Psychologists are well aware of many of the challenges and difficulties of working within our nation’s present health care system. Efforts to work within the managed care environment have been well documented (e.g., Alleman, 2001; Cohen, Marecek, & Gillham, 2006; Moffic, 2004; Murphy, DiBernardo, & Shoemaker, 1998) with attention paid to difficulties with autonomy and the ability of patients and their health professionals to make treatment decisions, threats to confidentiality, the rationing of benefits, conflict of interest situations, risks for inappropriate terminations and abandonment, steadily decreasing reimbursement rates, and fiscally motivated treatment decisions rather than clinically motivated ones. Beyond these first hand experiences interacting with the health care system as professionals many of us have interacted with it as consumers as well. Poor coverage, high deductibles and low reimbursement rates, ever increasing insurance premiums, and access to care issues abound.
For many, participation in the present health care system, both as provider and consumer, has been a major source of frustration. Efforts by psychologists to impact our current health care system have yielded only very limited success thus far and our fights against the large corporate entities that control health care in the United States must for many feel like Sisyphus, forever pushing a large boulder up a hill that continually falls back under its weight, condemned to the fate of “futile and hopeless labor” (Sisyphus, para 1).
While the United States spends more per capital on health care than most other nations, sadly, the quality of health care, and of health, in our nation fall far below average for industrial nations. A recent report by The Commonwealth Fund, “Why Not the Best? Results from a National Scorecard on U.S. Health System Performance” provides detailed information on the glaring weaknesses in the present U.S. health care system (2006). The U.S. rates quite poorly on 37 different benchmarks of health and health care quality. Examples include the U.S. being one-third worse than the benchmark country “on mortality from conditions “amenable to health care”—that is deaths that could have been prevented with timely and effective care” (para 7), “despite documented benefits of preventive care, barely half of adults (49%) received preventive and screening tests according to guidelines for their age and sex” (para 8), “national preventable hospital admissions for patients with diabetes, congestive heart failure, and asthma (ambulatory care sensitive conditions) were twice the level by the top states” (para 9), and “as a share of total health expenditures, U.S. health administrative costs were more than three times the rates of countries with the most integrated insurance systems” (para 9). Further, significant health disparities are seen racially to include Hispanics being 20% lower on indices of quality, access, and efficiency of health care. African Americans are found to experience a 24% gap in mortality, access, effectiveness, and efficiency indicators in comparison to Caucasian benchmarks. Further, African Americans are found to have significantly lower cancer survival rates and significantly higher infant mortality rates due to chronic conditions such as diabetes and heart disease.
Overall, this national Scorecard finds the U.S. health care system greatly lacking in indices of long, healthy, and productive lives for our citizens, health care quality, access to health care, efficiency, and equity. Among other recommendations made are a totally revamped health care system that focuses on prevention, integrated care, access to care in the community, and a removal of fiscal incentives that promote inefficiency and withholding care. Inefficiencies and gaps in care in our current system are estimated to cost the nation $50 to $100 billion each year in unnecessary health care spending as well as 100,000 to 150,000 preventable deaths. Further, the Center for Medicare and Medicaid Services (2008) estimates that preventable medical errors result in “2.4 million extra hospital days, $9.3 billion in extra charges (for all payors), and 32,600 deaths” each year (para 3). They further cite an Institute of Medicine Report (1999) that estimated 98,000 deaths each year from preventable medical errors, although that report includes both possibly preventable and definitely preventable errors.
It is reported that health care spending rose by 7.4% in 2005. This was the third consecutive year with increases between 7 and 8 percent (Center for Studying Health System Change, 2008). Approximately 16% of the U.S. population does not have health insurance coverage (over 47 million Americans) (Klein, 2007). It is reported that in 2005 the U.S. spent more on health care per capita than any other nation, spending $6,697. The next highest spending country was Canada, spending $3,326. (Klein, 2007). In 2007 $7,600. was spent per person (NCHC, 2008). After Australians, Americans have the highest rate of chronic health conditions, which account for approximately 2/3 of health care expense increases in recent years. Further, it is reported that up to 42% of those with chronic health conditions skip health care appointments, treatment, and medication doses due to costs (Klein, 2007).
What Else Do We Know?
At least 50% of all visits to primary care physicians have a primarily emotional, behavioral, or mental health component (Mosen, Cannon, & Reiss-Brennan, 2001). These may include health conditions secondary or related to obesity, cigarette smoking, diet, lack of exercise, chronic pain, poor treatment adherence, high risk behaviors, stress-related difficulties, depression, anxiety, substance abuse and dependence, relationship difficulties, parenting issues, abuse and neglect, self-injurious behaviors, insomnia, eating disorders, academic difficulties, and many others.
We also know that prevention is much more effective than trying to treat difficulties after they cause deleterious effects. Yet, many psychologists, especially those in independent practice tend to access patients through direct referrals from primary care physicians, schools, and other similar sources. While some psychologists work collaboratively as part of multidisciplinary primary care treatment teams, this tends not to be the norm. But, working in primary care physicians’ offices is one ongoing practice that attempts to reduce the difficulties associated with the current disjointed health care delivery system. This is especially important when one considers that only approximately one-half of patients with depression and anxiety disorders are accurately diagnosed by their primary care physicians and less than one-half of those accurately diagnosed receive the appropriate needed treatment (Williams & Dietrich).
America’s Health
A number of significant strides have been made in Americans’ health overall by integrated efforts that take a public health, health promotion, and prevention focus. For example, significant strides have been made in the reduction of cigarette smoking in the U.S. population. The percent of individuals smoking has dropped from 45% to 21% over the past 40 years (Christakis & Fowler, 2008). This reduction has a profound impact on health as well as on health care costs. Yet, the costs in lives, resources, and dollars are still staggering. The American Cancer Society reports that one of every five deaths in the U.S. is the result of cigarette smoking and that it is the #1 preventable cause of death in our country (May 22, 2008). The American Cancer Society also reports that in the U.S. 438,000 people die each year of illnesses secondary to cigarette smoking.
Other significant health problems are present in our society that are costly on a number of levels and which at present are not effectively being addressed. For example, obesity and overweight are reported by the Centers for Disease Control (CDC) as dramatically increasing the likelihood of Hypertension, Osteoarthritis, High Cholesterol, Type-2 Diabetes, Coronary Heart Disease, Stroke, Gallbladder Disease, Sleep apnea and respiratory problems, and some cancers (May 22, 2008). Further, the CDC cites Finkelstein, Fiebelkorn, and Wang (2003) in reporting that the medical expenses for conditions secondary to overweight and obesity in the U.S. are up to $78.5 billion each year (9.1% of health care expenditures).
What Should Psychologists and Psychology Do About This?
It is clear that there is a significant two-fold crisis in our country. As a nation, our health care system is broken and our state of health is dismal. At present, our nation’s health care system is inefficient, expensive, inaccessible to many, and not particularly effective. To call it a health care system may in fact be a misnomer. Instead, it should more aptly be named a disease management system. Do we idly sit by watching our nation’s health continue to deteriorate and our resources squandered? Do we continue to work within a myopic system where quarterly corporate profits and stock prices win out over actual measures of health? What is needed is a health promotion system. Little is being done to promote health. Psychologists are experts in health promotion. While it is politically very challenging, psychologists and organized psychology need to be at the forefront of the health care reform movement. We have decades of research highlighting the roles of prevention, integrated health care, and reduced costs secondary to unfettered access to outpatient mental health care. Yet, little is being done with these data to significantly impact our presently dismal system.
Psychologists need to be actively involved in creating new models of health care delivery and developing innovative insurance reform ideas. See for example, the work of Division 42 member, Ivan Miller, and his Balanced Choice national health insurance reform proposal (see http://www.balancedchoicehealthcare.org/ ). More psychologists need to apply their creative energies to solving our nation’s most pressing health challenges. We need to feel moral outrage over the current health care crisis. How can we allow so many to continue living without affordable health care and without access to effective health care? Providing pro bono sessions to a few clients each year may feel like we’re doing good, but it doesn’t do anything to actually impact the present system in a significant manner. APA and other professional organizations must work together to put their collective resources behind the development of a new cost effective, efficient, and accessible health promotion system. But, as individual members, paying our professional association dues and hoping that others will take care of this clearly has not worked thus far. We must each see ourselves as integral parts of the solution. We must mobilize and take action. There’s no one else who is going to do this for us.
We must also take the lead in addressing the nation’s poor state of health through the application of our research and proven interventions. We must actively apply our knowledge and expertise to creating new models and systems of health delivery. Reducing preventable medical errors is an example of an area where psychologists have much to offer, yet again, it is one where we have not as of yet had a significant or lasting impact.
Taking a public health approach to changing the habits, behaviors, and lifestyle issues that so significantly contribute to our poor state of health (a significant portion of rapidly escalating health care costs) is essential. Psychologists are the experts in behavior change. We have much to contribute to promoting lifelong health promotion and treatment compliance. To do so, we must each become active advocates. It is essential that those with decision making authority are educated about these issues and psychologists must be at the forefront of this effort. Legislators, their staff members, business leaders (those who purchase insurance benefits for employees and dependents), and the public must be educated about these issues, provided with relevant data, offered potential solutions, and lead by us to take action.
While all this may sound naïve knowing the power of the insurance lobby and the many forces conspiring to keep the status quo, failure to act and to be successful should not be considered an option. Rather than passively accept our fate like Sisyphus we must actively fight for change and see this as our essential mission. We must follow the lead of groups such as Mothers Against Drunk Driving; groups of citizen advocates who decided that change must happen, will happen, and that they will not stop until it does happen. We need to be at the forefront of a new movement for health care reform and health reform with psychologists and psychology as essential components of each. Our nation’s future depends upon it.
Editor’s Note: “For Your Consideration:” is a new feature of the Independent Practitioner written by Jeffrey Barnett, Psy.D., ABPP, a past president of Division 42, sharing views on important issues confronting our profession and our society. Readers are encouraged to respond to these commentaries either in writing to the Editor at frankf@adams.net or directly to the author at drjbarnett1@comcast.net . Representative responses received by the Editor will be published in subsequent issues of the Independent Practitioner space permitting. Original contributions for the “For Your Consideration:” feature are also welcomed and should be submitted directly to the Editor.
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