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Understanding the Behavioral

healthcare crisisThe Promise of Integrated Care and Diagnostic Reform

Edited by Nicholas A. Cummings

and William T. O’Donohue

http://www.routledgementalhealth.com/understanding-the-behavioral-healthcare-crisis-9780415876438


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Library of Congress Cataloging‑in‑Publication Data

Understanding the behavioral healthcare crisis : the promise of integrated care and diagnostic reform / edited by Nicholas Cummings, William T. O’Donohue.

p. cm.Summary: “The Promise of Integrated Healthcare is a necessary book, edited

and contributed to by a great variety of authors from academia, government, and industry. The book takes a bold look at what reforms are needed in healthcare and provides reforms and specific recommendations. Some of the serious concerns about the healthcare system that Cummings, O’Donohue, and contributors address include access problems, safety problems, costs problems, the uninsured, and problems with efficacy. When students, practitioners, researchers, and policy makers finish reading this book they will have not just a greater idea of what problems still exist in healthcare, but, more importantly, a clearer idea of how to tackle them and provide much-needed reform”-- Provided by publisher.

Includes bibliographical references and index.ISBN 978-0-415-87643-8 (hardback : acid-free paper)1. Mental health services--United States. 2. Health care reform--United States.

3. Integrated delivery of health care--United States. I. Cummings, Nicholas A. II. O’Donohue, William T. III. Title.

RA790.6.U53 2011362.196’89--dc22 2010043255

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v

Contents

Acknowledgment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ixEditors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xiContributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii

1 Chapter Where We Are, How We Got There, and Where We Need to Go: The Promise of Integrated Care . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Nicholas A. Cummings and William T. O’Donohue

2 Chapter Our 50-Minute Hour in the Nanosecond Era . The Need for a Third “E” in Behavioral Healthcare: Efficiency . . . . . . . . . . . . . . . . . . . . . 19

Nicholas A. Cummings

3 Chapter The Financial Dimension of Integrated Behavioral/Primary Care . . . . . . . . . . . . . . . . . . 33

Nicholas A. Cummings, William T. O’Donohue, and Janet L. Cummings

4 Chapter Mental Health Informatics . . . . . . . . . . . . . . . . . 59

Bruce Lubotsky Levin and Ardis Hanson

5 Chapter E-health and Telehealth . . . . . . . . . . . . . . . . . . . 83

Anthony Papa and Crissa Draper

6 Chapter Can Prescribing Psychologists Assist in Providing More Cost-Effective, Quality Mental Healthcare? . . . . . . . . . . . . . . . . . . . . . . 129

Morgan T. Sammons

7 Chapter Diagnostic System Innovations . . . . . . . . . . . . 149

Thomas A. Widiger



vi Contents

8 Chapter Evidence-Based Treatment . . . . . . . . . . . . . . . . 171

E. David Klonsky

9 Chapter The Quality Improvement Agenda in Behavioral Healthcare Reform: Using Science to Reduce Error . . . . . . . . . . . . . . . . . . 203

William O’Donohue, Rachel Ammirati, and Scott O. Lilienfeld

10 Chapter The Behavioral Health Medical Home . . . . . . . 227

Dennis Freeman

11 Chapter Reforms in Professional Education . . . . . . . . . 257

Ronald R. O’Donnell

12 Chapter Pay for Performance and Other Innovations in Reimbursement for Behavioral Care Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279

Nicholas A. Cummings and Janet L. Cummings

13 Chapter Trends in Behavioral Healthcare for an Aging America . . . . . . . . . . . . . . . . . . . . . . . . . . 299

Christina Garrison-Diehn, Clair Rummel, Casey Catlin, and Jane E. Fisher

14 Chapter Failure to Serve: The Use of Medications as a First-Line Treatment and Misuse in Behavioral Interventions . . . . . . . . . . . . . . . . . . 327

John L. CaccavaleWith the collaboration of Joseph Casciani, Nicholas A. Cummings, Jerry Morris, Dave Reinhardt, Howard Rubin, Elle Walker, and Jack G. Wiggins

15 Chapter Reforms in Treating Children and Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343

James H. Bray



Contents vii

16 Chapter Reforms for Ethnic Minorities and Women . . . 367

Lorraine Benuto and Brian D. Leany

17 Chapter Wellness and Prevention: Key Elements in the Next Generation of Behavioral Health Service Delivery Systems . . . . . . . . . . . . . . . . . 395

Monica E. Oss

18 Chapter Reforms in Veteran and Military Behavioral Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417

R. Blake Chaffee

19 Chapter Biofeedback . . . . . . . . . . . . . . . . . . . . . . . . . . . . 441

James Lawrence Thomas

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 469



33

Three

The Financial Dimension of Integrated Behavioral/Primary Care

NiCHOLAS A. CuMMiNGS, WiLLiAM T. O’DONOHuE, AND JANET L. CuMMiNGS

Very few people do anything creative after the age of 35 . The reason is that very few people do anything creative before the age of 35 .

Joel Hildebrand (2008)

iNTRODuCTiON

There are two reasons why mental health, now more appropri-ately termed behavioral healthcare, is declining: (a) a lack of understanding among psychotherapists of healthcare econom-ics, particularly the intricacies of medical cost offset; and (b) our failure as a profession to see the importance of behavioral interventions as an integral part of the healthcare system inas-much as the nation pays for healthcare, not psychosocial care . In recent years, we have relied on parity legislation, which ostensibly mandates equal importance between physical and mental health, and have spectacularly enacted it in 44 states as of this writing . However, lacking the appreciation that eco-nomics always trumps legislation, the profession is startled that the percentage of the mental health portion of the nation’s total health budget has declined from 8% before parity leg-islation to 4 .5% (Carnahan, 2002; Forbes, 2004) . Economists are well aware of such an untoward relationship, pointing, for example, to rent controls, which invariably result in drastic reductions of available low-cost housing (Sowell, 2003) .



34 N .A . Cummings, W .T . O’Donohue, and J .L . Cummings

This chapter will briefly describe the rapid changes in the economics of healthcare during the past 75 years, including the post-World War II enthusiastic espousal of psychotherapy by the American public . This was followed by a precipitous decline as our outcomes research in behavioral care remained ignorant of financial outcomes, leaving it to the government and managed care to curtail escalating mental health costs arbitrarily . Preceding this drastic economic shift, time-limited (brief) psychotherapy was developing, encouraged by finan-cially sensitive outcomes research .

Unfortunately, psychology fiercely resisted these trends and scoffed at the harbingers that the delivery of behavioral care was about to industrialize and that financial considerations would usurp the decision-making process . At the present time, psychology is on the cusp of becoming part of the healthcare system through integrated behavioral/primary care, renew-ing the primacy of financial considerations such as return on investment (ROI) and medical cost offset, as well as an urgency that we avoid the mistakes emerging in some flawed implementations of integrated care (Cummings, O’Donohue, & Ferguson, 2003) .

A BRiEF HiSTORy OF HEALTHCARE ECONOMiC DEvELOPMENTS: 1929–2009

When the Great Depression (1929–1941) engulfed the United States, medicine had come of age, transitioning from an often apprentice-trained profession to accredited medical schools and state laws with licensure governing its practice . Essentially, medicine was all of healthcare, with everything else (e .g ., nursing) being ancillary . Before World War II, there were about 200 psychologists in the private practice of psy-chotherapy scattered about the nation, most of whom were women practicing with a master’s degree who saw children . These were tolerated by the 5,000 psychiatrists in existence at the time—most practicing without board certification .

Physicians were far from wealthy in spite of a shortage . They were dedicated, often working long hours because they were determined to see every patient who wanted to be seen; never refusing a house call, even at night; and never remanding an unpaid bill to a collection agency because that was considered unethical and unprofessional . There was no healthcare insur-ance; few patients could pay in those economically depressed years, and those who could pay would be charged double to



Financial Dimension of Integrated Behavioral/Primary Care 35

make up for the destitute majority . This was the era of “Robin Hood medicine,” with tired, overworked, and underpaid phy-sicians looking old by their 50s and dying at an early age .

Patients were grateful and saw doctors only when abso-lutely necessary; they often paid in kind (bushels of corn, dressed chickens, handyman services, even housecleaning) . Physicians continued to treat patients, no matter how large the unpaid bill . Hospitals were all nonprofit, were often reli-giously affiliated, and held annual charity drives to make up huge shortfalls because they treated everyone in spite of inability to pay . It was the avowed responsibility of religious and charitable groups to see to it that everyone, especially children and the elderly, received at least the minimum in healthcare . Then came prepaid healthcare—very little at first, but once it took hold, the doctor–patient relationship would never be the same .

First on the scene were the so-called “Blues .” To create a much needed revenue stream, hospitals organized into an organization named Blue Cross . For those who could afford a monthly premium (small by today’s standards), any needed inpatient services were prepaid . In defense, physicians orga-nized into a parallel organization named Blue Shield that prepaid most outpatient services . In the 1930s, the need for prepaid care was so intense that special laws were created for “medical services corporations” that enabled their success by exempting the Blues from the rigorous regulations and large reserves required of full-fledged insurance companies . This special legislation was later used to keep out other forms of prepaid healthcare . It should also be noted that mental health-care was a stated exclusion .

During World War II, when both goods and labor were in short supply, the government imposed ceiling prices on all commodities and wages . The newly created war industries needed to recruit tens of thousands of workers from the farm belt, whom they would train for such purposes . Unable to use the inducement of higher wages, Henry J . Kaiser, in his ship-yards, as well as other industrialists in their aircraft and other war industries, hit upon the option of providing healthcare for workers and their families . Because healthcare was difficult to obtain in rural areas, the inducement worked; hundreds of thousands of farmers, especially from the economically depressed “dust bowl” (Oklahoma, Arkansas, Texas), moved to the industrial North and West . Employer-paid healthcare was born and soon became a standard in the United States .




Amid accusations of “socialized medicine” by both the Blues and the American Medical Association, after World War II Kaiser brought his previously in-house health plan to the general public . Beginning in Northern California, prepaid healthcare purchased by employers or labor unions was based on capitation: Each month, the Permanente Medical Group received a set fee for each enrolled member, in advance; in return, it provided all the care, both outpatient and inpatient, with no further fee or copayment from the patient treated . As the first health maintenance organization (or HMO, even before the name had been coined), Kaiser-Permanente so impressed the federal government in its delivery of quality care at effi-cient cost that, in the mid-1970s Congress passed the HMO Enabling Act . Heretofore, HMOs had been California and Minnesota phenomena, but soon there were HMOs in all parts of the country; they were the precursors to managed care .

Little noticed by the health professions, in the mid-1980s the U .S . Supreme Court ruled that healthcare was subject to antitrust and restraint of trade laws . This nullified state laws forbidding the corporate practice of medicine . Almost simul-taneously, the Congress enacted DRGs (diagnosis-related groups), which defined the maximum number of hospital days for which the federal government would pay for over 400 diag-noses . These two developments made possible and ushered in managed care and the rapid tethering of the spiraling health-care rate of inflation .

However, because DRGs could not be written for psychia-try, the problem of out-of-control costs for mental health was turned over to the private sector, and managed behavioral health organizations (MBHOs) were created almost overnight . Foreseeing the birth of MBHOs, Cummings (1986; see also Cummings & Fernandez, 1985) created a model whereby prac-titioners rather than “bean counters” would still determine the course of behavioral care . Called American Biodyne, its tre-mendous success as a practitioner-driven MBHO was rejected as unnecessary by psychology and psychiatry . Furthermore, these professions ignored the need as well as their responsi-bility to contain runaway mental health costs (Fox, 2004), and soon the practice lost control of its own destiny . Perpetuating this antibusiness bias and economic illiteracy (Cummings & O’Donohue, 2008), psychotherapists have seen a precipitous decline in their practices and in their incomes . Psychology is now the lowest paid doctoral health profession .




AFTER WORLD WAR ii: THE BiRTH OF NONPSyCHiATRiC PSyCHOTHERAPy

General William (Will) Menninger, chief psychiatrist for the U .S . Army during World War II, introduced many innova-tions, including the effective use of young, specially trained psychologists who rendered immediate behavioral interven-tions in the battalion aid stations (tent-style movable medical facilities just behind the battlefront) . To Menninger, the need for immediate behavioral interventions was necessary to pre-vent onset of chronic mental states . Thus, he implemented the world’s first integration of behavioral health into a primary care setting, a fact that has been lost in history . Nonetheless, this and other mental health innovations were widely heralded in books and movies, and there arose a tremendous interest in psychotherapy . The demand far exceeded the supply of psychotherapists, and the Veterans Administration and the National Institute of Mental Health (NIMH), reasoning there would never be enough psychiatrists, created student stipends and educational funding, not only for psychiatrists but also for psychologists and social workers .

The combination of intense societal interest and public funding launched nonpsychiatric psychotherapy, but it was not easy at first . Organized psychiatry opposed the private practice of psychology, fought its efforts toward licensure, and was joined, paradoxically, by the then academically controlled American Psychological Association . A 30-year battle ensued (chronicled in Wright and Cummings, 2005), but as soon as doctoral psychology won the intense struggle, social work on a master’s level followed in psychology’s footsteps, soon to be joined by such newly spawned master’s professions as mar-riage and family therapy (MFT) as well as counselors .

Soon there was an oversupply of psychotherapists—over 700,000 as of this writing (Hogan, 2003); although authorities recognize a great need in society for behavioral interventions, need does not necessarily translate into demand . The golden age of psychotherapy was over by the mid-1990s, done in by our insistence on long-term (largely psychoanalytically oriented) psychotherapy, as well as the profession’s refusal to address out-of-control mental health costs that, for a time, exceeded a 16% inflation rate . Controls were foisted upon the economi-cally helpless psychotherapy practitioners—often arbitrarily, but ever so drastically .




THE BiOMEDiCAL REvOLuTiON

In the mid-1980s, psychiatry began “medicalizing,” a term denoting that it had now become essentially a prescribing and hospitalization profession . Psychotherapy, disdainfully referred to as “talk therapy,” is essentially lacking in current psychiatric residencies; the relatively few psychiatrists who still perform psychotherapy tend to be over age 50 and prac-tice largely in the northeastern part of the country . DSM diag-nostic categories have been reformulated so that they resemble syndromes for which medication is the preferred treatment (Mojtabal & Olfson, 2008) .

However, it is interesting that up to 80% of psychotropic medications are prescribed by nonpsychiatric physicians—a practice predicted two decades ago . The ever prescient editor of the American Journal of Psychotherapy (Lesse, 1985) foresaw not only that medications would replace much of psychother-apy, but also that computers and a new, more easily prescribed generation of psychotropic drugs with fewer side effects would make it possible for primary care physicians to issue most of these medications . The past 10 years have seen referrals by physicians to psychotherapy fall by almost 50% . Where once 95% of patients discharged from psychiatric hospitals were referred to outpatient psychotherapy, by 2005 the figure had fallen to only 10% (Cummings & O’Donohue, 2008) .

The ever present seeking of the quick fix is now bol-stered by primary care physicians who find the prescribing of these medications easy and lucrative and avoid the angry confrontation of patients who resent being told they need to see a “shrink .” A mounting number of studies reveals seri-ous psychotropic drug side effects and even death, suicide, or violence—especially among children, teenagers, and the elderly (U .S . Department of Health and Human Services, 2008; Wiggins & Cummings, 1998) . However, it is anticipated that medication will continue to replace behavioral interven-tions until psychologists become an integral presence in the healthcare system .

WHERE ARE OuR PATiENTS?

In the decades of insistence that psychotherapy is not an integral part of the medical system, we created two silos: a huge silo called physical health, which gets the lion’s share of funding (about 95%), and a tiny, perpetually underfunded




silo called mental health . In our paranoia that psychotherapy is not medicine, we failed to appreciate what dentistry, nurs-ing, optometry, podiatry, and all other healthcare professions knew decades ago: It is healthcare that gets funded—not the esoteric mental health silo that suffers from stigma, qual-ity concerns, and lack of access . It insists on solo practices across town, while healthcare has become essentially group practices congregating in convenient, easily accessible health centers near hospitals where all other healthcare professionals practice (Cummings, 2007) .

An early, large-scale collaborative model research was the 7-year Hawaii Medicaid Project (Cummings, Dorken, Pallak, & Henke, 1991), an extensive demonstration that recouped its funding investment within 18 months . A congressionally man-dated three-way contract among the Health Care Financing Administration, the State of Hawaii, and the nonprofit Biodyne Institute launched an entirely new mental healthcare deliv-ery system in which the Medicaid (N = 36,000) and federal employee (N = 93,000) populations of Hawaii were random-ized into the control group, which received the extant health system, and the experimental group, which was treated in the innovative delivery system .

The Biodyne model was 68 targeted, evidence-based behavioral interventions; working closely with physicians, the highest 15% of utilizers of healthcare were outreached . The purpose of the experiment was to test in a prospective, controlled setting the results of previous nonrandomized research that revealed the medical cost offset effect: Brief, tar-geted behavioral interventions resulted in reduction of med-ical and surgical costs far beyond the cost of providing the behavioral interventions (Cummings & Follette, 1968; Follette & Cummings, 1967) . The NIMH had already conducted 28 rep-lications (Jones & Vischi, 1980), but they, too, were retrospec-tive studies .

Estimates are consistent for decades (see, for example, Follete & Cummings, 1967, to Kroenke & Mangelsdorf, 1989): 60–70% of visits to primary care reflect psychological issues and emotional distress through physical symptoms that mimic physical disease or have psychological and lifestyle problems that are interfering with medical treatment or contribute to noncompliance with the medical regimen . Primary care phy-sicians (PCPs) are constantly confronted with such patients, and they respond with medication and counseling to the extent that 85% of psychological problems are addressed by




these PCPs . This makes the primary care system the de facto mental health treatment system in the United States . This is where our patients are!

iNTEGRATiON, NOT JuST COLLABORATiON

Recognizing this, there is an increasing effort in health psy-chology to increase collaboration between physical and mental health (Peek & Heinrich, 1995), but this falls short inasmuch as it retains two silos and only seeks to increase the amount of communication and cooperation between the two . Beginning in 1997, however, a system emerged that would integrate behav-ioral health into primary care by placing behavioral care pro-viders (BCPs) into the primary care setting, working side by side with PCPs . A growing number of textbooks have emerged, along with training programs that would train psychologists working in the primary care setting (chronologically, some of these textbooks are Blount, 1997; Cummings, Cummings, & Johnson, 1997; Cummings, O’Donohue, Hayes, & Follette, 2001; Cummings et al ., 2003; O’Donohue, Cummings, Hayes, & Follette, 2005; O’Donohue, Byrd, Cummings, & Henderson, 2005; O’Donohue, Cummings, Cucciare, Runyan, & Cummings, 2005; Robinson & Reiter, 2007) .

One of the earliest demonstrations in which especially trained BCPs were colocated with PCPs in the primary care setting was the Hawaii Integrated Healthcare Project II (Laygo et al ., 2003), which was funded by the federal government . At about the same time, the U .S . Air Force integrated its medical system worldwide (Runyan, Fonseca, & Hunter, 2003) . There have been a number of successful examples of the integra-tion of behavioral health into primary care in TriCare, the Cherokee Health System, the Veterans Administration, and the U .S . Navy, but until Kaiser Permanente in Northern California retooled its delivery system accordingly, the private sector had lagged behind .

As the data emerge, a number of characteristics are attribut-able to appropriately conducted integrated behavioral/primary care . Unfortunately, some examples of so-called integrated primary care fall far short of adequate delivery of care because of insufficient training of the BCPs or the lack of orientation of PCPs in the effective use of the system . Furthermore, there exists a widespread lack of appreciation by administrators of the complexity of the system . The attitude, “Oh, this is simple to do,” results in a system that simply is not!




integrated Care and Medical Cost OffsetWhen fully and effectively implemented, there is a 20–30% reduction in overall medical and surgical costs . Since it was first discovered 40 years ago, there have been extensive repli-cations of the medical cost offset effect (see first the summary by Jones & Vischi, 1979) . A composite visualization is seen in Figure 3 .1, which shows a steady decline of medical and sur-gical costs from the year previous to the behavioral interven-tions through the succeeding 5 years . This resulted in a 65% decrease in the treated population . With integrated behavioral and primary interventions fully implemented, this translates to a 20–30% medical cost offset to the covered population .

These studies were all retrospective in design, raising ques-tions as to the validity of the findings . The aforementioned Hawaii Medicaid study not only was prospective, but it also randomized a very large population (N = 130,000) into an experimental group (the new model delivery system) and a control group (the traditional but very liberal Medicaid/fed-eral employees benefit in Hawaii) . It was conducted over a 3-year period with a 7-year follow-up and further delineated both the experimental and control groups into those who were chronically ill and those who were not .

90%

80%70%

60%

50%40%30%20%

10%0%

1:6 1:5 1:4 1:3

Figure 3.1 Composite schematization of the increases in the percentages of psychiatric/psychological treatment that can be conducted in primary care as a function of the ratio of BCPs to PSPs, whether it is 1:6, 1:5, 1:4, or 1:3. Compiled 2008 by the Cummings Foundation for Behavioral Health from data reported by family medical practices in Arizona and California. The second bar in each subset indicates the declining percentage of such patients that remain to be referred to specialty psych care (e.g., only 20% with the 1:3 ratio).




The results of the nonchronically ill population are shown in Figure 3 .2 . Those treated in the new delivery system revealed within 18 months a 35% reduction in medical and surgical costs, while those receiving traditional treatment in the com-munity increased these costs by 25% during the same period . Better off were those patients receiving no mental health treat-ment, who revealed only a 15% increase .

The results with the chronically ill population revealed similar results, as shown in Figure 3 .3, but with the costs and subsequent savings (or increases as in the group treated with traditional services) substantially higher . It is apparent that not only do chronically ill patients cost the system signifi-cantly more, but the potential cost savings is also over twice as much as in the nonchronic population .

100

90

80

70

60

50

40

30

20

10

01B 1A 2A 3A 4A 5A

Figure 3.2 Nonchronic group. Average medical utilization in constant dollars for the Hawaii Project nonchronic group for the year before (1B) for those receiving targeted and focused treatment, other mental health treatment in the private practice community, and no mental health treatment the five years after (1A, 2A, 3A, 4A, and 5A). (From Cummings, N. A., Dorken, H., Pallak, M. S., & Henke, C. J. 1991. The impact of psychological interven-tion on health care costs and utilization: The Hawaii Medicaid Project. HCFA contract report #11-C-983344/9.)




The startling finding that traditional therapy increases costs is further explained within an inadvertent design of this study . To fulfill the many issues of diversity so important in Hawaii required a larger staff than was otherwise needed to deliver the services . This was fulfilled by hiring twice as many providers, but for half the time . The other half of their time was a continuation of their private practices in their offices . The medical cost offset obtained reflects their functioning in the new delivery system . However, in their individual private practices, where they were not involved in constant monitor-ing, clinical case conferencing, and other quality measures, they reverted to traditional treatment in spite of their having been extensively trained in the new behavioral model . This serendipitous finding stresses the importance of continued supervision and quality assurance procedures in integrated behavioral/primary care to prevent regression to the mean of traditional practice .

700

600

500

400

300

200

100

0

Targeted, FocusedTherapy Treatment

Other Mental Health Treatment

No MentalHealth Treatment

Figure 3.3 Chronically ill group. Average medical utilization in constant dollars for the Hawaii Project chronically ill group for the year before (lightly shaded columns) and the year after (darkly shaded columns) for those receiving targeted and focused treatment in the private practice community, and no mental health treatment. (From Cummings, N. A., Dorken, H., Pallak, M. S., & Henke, C. J. 1993. In N. A. Cummings & M. S. Pallak (Eds.), Medicaid, managed behavioral health and implications for public policy (pp. 3–23), vol. 2, Healthcare Utilization and Cost Series. San Francisco, CA: Foundation for Behavioral Health.)




Effect of Traditional Therapy on CostsThe fear that traditional psychotherapy increases costs is disturbing, but justified . Ten years later, at the urging of the American Psychological Association, the Congress approved the Fort Bragg Champus Study, ostensibly to demonstrate that nontethered (i .e ., unsupervised or unmanaged) traditional psychotherapy would dramatically decrease costs . The under-lying belief was that third-party payer restrictions on practice were the high-cost culprit in mental health . The results were a disaster . An $8 million program increased 10-fold to $80 million without, as the researchers admitted, any demonstra-ble improvement in the well-being of the population treated (Bickman, 1996) .

Leveraging Physicians’ TimeThe cost savings do not stop there . Physicians’ time is lever-aged, releasing them to perform procedures more in keeping with their medical training . In private group practices, this most often means time to perform more income-generating medical procedures . An oft repeated exclamation is that, with a BCP present for the hallway handoff, “I no longer have to worry when a patient might unexpectedly break down in my office, absorbing 45 minutes while I have a waiting room full of patients .”

COST SAviNGS AS A MARKETiNG TOOL

From either lack of information or distaste for sound business principles, psychologists seldom invoke the medical cost off-set effect when they are marketing their services to the public . When they do, they are remiss in not having a full grasp of when it works and when it does not; a blanket statement that psychological treatment ipso facto reduces medical and surgi-cal costs turns off industry actuaries, who are far more knowl-edgeable . Most are well aware, for example, of the Fort Bragg Champus Study .

Until integrated behavioral/primary care impacts their ser-vices, psychologists are even less aware that it reduces spe-cialty psychiatric and psychological costs . The need to refer patients to specialty psych care depends upon the intensity of the integrated system—often measured by the ratio of BCPs to PCPs, which may range from a minimum of 1:6 to as high as 1:3 . At the Kaiser Permanente Health Plan, specialty psychiatry




has been reduced in size by 60% because it now treats only chronic psychiatric and psychological conditions .

Figure 3 .4 shows the decline in specialty psychiatry with the increase in BCP/PCP ratios and the corresponding per-centage of psychological conditions that can be handled more effectively and efficiently in the less costly primary care set-ting . It will be noted that up to 80% of these patients can be so treated, but it is imperative that while behavioral interven-tions are going on there is always at least one BCP available for the hallway handoff .

It is important to note that the reduction in referrals to spe-cialty psych does not translate into a diminution of psycho-therapy . To the contrary, there is an astounding increase in the number of patients who engage in follow-up treatment with the BCP after the hallway handoff . In the nonintegrated primary care setting, of the 40% of the emotionally distressed patients identified by PCPs, only 10% ever accept a referral and actu-ally enter psychotherapy . The others are given a prescription

$2,500

$2,000

$1,500

$1,000

$500

$0

TargetedFocused

Other MentalHealth Treatment

No MentalHealth Treatment

Figure 3.4 Composite schematization of the increases in the percentages of psy-chiatric/psychological treatment that can be conducted in primary care as a function of the ratio of BCPs to PCPs, whether it is 1:6, 1:5, 1:4, or 1:3. (Compiled in 2008 by the Cummings Foundation for Behavioral Health from data reported by family medical prac-tices in Arizona and California.) The second bar in each subset indicates the declining percentage of such patients that remain to be referred to specialty psych care (e.g., only 20% with the 1:3 ratio).




or they simple ignore the referral . In the integrated primary care system, where there is no stigma or other resistances because it is a seamless “healthcare” process (as differenti-ated from “mental health”) in which the patient always feels comfortable, 85–90% of those hallway handoffs will engage in subsequent behavioral interventions . This finding is generally consistent in all integrated settings offering sufficient follow-up services .

QuALiTy ASSuRANCE

In the delivery of mental and behavioral care services, too often the need for quality assurance is neglected, resulting in needless substandard care and even questionable interven-tions . At American Biodyne, even after the rigorous retraining affectionately dubbed the “Biodyne Bootcamp,” fully 15% of clinicians’ time was spent in quality assurance . This included a 3-hour case conference each Friday morning, in which the staff eagerly presented their failures or near-failures; one-on-one supervision; and group supervision .

Such an expenditure of time was and continues to be startling to the practitioners and the industry, but recent extensive research by Scott Miller (2008) and his colleagues demonstrates that the one feature that determines the master psychotherapist (defined as effectiveness) is constant evalua-tion and feedback . This investment at Biodyne was reflected in the total absence of malpractice claims: In 10 years with 25 million enrollees and 10,000 psychotherapists, there was not a single malpractice claim or a patent complaint that had to be adjudicated . When Biodyne passed into new hands in 1992, one of the first features eliminated was the 15% of time devoted to quality assurance . Within months, malpractice suits began to appear .

Quality can be defined as “exceeding your customer’s expectations .” Quality improvement should be continuous; the bar is always moving higher . Quality always requires con-sistent measurement to determine the extent to which these objectives are being achieved . Because behavioral health has not embraced the quality ethic, there are precious few data to determine the extent to which we even come close to our customers’ expectations . However, there are plenty of reasons to be concerned .

We also have to be careful to define who our customers are . Clearly, one focus has to be on the patient . If patients do not




like what we are providing, then they simply will not show up in the first place (e .g ., they will go to their primary care physi-cians for their problems), or they can simply stop attending (the modal number of psychotherapy sessions is one) . Many health professionals now have

created wonderful waiting rooms (e .g ., pediatric dentists have high-quality arcade games and flat-screen TVs)

developed incentive systems for compliance (the ortho-dontist of the second author’s children rents the swim-ming park the last day of the season exclusively for compliant patients)

developed additional services and procedures that cus-tomers want (teeth whitening, sealants)

invested in electronic medical records that vastly decrease errors (the saying now in medicine is that “paper kills”)

promoted evidence-based practice to decrease unwanted variability in practice patterns

All these actions have created more satisfied patients .However, another customer is the third-party payer . In

behavioral health there is actually a stream of payers, usu-ally consisting of care management organizations such as Magellan, Value Options, Cigna, etc ., who often have contracts with an HMO (such as United or Blue Cross/Blue Shield) that, in turn, contracts with an employer, union, or federal govern-ment agency (e .g ., the Department of Defense) . Each of these payers cares about the value it receives for its dollar (i .e ., has expectations that we, in taking a quality perspective, try to exceed) . As a profession, we have not understood what the expectations of these organizations are, have not innovated in trying to meet these expectations, and have not measured on dimensions that might impress them .

Instead, we have vilified our payers, spent a lot of money suing the folks who write our paychecks (APA has spent over $10 million in such lawsuits) . When we do measure, our efforts often fall short of what might interest the payer, especially if it is an employer . Typically, for example, our outcomes research, if any, might focus on BDI (Beck’s Depression Inventory) scores, but not measure anything related to missed workdays or medi-cal utilization, which are vital to our customer .

The quality problem in behavioral care services is often the “elephant in the room” when business decisions are being




made . Part of the reason why people may go to their primary care physician is that this individual is more trusted than the mental health practitioner . Surveys of patients have revealed that they are concerned about the effectiveness of mental health interventions as well as the “normality” of mental health practitioners . We are too often seen as strange and inef-fective—a perception that may not be all that delusional . It is important that integrated care does not adopt this same qual-ity problem, for integrated care is doomed if it merely colocates something resembling a Rorschach-administering, rebirthing psychotherapist who is simultaneously dealing with his or her own issues .

Such a flaky, non-evidence-based, ineffective, and even del-eterious practitioner invokes in the patient what economists call the “lemon problem .” Value of a product (astonishingly, psychotherapists still do not see their services as a product) determines the price the customer is willing to pay, while the consistency of the quality is directly related to price . A cus-tomer will pay the price, for example, for milk that has value: consistently high quality, absence of contamination, curdling, or skimming . If two thirds of the time the milk manifests low-ered quality in the form of one or more of these quality prob-lems, the price will drop dramatically, or the customer may switch to soy milk . When the latter occurs, the price may drop below the cost of producing the milk, and it might disappear from the store shelves altogether .

Consider, then, if the public perception is that psycho-therapy is effective only occasionally, or not at all, or that the practitioner suffers from psychological issues of greater magnitude than the patient . The demand for such services diminishes while at the same time our educational sys-tem has produced a glut of psychotherapists (Cummings & O’Donohue, 2008) .

As a profession, we have conveniently blamed price depression on the greed of managed care . Some of this is true because there are good- as well as bad-quality managed care companies, but it is not clear what we can do about this . We can, however, address the factors under our control . We have ignored quality factors, and our several national men-tal health organizations have neglected to adopt and enforce quality improvement practices that are substantive . Only then can we reverse the price depression in psychotherapy (see O’Donohue & Fisher, 2007, for more on quality improve-ment in mental health) .




FuNDiNG OF iNTEGRATED CARE

Integrated behavioral/primary care is like a pomegranate: Overwhelmingly, people say they like it, but few buy it . It has often been pointed out that, in healthcare, it is 20 years after the proven effectiveness of a treatment before it is fully adopted . In this point of view, it will be 10 more years before integrated care is mainstream . Aside from this, however, what are some of the impediments?

Public FundingThe military, TriCare, and the Veterans Administration have been at the forefront in funding demonstration projects . This has been made possible through top-down decisions, and it has been facilitated by the fact that all of these demonstra-tions are in staff model delivery systems rather than networks . Invariably, these demonstration projects have been showered with high praise and general satisfaction, but when the fund-ing dries up, the heretofore successful delivery system is allowed to wither and dry up . Even in the one extensive pri-vate system in which integrated care has been acknowledged and mandated, some of the scores of Kaiser Permanente medi-cal centers have been allowed to opt out or lag behind .

Private FundingIn the 1990s, the managed care organizations, including the managed behavioral health organizations (MBHOs, commonly referred to as “carve-outs”), began to morph out of managed care, in which they took an active part in the delivery of services and even made service decisions, and into care management, in which they manage the benefit but do not tell the doctors how to practice in their offices . Much of this was in response to an outcry from both the practitioners and the public

The current care management organizations like and sup-port the concept of integrated behavioral/primary care, would welcome the effectiveness of such an innovation, and would be willing to create payment mechanisms through which BCPs could be reimbursed . However, they cannot direct profession-als to practice in this manner . The question then arises: How is this to be funded? It is time for practitioners to rise to the occasion, paying attention to the following considerations .

Every industry attempts to become more efficient . Competition is a key driver in this pursuit, for if a competitor can provide the same or higher quality service (or product) at a




lower price than you can, you will soon be driven out of busi-ness . Customers enjoy more for less and will not be dissuaded by your poor value proposition; in spite of your pain, this is a good thing because value continues to increase . Economists call this process in the competitive marketplace “creative destruction,” and it behooves our profession to become more productive and efficient . In the current marketplace, the major-ity of the American public is not convinced that psychother-apy is of greater value (cost, time expended, outcomes) than psychotropic medication, so how is this to be done?

Integrated care as a model of service delivery achieves increased efficiencies because it places service where folks seem to want it: one stop shopping in their primary care phy-sician’s office . It also allows the practitioner to be more pro-ductive by adopting a number of practice standards that differ from standard mental health specialty care (whether in pri-vate offices or mental health clinics and centers):

Brief, evidenced-based assessment (not utilizing •MMPIs, Rorschach tests, or extensive histories)Consultation liaison models (the BCP is seen as an •extender of the physician and augments the PCP’s treatments without taking over the patient and start-ing anew)Focused, evidence-based interventions saving time and •money over the non-evidence-based interventionsEvidence-based groups possible because of the large •number of patients with a particular behavioral prob-lem (e .g ., obesity, chronic pain, depression, noncom-pliance with medical regimen)The standard of restoring functioning rather than com-•pletely curing or personality restructuringA wider scope of practice—the BCP is not just a spe-•cialist in DSM problems but also effectively treats subclinical problems and pathways to medical utiliza-tion (e .g ., stress, noncompliance), as well as behavioral medicine interventions (e .g ., chronic pain, obesity)

Integrated care is based on the premise that has generally been supported by data that reveal that clinicians practicing in this way can decrease overall medical costs . Behavioral care costs rise slightly due to provision of behavioral/pri-mary care services, but more expensive medical and surgical costs decline to a much greater extent . The net savings have




often been in the range of 20–30%, which is staggering (see Cummings et al ., 2003, for a review) . Thus, payers can see that the more productive, efficient system is integrated behavioral/primary care .

Therefore, the premise for arguing for integrated care is not, “We will help you find more money,” but rather, “The money is already there if you rearrange the way funds are being spent now . You will have healthier patients demanding fewer medi-cal services, as well as extra funds left over .”

The “Laboratory Model” of integrated CareMost practicing psychotherapists see patients who belong to a variety of third-party payers . Consequently, BCPs are econom-ically unable to contract directly in a special network with one carrier because the patient flow would probably not be sufficient . Medical laboratories faced this same problem and solved it decades ago by locating in the midst of existing medi-cal centers, enabling them to serve many surrounding phy-sicians’ offices as well as health plans . Physicians are “herd animals”: They congregate in medical centers . The key is prox-imity and immediate accessibility—a successful model that a number of psychologist groups practicing integrated care have replicated . One such group, which began with 3 psychologists, now has grown to 23, while another went from 5 to 42 . They belong to all networks, but the reason for their success is the appreciation by the independent physicians for their remark-able adaptation of the hallway handoff .

BCPs in Physician Group PracticesA number of psychologists in scattered locations around the country have persuaded family medical group practices to include one or more BCPs . When the group practice is large, it is easy to have more than one BCP, but economics limits a group of five or six physicians to just one BCP . This precludes the ability to have one BCP always available for the hallway handoff while the other is doing the treatment . Through accommodated scheduling, however, these limitations can be largely overcome .

DiFFiCuLTiES, PERvERSE iNCENTivES, AND iNADEQuATE iMPLEMENTATiON

The road to integrated behavioral/primary care has not been and will not be easy . There are a number of key difficulties




and even perverse incentives (economists call them “moral hazards”) in the field . Here is a brief listing of the major finan-cial difficulties:

Chief financial officers (CFOs) require a fairly sophis-•ticated return on investment (ROI) analysis that will compare this proposal to all other possible invest-ments . Integrated care is competing for scarce dollars against such alternative investments as disease man-agement programs, hiring more employees who can bill additional amounts, or even new information systems such as electronic medical records—all of which pre-suppose savings . Promoting integrated care needs to generate clear and credible financial data that can be compared to these alternative investments . Currently, there is a paucity of such data . These data need to show that in population X (e .g ., urban Medicaid), an invest-ment of Y will produce an ROI of Z (usually a return of 5:1—a difficult goal to achieve in the 12-month period favored by CFOs) .The outcome data that exist for integrated care are •often missing key financial outcomes . We find that BDI scores decrease, but we know nothing about the impact on medical utilization, disability payments, or absenteeism .Perverse incentives abound . Healthcare budgets are •usually constructed from that of last year . If inte-grated care decreases costs, a smaller budget next year may result . In federal funding, the government often demands that any savings be sent back to Washington, removing local incentives to save money .A lot of innovation is going on in healthcare, often •producing “innovation fatigue”: Management does not want to administer one more innovation .One of integrated care’s competitors is the nurse-•driven disease management that has proliferated into a several billion dollar industry . These programs appear to be less risky to managers, they often have impressive ROI data, and they do have some positive clinical impact . However, they are not a panacea . They can be useful in the easiest cases but are no substitute for astute clinicians dealing with the complex cases found in integrated care (see Cummings, O’Donohue, & Naylor, 2005) . However, comparative studies are




needed to show the relative advantages and disadvan-tages of these programs . Ideally, they should comple-ment each other .Many insurers will not pay for behavioral health con-•sultation codes . In fee-for-service environments, these are essential in supporting integrated care because they allow the BCP reimbursement for non-DSM prob-lems (e .g ., chronic pain, treatment compliance) .Medicaid does not allow for medical and behavioral •billing on the same day—an archaic regulation unsuc-cessfully intended to prevent fraud that essentially stops the hallway handoff in its tracks .Although there are now a number of large-scale inte-•gration systems (e .g ., the U .S . Air Force, Veterans Administration, U .S . Army and Navy, TriCare, Cherokee Healthcare, Kaiser Permanente), there is per-haps even a larger number that are poorly constructed and are jeopardizing the concept by predictably poor and even negative results . These range from collab-orative models that maintain the two silos or employ poorly trained personnel who lack training in such imperatives as neurology, clinical medicine, medical psychology, and pharmacology to a lack of apprecia-tion of how the medical system works and the lingo that accompanies it .

SuMMARy AND CONCLuSiONS

The recent precipitous decline in referrals for psychotherapy has rekindled the need for reevaluation of psychology’s long-standing and self-defeating stance that we are not part of the healthcare system . America pays for healthcare, not psychoso-cial care; all other professions rendering treatment (e .g ., den-tistry, nursing, osteopathy, optometry, podiatry) have taken advantage of the nation’s evolution from a medical system to a healthcare system . As part of this healthcare system, they are prospering, while psychotherapy is languishing .

The integration of behavioral health into primary care, in which BCPs are colocated in the primary care setting along-side PCPs, has evolved in the last decade as a successful, viable method of bridging this gap . Many impediments to suc-cessful implementation persist . These range from the reluc-tance of mental health practitioners to give up solo practice, the 50-minute hour, and their traditional mode of practice to




the fact that our current third-party payer system is not con-structed to meet the funding of this evolving system . Henry J . Kaiser, the industrialist hero of World War II who built the Victory ships (often in 5 days from keel to launch) and saved Great Britain and who, through Dr . Sidney Garfield, founded the Kaiser Permanente system, would admonish, “Find a need and fill it .” The need has been found, but filling it will require boldness and innovation from psychological practitioners .

Generally speaking, psychology training programs have been predictably unresponsive, but there are now a few with state-of-the-art programs about to debut by 2009 . It is the strong belief of the authors that these will more appropriately emerge from the health sciences divisions of medical schools than through traditional clinical psychology doctoral programs .

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