Collaborative Care Model Promotes Justice and Equity

The private practice of psychiatry is in slow decline, and collaborative care will be its replacement. This is an inevitable result of the reality that there are too few psychiatrists being trained to cover the psychiatric needs of a growing population; increased rates of depression, anxiety, and substance use disorders across the population; and reduced stigma, which previously served as a barrier to seeking treatment. The Collaborative Care Model (CoCM) is a strategy to bring high-quality treatment to the greatest number of patients and is the more ethical approach to resource allocation.

In CoCM, a primary care physician, a psychiatric consultant, and a care manager work as a team to provide evidence-based treatment for patients with mental health conditions, measure their progress, and adjust care when appropriate. This model’s efficacy in improving patient outcomes has been repeatedly validated and is covered by Medicare, most private insurers, and many states’ Medicaid programs. In September 2021, APA announced that it had joined 17 other health organizations in support of the Collaborate in an Orderly and Cohesive Manner Act, which will improve access to evidence-based mental health care and substance use treatment by investing in the implementation of CoCM in primary care offices.

CoCM may feel familiar to consultation/liaison psychiatrists, who also provide expert diagnostic and management advice to hospital-based physicians and don’t take over the treatment of the patient. Unlike the integrated treatment approach, in which a psychiatrist provides direct clinical evaluation and treatment within primary care clinics, CoCM is a more efficient use of a psychiatrist’s expertise. In the integrated treatment model, the availability of mental health treatment is limited by the number of hours the psychiatrist is in the primary care clinic, which is limited by poor reimbursement. Using the psychiatrist as a consultant whose time is not constrained by a burgeoning caseload allows more patients to receive evidence-based treatment and builds the psychiatric competence of primary care providers over time. A study by John C. Fortney, Ph.D., et al., comparing the treatment of posttraumatic stress disorder or bipolar disorder delivered either by telehealth referral to a psychiatrist or by teleconsultation to the primary care team demonstrated similar efficacy. The study was published August 21, 2021, in JAMA Psychiatry.

From a health care ethics perspective, CoCM is a solution to a health care justice and equity problem that has festered for decades. People who are privileged with wealth, good health insurance, or the ability to pay out of pocket receive a different standard of mental health treatment than those who are uninsured or underinsured. Although many in private practice see a handful of less economically privileged patients pro bono or for a reduced fee, unconscious bias may determine which lucky few patients are offered this gift. They may possess another type of privilege that gets them into private practices, such as race, education, or some other status that renders them “special.” The vast majority of patients struggle to find a psychiatrist on their insurance who is accepting new patients, deal with months-long waiting lists at community mental health centers, or settle for whatever mental health treatment their well-meaning but underresourced primary care provider can offer. Only one-third of patients with complex psychiatric disorders receive specialty mental health care, and only one-tenth receive adequate mental health treatment in primary care. This is not health care justice.

Justice in health care requires fair and equitable distribution of resources and focuses on maximizing the health of the entire population, rather than an individualistic perspective. The goal of doing the most good for the most people is not served when psychiatrists practice psychoanalysis, which allocates four or five hours every week to a single patient, significantly limiting the number of patients a psychiatrist can treat. That doesn’t mean psychoanalysis is unethical. It is an effective treatment for people suffering from a variety of mental health problems; however, from a public health and health care justice perspective, it doesn’t distribute the valuable resource of psychiatric expertise fairly.

Mental health care justice also concerns minority communities, sexual and gender minorities, and other groups that have reduced access to quality care despite high need. Financial, cultural, and structural barriers to treatment have been repeatedly documented and represent a significant injustice in our health care system. A review of studies of collaborative care for major depression that included outcomes based on racial and ethnic minorities concluded that collaborative care, with or without cultural or linguistic tailoring, is effective. The study was led by Jennifer Hu, M.D., and was published in the November-December 2020 Psychosomatics.

Change entails loss, such as the loss of a practice style dear to many psychiatrists. Simultaneously, change facilitates adaptation to reality and invites beneficial innovations. In this case, the rise of CoCM will permit psychiatry to be more equitable in how we distribute our expertise so we can reach more patients, including those in communities we have not served effectively in the past. The knowledge that this change will align our field with a more ethical position in society may help ease sadness about the loss of the venerable tradition of private practice. ■

Claire Zilber, M.D., is a psychiatrist in private practice in Denver and a faculty member of the PROBE (Professional Problem Based Ethics) Program. She has served as a member of the APA Ethics Committee and chair of the Ethics Committee of the Colorado Psychiatric Society and is currently its immediate past president. She is the co-author of Living in Limbo: Creating Structure and Peace When Someone You Love Is Ill.