This is a major deficit—consumers expect most healthcare to start in primary care, not in unfamiliar offices.
While primary care is meant to be a healthcare hub, behavioral health has historically been separate. Our field must reorganize this welcoming care access point for our services. Placing new EAP delivery models like Spring and Headspace in the primary care setting is the final adjustment needed. It combines easy access to care with a range of behavioral service modalities.
The Transformation of the DM Benefit
DM targets conditions generally managed by a PCP (e.g., diabetes, heart disease), with nurses usually providing telephonic support. These programs were created as care extenders detached from primary care, but they ultimately belong in the primary care hub connected to the PCP. This change alone should boost service utilization.
DM’s services merit an overhaul as well. Much of DM is behaviorally focused—diet and exercise are core issues—and this work is best offered by a behavioral organization. Licensed therapists can address the full range of clinical issues, with other staff and digital therapeutics in support. That is, the model described for reconfiguring EAP within primary care works as well for DM, with minor modifications.
Transformation Takes Persistence
There are several critical pieces to assemble in realizing this integrated care strategy:
- Using a combination of digital, telephonic, and in-person modalities;
- Capitalizing on poorly utilized health benefits; and
- Creating a behavioral level of care within primary care’s clinical hub.
Persistence is needed to pursue such a long-term, disruptive idea, but it delivers rewards for all stakeholders when assembled.
We may need to accept integrated care contracts with unfavorable terms today, but each one should rekindle our drive for a brighter future. Long-term plans might be criticized as impractical today, but this is often how stretch goals first appear. Healthcare companies do not rise on clinical innovation alone—astute business planning is also essential. The long game we must play is a business sport.
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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