Psychiatrists Can Take Steps to Enhance Value of Services

As consumers of goods and services, we would like to get the highest quality product at the lowest possible price. We commonly think of this as getting a good bargain or getting the “biggest bang for our buck.” Another way to express the quotient of quality/cost is value. Well-run businesses attempt to produce products that will satisfy customers at an affordable price. In competitive markets, where there is moderate demand, this will generally assure success. However, if the demand for a product is much greater than the supply, prices will likely increase, and quality may be diminished. Such is the case in the U.S. health care system.

The United States has the largest economy in the world and also spends more of its gross domestic product on health care (now nearly 20%) than any other developed nation, by at least a factor of two. If our results were twice as good as these other countries, then we might consider the spending worthwhile. Similarly, we would likely feel justified in buying an expensive luxury car if that car performed very well. But if that car performed poorly and required frequent repairs, we would feel deceived and betrayed. In almost all respects, the U.S. system (which is really a fragmented conglomerate of systems) performs much worse than the systems of other developed countries. What created this system that clearly lacks good value and what sustains it? How can we fix it?

Unfortunately, American medicine has paid insufficient attention to value, as medical practice has become more complex and expensive. As an example, it is only recently that greater attention has been paid to the interaction of physical and emotional health. While American medicine has excelled in delivering high-technology life sustaining procedures and devices, it has failed to promote a healthy population, which requires a strong emphasis on emotional health. The shape of the American system is sculpted primarily by free-enterprise market forces rather than any centralized or unifying planning. As a result, the quality of services is quite variable, and we are ill equipped to respond to public health emergencies, as the current pandemic has clearly illustrated.

We can do better. Over the course of time, many factors have led to fragmentation, waste, and unnecessary expense. Many attempts have been made to circumvent these problems, but they have not amounted to much more than Band-Aids on gaping wounds. There is a glaring need to think about real solutions as we confront the major challenges that lie ahead. Our dysfunctional and costly systems of care will not be sufficient to meet them. Systems must change to provide more appropriate incentives for efficiency, reduction of administrative waste, an emphasis on prevention and population health, and the incorporation of technology. There are other unique opportunities to increase the overall value of services, such as harm-reduction strategies, correctional reform, workplace health, end-of-life care, and even working with individuals and communities to alleviate the corrosive effects of climate change.

While system change would deliver the most significant and uniform results, such outcomes are also the most difficult to achieve. There are significant ways that individual psychiatrists and the profession can alter their practices to enhance the value of services provided. Changes in psychiatrists’ scope of practice, including their relationship with other professionals, can have a positive impact. An expansion of the workforce, and psychiatrists’ capacity to provide consultations and supervision that are appropriately reimbursed, are required. Improving the diagnostic system, prescribing practices, and the psychiatrist’s role in advocacy and leadership are items that will potentially contribute to enhancing the value of services.

A vision for a comprehensive and effective health system that prioritizes emotional and population health is sorely needed but is only the first step toward change. Short- and longer-term strategies for incremental transformation have to be part of the plan. These strategies must recognize that meaningful change will be accomplished only through collaboration with varied stakeholders at all levels of society. For readers who are interested in delving deeper into these issues, a new book produced by the Mental Health Services Committee of the Group for the Advancement of Psychiatry (GAP) titled Seeking Value: Balancing Cost and Quality in Psychiatric Care is now available from APA Publishing. The book provides an analysis of the factors that have helped shape the current system and prevent it from meeting acceptable standards for community health. In addition, it explores the relationship of emotional health to overall population health. Looking beyond the current quagmire of American medicine, a roadmap for change, which will achieve the high value health care system that Americans need, is an urgent priority. This volume will be a compelling and practical read for anyone interested in actively seeking value in American health care. ■