My friends who are primary care physicians have all described a common occurrence in their practices and they do so in nearly identical terms. Perhaps this scenario sounds familiar. The patient in the exam room is a 50-year-old woman, presenting with a coterie of symptoms and complaints around pain, sleep and frequent ailments. With very little prodding, she breaks into tears and says she is angry, frustrated, lonely, trapped, disappointed and scared. “I have reached a glass ceiling at work,” “there’s no intimacy in my marriage,” “I feel so lost and lonely,” or, “I just hurt … ”
But it is minute 10 of the 13 minutes the PCP spends with each patient and he or she can’t destroy the schedule and generate long patient wait times. Physicians tell me they have great empathy for this patient but don’t have the time nor the training in behavioral health screening required to diagnose or treat her. And even if they had the time, they lack the coding expertise to ensure they are fairly compensated for their efforts. They also know that suggesting a psychiatric visit will be met with resistance due to stigma and a lack of trust. Time, money and stigma are hard barriers to overcome.
So they reach for their pad and scratch out a prescription for an antidepressant or antianxiety medication, offering words of reassurance: “What you are going through is normal ... this medication will help ... make an appointment to see me again …” The PCPs make the best decisions they can for their patients’ health and well-being, despite very real constraints and limitations.
Think this is a very rare occurrence?
Reaction Instead of Genuine Response
Research shows that in 2007 nearly 12 percent of primary care visits resulted in prescription of an antidepressant medication – nearly double what it was in 1996. What is startling is how many of these prescriptions are written without an actual psychiatric diagnosis. That rate has increased from 59.5 percent to 72.7 percent. An analysis found that those at highest odds of receiving such a prescription without diagnosis were:
- Women more than men
- Aged 50 and older more than any other age
- Patients with two or more medical diagnoses
- Patients with diagnoses of heart disease or diabetes
This profile is similar in many ways to the population we regularly serve in Health Integrated’s Multichronic Care Management (MCCM) program. MCCM members have multiple chronic conditions, high psychosocial risk factors, at least one diagnosed psychological condition, and are frequently prescribed antidepressant and/or antianxiety medications. By the time they enroll in our program, they have spent years reacting to symptoms, complications and comorbidities, without ever directly confronting the root cause/s of their health vulnerabilities – their behavioral and social risk drivers.
These patient stories and the research persuade me that they are both describing our MCCM member years before she ever enrolls in our program. When she saw her PCP, she received medication that lessened her pain or treated her other symptoms, but did nothing to address her real health drivers. Instead of identifying and addressing her fears, anxieties and barriers through validated talk therapy interventions, she more than likely pushed them deeper inside and for years followed that all-too-typical path of slow self-destruction into moderate to severe obesity, substance use and the burden of multiple chronic conditions. Years later, she has accumulated more risk, added one or more psychiatric diagnoses and has undermanaged her chronic medical conditions. She is now the right candidate for MCCM, which provides members like her with therapeutic care management.
Acting Sooner Could Save Suffering and Cost
But could we have done something better for her when she first presented at her PCP’s office? Could we not have integrated low-stigma, highly competent and fairly compensated psychosocial assessments into the primary care setting? Could we not have then given the PCP a tool kit of validated intervention pathways to build into her care plan? An estimated 60 to 80 percent of all primary care encounters are driven by a patient’s behavioral need. Patients and health plan members are clearly telling us what they need and want from their PCPs. Skill sets and compensation models must evolve and we at Health Integrated think our therapeutic model for Precision Empowered Care Management™ can play a critical role when integrated into the practice setting. In doing so, we can drive sustainable risk reductions and avoid the costly and devastating complications from unmanaged medical, behavioral and social vulnerabilities.
Tracy W. Korman is executive vice president of Innovation for Health Integrated.