Sunday, May 17, 2009

APA Summit Dispatch 3

Day two Summit: The Drivers of Change

There is no resource publication on the economics of practice in psychology. Why is that?

Topics discussed in this session include:
Demographics & Diversity
Science & technology

The factors alter strategy, some are inevitable factors, others represent uncertainties that might drive change.

First Speaker is a Professional Economist:

MH care is unbalanced in the sense that its potential is underinvested, but investment in it may be cost effective. Rebalancing will require policy changes, because current investment is limited by government regulation and third party payer policy.

There has been a 2/3 increase in MH treatment rates since the 1990s. Between 20% to 40% of people needing treatment get it now.

Health care spending is about 2.2 trillion in the US. We spend 17% of GDP in heath care of all types, but only 1% on MH services. Access to Mental Health (MH) care is up, and cost is flat. Quality is not clearly characterized in any standard metric. Medicaid and Medicare cover a bit more than half the current mental health care expenditures, the rest is covered via Behavioral Health carve outs and increased coverage for psychiatric drugs. The economics of all this is pushing care models toward pharmacotherapy obtained in primary care prescription of drugs.

More people get MH treatment from general medical practitioners (40% or so) and 25% or so from psychiatry (the rest is us and shrinking). Counted in the general medical category are general hospitals where, as in my own case, the care may be provided from psychologists. Note: the economist derived all his estimates from statistics on treatment of depression and ADHD. (ADHD behavioral treatment is actually drifting downward) Apparently he could find little long-term data on the quality of much else. Psychosocial treatment seems to be getting harder to get due to economic forces.

Change is possible, and perhaps beneficial, but it won't be easy to alter current trends. Using evidence based treatment delivered by people who can deliver the treatment with the same skill and training as that which was present when the research team delivered it may be required to reveres the trend away from psychosocial interventions.

Second speaker-a family physician running a federally qualified community health center (serving underserved populations).

MH needs, when unmet are destroying families and impairing their ability to be economically productive. The MH system is designed to get poor outcomes, frustration and failure. Most people won't go to a MH center or provider, preferring general medical settings. Most diagnostic efforts are economically wasteful. It is the symptoms that matter in terms of wellbeing and outcome. This suggests that psychology must be increasingly located in primary care settings, both for reasons of improving access and efficiency. Brief cognitive and behavioral interventions are the ones most appropriate for primary care settings. This makes patients comfortable with obtaining help from a MH specialist, and starts a relationship that may be expanded in the future.

These factors require practitioners who know what they are doing, who are able to convey to patients that they are supportive and solution oriented. Training for this is not typical of most graduate or practicum settings in psychology. Patients want to be listened to, sometimes more than they want the problem they mentioned as the reason for seeking help fixed. BTW, when physicians read reports, they read the last line, and this is something psychologists who work in these settings will have to learn to deal with. Brevity is required for communication in interdisciplinary settings. There are major funding barriers to the wide adoption of a primary care model for psychology, because MH service is not as reimbursable in community settings outside of hospitals as it sometimes is in hospitals.

An economist responder noted that the availability of psychology in primary care is prevented because the costs of it are incurred in the primary care setting, but the savings are accrued in an altogether different setting for the most part. The savings are dispersed and hard to quantify, because the benefits of improved health are not only to the individual, but also to the family, the economy and society.

Patrick Deleon noted that soon, with the wide adoption of the electronic medical record, we will be able to begin to discover the outcomes of behavioral treatment on a national, system-wide basis. The eRecords will be linked across the country.

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