Understanding the Opportunities of Integrated Primary Care

Daniel Bruns, D. and Johnson, R. (1999). Understanding the Opportunities of Integrated Primary Care. The Health Psychologist, Winter, 21 (1), 14, 19.

Integrated primary care (IPC) is an outgrowth of the collision of medical and business traditions. As market forces have driven wrenching changes in the way that medical care is delivered, it has led to a variety of service redesigns. IPC is an example of this, and it involves combining primary medical care and behavioral health services in one setting. In IPC models, psychologists can be an integral part of the primary care system, as contrasted with functioning as specialists whose services are applicable only for mental health populations.

Upon closer inspection, this paradigm shift has even more profound philosophical and practice implications than would appear at first glance. Most psychologists have been trained to think in terms of treating individual clients. Traditionally, these services have been provided through a fee-for-service model, usually in a private practice setting. In order to understand IPC however, one must take the perspective of operating within a healthcare system.

Three tenets are important to recognize as being inherent in this shift:

Healthcare design is best done from a population management point of view.

Resources need to be allocated to fit the composite of healthcare needs of members, viewed from a population management perspective.

Coordination of resources is a vital, albeit challenging goal, given the current fragmentary nature of healthcare funding.

At its core, a well-designed IPC uses population-based interventions, which revolve around epidemiological conceptualizations of healthcare. For example, if studies show that 4% of covered lives will require some behavioral intervention annually, what will the system do to ensure those people have ready access to services? In other words, planning begins not by focusing on the needs of individual clients, but rather on the needs of the population.

Based on a needs assessment, healthcare planners can systemically identify where and when in the system interventions are best made. Some are importing into healthcare the "just in time" concept used by many businesses for process. Using this approach, the attempt is made to identify systemically the right time, place, and person to intervene in a particular health problem so as to maximize the impact. Interestingly, in primary care, there is substantial research to suggest that the right person is often a psychologist, in collaboration with the physician.

An example will serve to illustrate this paradigm shift. In a local medical center, it was established that the single most expensive diagnosis in the emergency room was noncoronary chest pain. These patients came to the emergency room, thinking they might be having a heart attack, but were later told that this diagnosis had been ruled out. Although it was quite likely that these were stress or panic-related conditions, such a diagnosis was not made. Rather, the person was simply discharged, and told "It wasn't a heart attack." Many of these persons came back on a later occasion, having similar such symptoms, and further coronary testing was done. All this was quite expensive, and an ineffective use of resources.

Now suppose you are the Director of Behavioral Health at XYZ Medical Group, and you can allocate where a 100 hours of clinical time should be spent. These 100 hours could be devoted to the identification of 100 patients with panic disorders in the emergency room, and referring them for appropriate care. In contrast, these 100 hours could be devoted to sessions of psychotherapy for a single borderline patient. It can be seen that by selectively choosing where to allocate resources, there can be a greater or lesser impact on the population at large.

Some models of IPC have been criticized for focusing on the population, and short changing the individual by "rationing care". Conversely though, more traditional approaches to health care could be criticizedfor looking only at the individual patient, without regard for the consequences of policies to the population as a whole. Similarly, many criticisms have been voiced about capitated reimbursement approaches. At the same time, it is capitation which aligns the financial incentives that allow IPC models of care to become viable.

As suggested earlier, one factor driving IPC is the recognition that physician resources in the past have often been used both ineffectively and inefficiently, especially when dealing with nonmedical matters. A great deal of physician time is required to treat somatized emotional disorders, stress-related illness, and conditions which are the product of dysfunctional lifestyles. Many of these conditions can be better treated when done in conjunction with a health psychologist and other allied health professionals. If a positive diagnosis of panic disorder, somatization or other such conditions can be made earlier in the course of care, unnecessary medical treatments and diagnostics can be avoided.

In its best expression, IPC is not simply about multidisciplinary care of single patients. It goes far beyond that. It is about a systematic attempt to deliver efficient, cost effective, multidisciplinary treatment to a population. It is about analyzing the needs of a population, and identifying the most effective time and place to intervene. Thus, interventions may be scheduled even when the patient isn't seeking care, but rather the IPC team may devise ways to seek out persons and provide that care in a preventative manner.

Integrated delivery systems such as Kaiser Permanente currently have an advantage for successfully implementing IPCs because the financial incentives are more easily aligned than is usually the case. The more typical situation is that primary medical care, specialty medical care, behavioral health, hospital services, and pharmacy benefits are each contracted separately, and therefore services (and financial incentives) are not coordinated. Consequently, in these more fragmented systems, change needs to be incremental.

Practitioners interested in constructively collaborating with managed care efforts might begin by identifying significant areas of need which are being underserved or served ineffectively. By designing more potent interdisciplinary interventions for such conditions, and then selling those services to medical care decision-makers, psychologists have anopportunity to contribute to a healthier system of managed care.