Advocacy: Washington Update

We are living in truly interesting times, as the ancient Chinese curse goes. The 21st century promises monumental changes in health care. The technology currently available has already provided the tools whereby educated consumers can make critical decisions regarding their own health care, and health care providers can call up databases (such as Epocrates ®) to receive up to date information on pharmaceutical agents. Yet despite these promising technological developments, the status of health care in the U.S. is very troubling.

Serious Problems in the U.S. Health Care System

Health care costs have once again begun to escalate faster than other segments of the economy, and the number of uninsured is now 43.6 million Americans. The Secretary of the Department of Health and Human Services (HHS) met with leaders from the National Academies and challenged them to propose bold new ideas that might change conventional thinking about the most serious problems facing the health care system today. In response, the Institute of Medicine (IOM, 2002, p.1) reported: “The American health care system is confronting a crisis…Tens of thousands die from medical errors each year, and many more are injured. Quality problems, including under-use of beneficial services and overuse of medically unnecessary procedures, are widespread. And disturbing racial and ethnic disparities in access to and use of services call into question our fundamental values of equality and justice for all. The health care delivery system is incapable of meeting the present, let alone the future needs of the American public.” (emphasis added)a

These problems are clearly so serious that they should compel a complete re-examination of the U.S. health care system from the ground up. One central assumption that requires re-thinking is the idea of the separation of mind from body, the notion pervading our concepts of health and illness that there are some illnesses that are physical and others that are mental, a notion that is enshrined in the current practice in healthcare reimbursement of “carving out,” or sub-capitating, mental health benefits. In fact, mind and body are not separate, but rather they are inseparable. By maintaining the fiction that mind and body are separate, and, further, assuming that the only role that the mind plays in health and illness is in mental health and illness, we have developed a healthcare system that is hobbled in its ability to deal with the many varied roles that mind and behavior play in so-called physical illness. This system, further, does not even deal with mental health and illness, per se, effectively.

Magnitude of the Cartesian Error

Mind-Body dualism has an enormous negative impact on our health care system. Because of it, our health care system does not systematically attend to the many psychological risk factors for both morbidity and mortality, and it virtually ignores the psychosocial pathways that lead to unnecessary utilization of medical and surgical services. Further, our health care system does not fully utilize appropriate tools to tackle the current chronic disease epidemic, such as the numerous disease management programs aimed at treatment adherence and lifestyle improvement developed and validated by psychologists. Nor does it utilize fully the many well-documented psychological interventions for acute illness and management of stressful medical procedures. In addition, the psychological impact of having a medical illness is not well addressed by the health care system, nor is the fact that many people suffering from a physical illness have comorbid psychological illness, nor is prescription drug abuse. Finally, the lion’s share of mental health problems are treated, ineffectively, by primary care providers. Let’s take a look at some of the evidence.

Seven of the top health risk factors are behavioral (tobacco use, alcohol abuse, poor diet, injuries, suicide, violence and unsafe sex, USDHS, 2002).
Seven of the nine leading causes of death have significant behavioral components (McGinnis & Foege, 1993, New Ref).
At least 50% (and maybe as much as 75%) of all visits to primary care medical personnel are for problems with a psychological origin (including those who present with frank mental health problems and those who somaticize), or for problems with a psychological component (including those with unhealthy lifestyle habits such as smoking, those with chronic illnesses, and those with medical compliance issues), (O’Donahue, Ferguson & Cummings, 2002).
Stated another way, one study found that less than 16% of somatic complaints had an identifiable organic cause (Kroenke & Manglesdorff, 1989).
A large number of studies have demonstrated that providing behavioral health care reduces the utilization of medical and surgical care (Chiles, Lambert, & Hatch, 1999).
The vast majority of people receiving mental health treatment are cared for by medical professionals with minimal specific training in mental health (Glied, 1998).
Moreover, there is a growing body of empirical evidence supporting the effectiveness of psychological interventions in ameliorating a wide range of physical health problems, including both acute and chronic disease affecting literally every organ system and encompassing pediatric, adult and geriatric populations. In addition to being clinically effective, these interventions are dramatically less expensive than alternative somatic interventions across a wide variety of illnesses and disorders, including cardiovascular disease, hypertension, diabetes, neoplasms, and traumatic brain injury (Smith, Kendall, & Keefe, 2002).

Toward a Biopsychosocial Model

Descarte’s 17th century philosophy, which separates mind from body, is, quite simply, bankrupt. We, as a nation, need to transform our biomedical health care system to one based on the biopsychosocial model. This coming transformation will create tremendous opportunities for psychology to play a major role in resolving some of this nation’s health care problems with regard to cost, quality, and access.

The recent approval by the Center for Medicaid and Medicare Services of the Health and Behavior codes for psychologists will facilitate these developments. These new codes allow psychologists to see patients for medical diagnoses in their private offices and bill for assessment and intervention (Foxhall, 2000).

In order to rise to this challenge, psychology must define itself as a health profession rather than as a mental health profession. An APA Board of Professional Affairs Work Group recognized this need when it called for a “figure-ground reversal” in professional psychology. The Work Group advocated that, rather than viewing psychology as a mental health profession with health psychology representing a subset of its expertise, we should view psychology as a health profession, with mental health as a subset of its expertise.

The American Psychological Association took a major stride in this direction, when, in 2001, under the leadership of then-President Norine Johnson, the mission statement was amended to include health as part of its mission, which now reads: “to advance psychology as a science and a profession, and as means of promoting health, education, and human welfare.” This bylaw change was approved by one of the largest pluralities ever.

This change in perspective, to viewing psychology as health discipline operating from a biopsychosocial perspective, would, of course, require a dramatic change in our training programs. If psychology truly wishes to rise to the challenge presented by the failures of the US health care system and respond in a fulsome way to the tremendous opportunities in health care, we would have to change not only the doctoral curriculum but also the undergraduate pre-requisites. Both are long on the “psycho” and “social” parts, but short on biology and the related areas of mathematics, physics, and chemistry. So too, training programs are highly variable in the degree to which students gain experience working in interdisciplinary collaboration in the broader health care arena, whether it be primary care, general hospitals, academic medical centers and the like, and this would have to change to ensure significant training in health care.

Undertaking a change of this scope will, of course, not be easy. However, to put this in perspective, consider that psychology now has before it a rare transformational opportunity, on the scale of what took place more than 50 years ago at the end of World War II. Prior to World War II professional psychologists had very limited roles as psychodiagnosticians working under the direction of psychiatrists. The war and its aftermath brought with it a tremendous demand for mental health services, including psychotherapeutic treatment, which helped wrest control of psychotherapy from psychiatry and opened this field up to psychology. This, in turn, led to a tremendous expansion of the scope of practice for professional psychology (Humphries, 1996).

References

Chiles, J. A., Lambert, M. J., & Hatch, A. L. (1999). The impact of psychological interventions on medical cost offset: A meta-analytic review. Clinical Psychology: Science and Practice, 6, 204-220.

Engel, G. (1977). The need for anew medical model: A challenge for biomedicine. Science, 196,129-136.

Foxhall, K. (2000). New CPT codes will recognize psychologist’s work with physical health problems. Monitor on Psychology, 31, 46-47.

Friedman, R., Sobel, D., Myers, P., Caudill, M, & Benson, H. (1995). Behavioral medicine, clinical health psychology, and cost offset. Health Psychology, 14, 509-518.

Glied, S. (1998). Too little time. The recognition and treatment of mental health problems in primary care. Health Services Research, 33, 891-910.

Humphries, K. (1996). Clinical psychologists as psychotherapists: History, future, and alternatives. American Psychologist, 51, 190-197.

Institute of Medicine (2002). Fostering rapid advances in healthcare: learning from system demonstrations. Washington, DC: National Academy Press

Kroenke, K, & Mangelsdorff, D. (1989). Common symptoms in ambulatory care: Incidence, evaluations, therapy, and outcome. The American Journal of Medicine, 86, 262-26.

McGinnis, J. M., & Foege, W. H. (1993). Actual causes of death in the United States. Journal of the American Medical Association, 270, 2207-2212.

O’Donahue, W. T., Ferguson, K. E., Cummings, N. A. (2002). Introduction: reflections on the medical cost offset effect. In N. A. Cummings, W. T. O’Donahue, and K. E. Ferguson (Eds.). The impact of medical cost offset on practice and research: Making it work for you. Reno, NV: Context Press.

Smith, T. W., Kendall, P. C., & Keefe, F.J. (2002, Ed’s). Special issue: Behavioral medicine and clinical health psychology. Journal of Consulting and Clinical Psychology, 70, 459-851.

Snyder, C. R., & Elliott, T. R. (2004). 21st Century Graduate Education in Clinical Psychology: A four levels matrix model. Journal of Clinical Psychology, this issue.

U.S. Department of Health and Human Services (2000, November). Healthy people 2010:Understanding and improving health. Washington, DC: U.S.G.P.O.

Ronald F. Levant, Ed.D., M.B.A., A.B.P.P., is President-Elect of the American Psychological Association. He was the Chair of the APA Committee for the Advancement of Professional Practice (CAPP) from 1993-95, a member at large of the APA Board of Directors (1995-97), and APA Recording Secretary for two terms (1998-2000, 2000-2003). He is Dean and Professor, Center for Psychological Studies, Nova Southeastern University, Fort Lauderdale, FL.

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