The financial dimension of integrated behavioral/primary care.

There are two reasons why mental health, now more appropriately termed behavioral healthcare, is declining: (a) a lack of understanding among psychotherapists of healthcare economics, particularly the intricacies of medical cost offset, and (b) our failure as a profession to see the importance of behavioral interventions as an integral part of the healthcare system inasmuch as the nation pays for healthcare, not psychosocial care. This paper will briefly describe the rapid changes in the economics of healthcare during the past 75 years, including the post World War II enthusiastic espousal of psychotherapy by the American public which was followed by a precipitous decline as our outcomes research in behavioral care remained ignorant of financial outcomes, leaving it to the government and managed care to arbitrarily curtail escalating mental health costs. At the present time psychology is on the cusp of becoming part of the healthcare system through integrated behavioral/primary care, renewing the primacy of financial considerations such as return on investment (ROI) and medical cost offset, as well as an urgency that we avoid the mistakes that are emerging in some flawed implementations of integrated care.

The unmet educational agenda in integrated care.

One of the reasons integrated care has not become a dominant service delivery model is the unmet training agenda. This article argues that the typical mental health professional is not trained to adequately address the challenges of integrated care. To insure competency both a macro and clinical training agenda are needed. At the macro-level, mental health professionals need to understand healthcare economics and basic business principles as any integrated care service delivery system is embedded and driven by economic forces. Integrated care practitioners also need some basic business skills to understand these forces and to create and manage a financially viable system, given the future flux of the system. Traditional mental health professionals also do not have the clinical skills to implement integrated care. Integrated care is not simply placing a traditionally trained mental health professional and letting them practice specialty mental health in a medical setting. Thus, the special skills needed in integrated care are enumerated and discussed. Finally, a new degree program is described as it is time given the huge need and advantages of integrated care to develop specialty training in integrated care.

Herbert Dorken (1926-2012).

Herbert Dorken was born in Montreal, Canada, on July 7, 1926, and died in Grass Valley, California, on February 18, 2012, at the age of 85. Dorken was a prolific writer, with nearly 100 publications to his credit. He was particularly adept at taking raw health care data that the government had assembled with no apparent interpretation and translating it so that its meaning and implications for health care practice were clear. He strongly believed that the health care system in America, and particularly its mental health system, was in need of extensive reform. At the invitation in the mid- 1980s of the National Academies of Practice, he designed a model health care system that was heralded by many health economists, but it went nowhere because it was not in keeping with either of the two most prominent prevailing political health biases. In his later years, and after his daughter almost died of Lyme disease, Dorken became an advocate of the then neglected victims of this condition, the effects of which may persist for years after initial infection.

Delivering the nuts without the bolts: the plight of clinical psychology practice.

A vision as bold as that expressed by C.R. Snyder and Timothy R. Elliott in their target article, "Twenty-First Century Graduate Education in Clinical Psychology: A Four Level Matrix Model" (this issue, pp 1033-1054), should make the long-awaited breakthrough in training that would include development, implementation, and evaluation of large-scale health delivery systems. The realization that clinical psychology is part of the health care industry, and not just psychotherapy or mental health, would enable psychologists to go beyond the laboratory and become important decision makers in the health care arena and thus command a greater share of health care funding.

Case vignette: the vicissitudes of managed care.

Lee Wilson, age 26, was referred to Dr. Jackson for psychotherapy 5 weeks ago by a friend. Lee has been feeling increasingly depressed about longstanding family issues and the recent breakup of a 2-year relationship with a live-in companion. Over the course of the once-per-week sessions, Dr. Jackson notes persistent suicidal ideation, with vague plans to act if, as Lee puts it, "things get any worse." Just before the sixth session, Dr. Jackson is contacted by a reviewer for the managed care health insurance program covering Lee's therapy. The reviewer informs Dr. Jackson that the company will not authorize payment for further psychotherapeutic care. Dr. Jackson knows that Lee is in need of continued treatment and fears that terminating therapy at this time could result in increased suicide risk. Lee's income could cover only a small portion of Dr. Jackson's usual fee. Dr. Jackson does not wish to abandon Lee, but he already provides a significant amount of reduced-fee service to other clients. Is the health insurance carrier's stance ethical? Should Dr. Jackson be expected to treat Lee for the foreseeable future at a greatly reduced fee? How should Dr. Jackson handle this situation?