The Current State of Healthcare

Susan McDaniel and Tom Campbell

To understand the current state of primary care, we have to start with the current state of healthcare, which is very uncertain, to put it mildly. Managed care has penetrated much of the USA, but the extent of the penetration varies considerably by region. This penetration has had a huge impact on the delivery of healthcare and mental health. The promise of managed care, to deliver healthcare to a population rather than an individual, has been largely unfulfilled because the organizations have focused primarily on cost rather than quality. Initially, managed care resulted in stabilization of healthcare costs, but now costs are going up rapidly again. This makes support for innovation and new models less and less likely. To bring this to the level of mental health: for-profit, "carve-out" HMOs for mental health are in the majority right now; these entities have incentives that discourage or prevent collaborative care. Managed care, and the Medicare cuts, is also having a terrible impact on medical education. Academic medical centers, many are in huge debt and some with major reputations are closing down. Perhaps the biggest reflection of the degree of change in health is that AMA is starting a union (a new role for AFTA? Just kidding…).

The Current State of Primary Care

The question regarding healthcare: Will we continue to tinker with the current system, with greater participation by the government to protect consumers like the recent Patients Bill of Rights? Or, with hospitals going out of business, etc., will there be a big movement for more substantial change? For a while, it looked like primary care has experienced the same cost cutting as other specialties with the most in common with family therapy, is being squeezed.

What does this all mean for Family Therapy?

While there is significant progress in the adoption of the collaborative care model with a minority subgroup who work in primary care (and in the research which we'll discuss below), collaborative care is not a high priority for most primary care clinicians because they have bigger problems to face right now. Also, carve-outs make it very difficult for primary care physicians to collaborate. So, the initiative has to come from family therapy.

Research on Collaborative Care

The recent research on collaboration supports our interest in treating mental health problems in primary care. These results come from the increased recognition of the high prevalence of mental health problems in primary (documents by NIH research) and the desire of managed care to save money. The latter is sometimes accomplished by shifting mental health care to primary care clinicians rather than mental health professionals, hoping that more effective treatment of mental health problems will lead to overall decreased cost. This cost reduction, by primary care clinicians alone or with collaborative mental health clinicians, as well as collaborative care, has not been definitively documented. What is supported by research on collaborative care is that it leads to better outcomes and better value/dollar (as opposed to saying conclusively that it saves money).

The four areas that are most promising in terms of research support for collaborative care in primary care are:

1. Depression (Katon et al. 1995). A series of studies have demonstrated effective and cost-effective collaborative approaches to the treatment of depression in primary care. These results may lead also to support for collaborative care in treating substance abuse and anxiety disorder.
2. Wellness groups for somatizers (Hellman et al. 1990). Some of these studies have actually saved money. We have one of these ourselves, from a systems point of view, but have not analyzed the data yet to know if it was effective as a part of a collaborative care intervention.
3. Family psychoeducational interventions for chronic illness (Mittleman et al., 1996). Mittelman was able to improve the mental and physical health of AD caregivers and delay nursing home admission for AD patients, resulting in enormous cost saving. This study and intervention could serve as a model for other family psychoed interventions for other physical chronic illnesses.
4. Family/motivational approaches for healthy lifestyle changes (British Family Heart Study Group, 1994; Miller & Rollnick, 1991)

Conclusion/Recommendations:

1. Continue to work for health care reform (through the Public Policy Committee) at a national level and oppose for-profit and carve-out HMOs.
2. Collaborate with other groups who have similar political goals.
3. Encourage AFTA members to become active in their local HMOs, serve on committees and promote collaborative models of practice.
4. Promote and publicize collaborative care studies (such as Katon's work) and family psychoeducational interventions for medical illnesses. Consider inviting researchers in this group to present at AFTA annual or research meeting (Mittelman, Katon, etc.).
5. Collaborate with primary care clinicians in your own work.

References:

• British Family Heart Study Group. Randomized controlled trail evaluating cardiovascular screening and interventions in general practice. Principal result of the British family heart study. BMJ 308:313-310, 1994.
• Hellman, C.J., Budd, M., Borysenko, J., et al. A study of the effectiveness of two group behavioral medicine interventions for patients with psychosomatic complaints. Behavioral Medicine 16:165-173, 1990.
• Katon, W., Von Korff, M., Lin, E., et al. Collaborative management to achieve treatment guidelines. Impact on depression in primary care. JAMA 273:1026-1031, 1996.
• Miller, W.R., Rollnick, S. Motivational Interviewing: Preparing people to change addictive behavior. New York: Guilford Press, 1991.
• Mittelman, M.S., Ferris, S.H., Shulman, E., et al. A family intervention to delay nursing home placement of patient with Alzheimer's disease. A randomized clinical trial. JAMA 276:1725-1731, 1996.