The Role of Psychiatrists in the Brave New World of Health Care

Health care reform has been a long time coming. Although many date the start of the health care reform process by the passage in 2010 of the Affordable Care Act (aka Obamacare), the economic and social forces that are driving it have been building for decades. (Think Medicare, Medicaid, HMOs, managed care, Hillary Clinton, Ira Magaziner, and Harry and Louise [see here]). However, even now, many health care providers, and physicians in particular, would prefer to deny the inevitable: the transformative changes that will occur in the U.S. health care system.

It is true that we don’t know whether this change will be a gentle set of waves or a tsunami, and we don’t know into what form the health care system and the roles of its providers will ultimately be reconfigured. We just know that a comprehensive transition is looming.

In a previous column (“Change, Challenge, and Opportunity: Psychiatry in the Age of Health Care Reform,” Psychiatric News, October 4, 2013), Howard Goldman and I discussed the health care reform process from the macro health policy and economic perspectives. In this article, Grant Mitchell and I will discuss how this will impact individual psychiatrists.

The goal of a transformed health care system is to expand care, improve quality, and lower costs. These goals may seem antithetical. Indeed, this is especially concerning to patients with mental illness and limited resources who have historically had limited access to care. Psychiatrists know firsthand this frustration, and that of their patients and their families, with the current models of care and financing: limited payments and visits, with silos between physicians that contribute to fragmented care. And although it’s gratifying that timely and ongoing treatment of psychiatric disorders is finally being recognized as critical to controlling health care costs, we are waiting for stronger policies that will remove the barriers to access to care and payment for such care.

These concerns notwithstanding, we must collectively make a leap of faith and be prepared to make changes on the ground in the way that we as psychiatrists practice medicine. Psychiatrists will still continue to provide psychopharmacology and psychotherapeutic services. But this might be focused on specialty mental health care for the most complex patients, while primary care providers increasingly may conduct the first line of mental health screening and provide basic care. It is likely that the relationship between primary care providers and psychiatrists will expand exponentially with brief phone and “curbside” consultations replacing many of the more formal referrals for consultation.

Many psychiatrists will become leaders of multidisciplinary mental health teams providing coordinated services and, in some cases, may be located within large primary care practices. Conversely, we can expect to see primary care providers move into settings such as community mental health clinics to better provide general health care to severe and persistently mentally ill patients (SPMI).

A possible variant of this is that some psychiatrists and allied mental health providers will assume some basic primary health care responsibilities for SPMI patients or may even become their principal caregivers in collaboration with primary care providers. There is an increasing emphasis on addressing health behaviors such as diet, smoking cessation, and exercise as the understanding of the link between mental health and other health behaviors has deepened. Psychiatrists are finding they need to counsel their patients on these issues and even provide more basic medical screening and care to patients or in consultation with primary care providers. Some psychiatrists are even taking refresher courses in primary care to be able to better address this patient need.

To reiterate, multidisciplinary mental health teams will also become more common within hospitals and local health systems. To meet the anticipated demand from more patients while reducing costs, psychiatrists as the team leaders will provide less direct care (again, focusing their direct care efforts on complex, high-risk cases) and more supervision of care, while monitoring and tracking patient progress and increasing their consultative role with other specialists.

In fact, the CMS Center for Medicare and Medicaid Innovation issued its first 10 grants to hospitals to test their models on providing better mental health care. Each has different ideas of execution, but most share the concept of psychiatrists leading a care team and providing more effective coordination of care with other medical disciplines.

CMS isn’t the only driver of change. With the enormous pressure to contain costs, health systems and payers are more receptive to trying new models of care, including a new emphasis on early detection and treatment of psychotic disorders. Change is increasingly local and driven by psychiatrists who have a vision and commitment and are willing to examine current practices, determine why care isn’t succeeding, and try something new. They realize it isn’t always necessary to conduct a formal research or demonstration project to improve care. Trying new ideas may instead require involving staff, patients, and families in the process to garner their insight and a commitment to tracking and collecting data to monitor what is and isn’t working to inform ever-evolving care models. Some psychiatrists are becoming entrepreneurs: developing IT solutions or consulting to practices and systems to facilitate these new care models.

The difference between challenge and opportunity is often one of perception. Psychiatrists can view health care reform as leading to an inevitable change from the status quo and worrisome loss of autonomy. Alternatively, they can recognize that psychiatrists are well positioned to participate in and direct new health care initiatives—to become leaders of change, rather than siloed providers outside the mainstream of modern health care. We are the most highly trained, knowledgeable, and best positioned of all health care specialists to determine and provide (or at least oversee) the care of people with mental disorders. We are also mental health advocates who can identify gaps in service, educate others on the role of psychiatry, and offer concrete ways to better serve those within our communities.

There is a historic and exciting opportunity for psychiatrists to influence the future of medical care and occupy our rightful position in the field of medicine. Our nation is still at the beginning of the reform process, and we have the ability to influence its direction, but not if we choose to sit on the sidelines. It is important for psychiatrists to stay involved, not only in practice settings, but as APA members at the local and district branch levels. Step up and make your thoughts known to health care and government leaders; most are willing to listen if we offer ideas and solutions.

The health care reform process is under way; the world will be changing around us. If psychiatrists are engaged in influencing that change—if we take a more active role—then we are more likely to be satisfied with the end result. This may be our most important role of all. ■