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Structural Change Is Needed to Transform the Behavioral Health Field
Our field will only realize its potential with structural change. While it may be challenging and expensive, the benefits of solving fundamental problems are deep and lasting. Whether we call them structural, system, or institutional changes, business executives hold primary accountability. Changes of this magnitude tend to be driven by a combination of business and clinical issues.
The domains that will be discussed here have 2 common features:
- They have fundamental flaws that broadly impact clinical care; and
- Realistic solutions exist, but implementation depends on leadership and funding.
Executives can transform our field by focusing on structural changes in 3 key areas:
- Care access;
- Care integration, and
- Clinical outcomes.
The goal here is to articulate the need for structural change and expose the weakness of today’s common alternatives. Little detail will be offered on specific structural changes.
Care Access
Our field is broadly failing to provide accessible care. While many solutions today seem sensible, they are far too limited. They are more conceptual than operational. For example, to address how we fail those with serious mental illnesses, we stress that these illnesses are like any other. Similarly, we analogize delays in treating addiction to waiting for stage 4 cancer before intervening.
However compelling appeals to the medical model might be, they focus on cultural change when institutional change is more pivotal. Systems are unchanged by acknowledging that behavioral conditions are shortchanged compared to medical ones like diabetes. Likewise, emulating the medical field’s pre-diabetes category with one for pre-addiction is doubling down on weak solutions.
It is misguided to rely on clinical problem-solving when institutional solutions are needed. Let us consider one institutional solution as an example—the primary care setting could be transformed into the initial level of behavioral care, staffed heavily with therapists, and focused on early intervention. What about training more clinicians? Fine, but do not hide them away in separate clinics and offices.
Care Integration
Clinical consensus may already exist on the importance of treating mind and body together. However, conceptual agreement on their “inseparability” means little if care integration is infrequent in practice. This problem stems from our history of partial clinical solutions. Various efforts at care integration beginning decades ago set us on the wrong path.
Primary care integration has been designed to be consultative and diagnosis-driven. Psychiatrists seek to improve primary care physician (PCP) prescribing, and therapists offer brief clinical interventions in collaboration with PCPs. They reach few primary care patients since staffing levels are low (especially for commercial populations), and the focus tends to be limited to specific diagnoses.
These models can be helpful, but we need to prioritize population solutions. Therapists are needed to address psychological contributions to health more broadly and have brief therapeutic conversations as behavioral problems are emerging. The very name “integrated care” cries out for redesigning care systems. Sending a few consultants into foreign territory was early pioneer thinking.
Clinical Outcomes
Behavioral healthcare has a trust problem. Many believe our services are ineffective, even though research is strongly supportive. A commonly recommended solution is to limit treatment to techniques found effective by research—i.e., evidence-based treatment. Does this eliminate the need for measuring results? It does not suffice in other areas of healthcare and will not solve our trust problem.
Our field lacks a tradition of measuring real-world clinical outcomes, but we have a term for it: measurement-based care (MBC). We can improve episodes of care with MBC while also taking accountability for overall results. MBC is a patient- and population-level initiative best implemented by executives. They lack the immobilizing ambivalence clinicians feel about tracking results.
While MBC was developed in the context of outpatient psychotherapy, it should be used as a routine part of behavioral services in every setting. Accordingly, MBC should be established in primary care to track outcomes for behavioral work done there. It provides added value in this setting by offering a data-driven way to identify distressed patients who might benefit from a behavioral visit.
Improving Structurally as Healthcare Consolidates
Many clinicians mistakenly believe our field improves primarily through new treatments and quality studies. On the contrary, some of our most important changes are structural, impacting care delivery in pervasive ways. The initiatives discussed here would make outpatient care easier to access, more likely to be medically integrated, and more focused on clinical outcomes.
While these changes are overdue, our field is also managing healthcare consolidation. Our services are among those being merged into health systems. It is unclear how this will impact us.
We would be wise to restructure our field now, as we transition to new ownership within consolidated health systems. Let us discuss structural changes as part of this investment phase for our field. This may be the defining challenge for today’s 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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