In healthcare, it is one thing to complain about the problems – it is something quite different to do something about it.
Let me give an example of a problem, and then let me offer an example of what was done as a potential solution.
The rules and organization of our healthcare system include fragmentation and ineffectiveness as a byproduct of its design. This is most prominently seen in the separation between the mental health and physical health systems of care. Convincing arguments for the inclusion of mental health as part of primary care have been made for the past thirty years and our research examples are numerous in demonstrating the inseparability, need and demand.
Therefore, there is a high likelihood that pressure will continue be put on primary care to address mental health issues. A recent NAMI survey written up extensively in the American Medical News reported the following:
“A survey of 554 parents and caregivers, released May 11 by the National Alliance on Mental Illness, found that 83% wanted to discuss mental health issues with their child’s primary care physician even if the parents saw no evidence of problems. More than one in three families wants the doctor to initiate the conversation, and 32% prefer the discussion to take place in person without the child present. When those discussions happen, 42% of participants do not think physicians give them enough time to answer their questions. About half of parents said they didn’t feel their child’s primary care doctor was knowledgeable about mental illness.”
What does this mean?
Reading through the report, there are several areas that highlight the need to better address how mental health is approached and treated in primary care.
First, there appears to be a training issue:
“Part of the problem is that some primary care physicians feel uncomfortable discussing mental health issues and identifying mental illness due, in part, to the lack of training they received on the subject, doctors say. Physicians also struggle to fit conversations about mental health into the limited time they have for each patient’s office visit.”
Second, there appears to be a systems issue:
“…we have a fragmented system in which primary care physicians are almost always the first resource and in some places the only resource available.”
Third, there appears to be a misunderstanding that the reason more people are being seen and treated in primary care for mental health issues is not solely related to a shortage of psychiatrists (though this is one issue).
Recall that difficulty accessing mental health services from primary care goes beyond just a specific discipline and applies across the board. From a 2009 Health Affairs article:
“About two-thirds of primary care physicians (PCPs) reported in 2004–05 that they could not get outpatient mental health services for patients—a rate that was at least twice as high as that for other services. Shortages of mental health care providers, health plan barriers, and lack of coverage or inadequate coverage were all cited by PCPs as important barriers to mental health care access. The probability of having mental health access problems for patients varied by physician practice, health system, and policy factors. The results suggest that implementing mental health parity nationally will reduce some but not all of the barriers to mental health care.”
There still exists a chasm in healthcare. There is the system we want, and the system we have. No better place can this be seen then in watching mental health and primary care work towards integration.
This issue is not going away any time soon. Isn’t it time we start addressing this problem head on? So what do we do?
Rather than flag this issue and simply complain about it, there are many who have chosen to try and actively make changes.
Consider the Collaborative Family Healthcare Association. From their website:
“In March of 1993, 15 colleagues from family medicine and family therapy met to develop a better healthcare paradigm. This model aimed to address pressing clinical and economic problems in healthcare. This group aimed to address a quite urgent question:
No matter how financed, what should a thoroughly modern healthcare delivery system look like at the clinical level?
It was agreed that a truly contemporary system would thoroughly integrate the expertise of biomedical and psychosocial providers and include family and community as key elements in the practice model. This became their design goal.”
These 15 individuals decided that something was broken and wanted to try and make a difference in fixing it. They were not satisfied with complaining, but rather wanted to work towards something different.
The rest is history as this year’s conference in Philadelphia (October 27-29) continues the goal of designing a healthcare system that can meet the comprehensive needs of the community (mental health and primary care being one of those areas to address). The conference itself is preceded by a policy summit that tackles the heavy policy issues surrounding healthcare redesign. These 15 individuals attempt to change healthcare is ongoing 18 years later.
So while it is easy to point out the flaws in the system, it is often more difficult to do something to change it.
What are you doing?
Dr. Miller has his doctorate in clinical psychology and is an Assistant Professor in the Department of Family Medicine at the University of Colorado Denver School of Medicine where he is the Director of the Office of Integrated Healthcare Research and Policy. His core task is to integrate mental health across all three of the department’s core mission areas: clinical, education, and research. Opinions expressed here are his own and not those of his employer.
