Issues with the health care system are coming to a head in this country. As health care delivery evolves in response to calls and mandates for far-reaching reform, concerns of cost and creating a system ready to handle the aging baby boomer and Gen-X populations are taking center stage. To keep pace with the changes and to ensure that psychology plays a role in the evolution, state psychological associations have stepped up more to participate in the discussion.
The Rhode Island Psychological Association recently created a task force of members working to have a say in the decision-making process. New England Psychologist’s Catherine Robertson-Souter spoke with task force member Bill Macaux, Ph.D., MBA, whose consulting psychology practice, Generativity LLC, has given him unique insight into the daunting task of re-structuring the organizational aspects of health care. He talked about the task force, its work in the field of reform and ways that psychology can participate in the on-going process.
Q: How did you get involved in the task force?
A: With the Affordable Care Act and the Accountable Care Organization reform, there has been so much going on that it is much more than any one or two people could handle. They invited me and several others to join in on a task force and we each signed up to follow various tracks of reform.
Q: What track have you been following?
A: I am mostly involved with the patient-centered medical home (PCMH) model. There are initiatives underway in Rhode Island and nationally to figure out how to best implement this model of care. It is the paradigm that much of the health care reform is based upon.
With a PCMH, you would be treated by a primary care team with whom you would interact over time. The whole upshot is to empower you to self manage your behavior to be in compliance with treatment for any health conditions that you have and to maintain health.
Q: How does psychology fit into a re-structuring of the delivery of health care?
A: Number one, psychology brings an expert perspective, what I would refer to as direct service. That direct service may be clinical diagnoses and treatment of a patient or consulting and referrals. It could be the design and delivery of a psycho-educational group that maybe addresses a certain demographic or consulting with primary care physicians and physician assistants.
Second, is organizational transformation. The work I’ve done is with assessments and helping senior leadership think about how to make changes, what are going to be sources of resistance and how to get data to let us make course corrections.
The third bucket is designing and facilitating organizational learning. Traditionally, primary care practices have been physician-centric not patient-centric. It’s all about work flow and everybody else is there to move patients through, a production line mentality. If you start to work more as an inter-professional team that is compensated to deliver quality and value, you might need to organize differently.
Finally is this whole notion of integrating behavioral and physical health. We can help conceptualize how to design that. There has been a lot of good work done in this area.
Q: You have said that integration on its own is not enough.
A: When you talk about integration, one thing that probably would not work is to simply insert psychology into what is already a rather dysfunctional medical system. Everyone knows it is not working. It is too expensive. It is not meeting expectations on quality, cost or safety. I think we have to be careful to assert our role constructively and not simply be assimilated into something that is not going to work.
Q: How do you do that? How do you make your voice heard?
A: Many meetings are open to the public but typically only the interested parties will attend, people from insurance companies, the insurance commissioner’s office, from Medicaid and those responsible for implementing the Affordable Care Act. One thing that became immediately clear to me was that topics of behavioral health and health behaviors were noticeably absent or not front and center. As I began to speak up and my point of view became noticed as relevant, I was invited to participate in more committee activity.
Q: What are the tracks others are following in the task force?
A: For one, some of the people are involved in ensuring that reimbursement rates are properly treated. Psychologists are paid significantly less than a psychiatrist, who might be paid as much for a 20-minute medicine check as a clinical psychologist is paid for a full hour of therapy. We are hoping to ensure that there is actually mental health parity; that people have equal access to services for mental health and that professionals are adequately compensated to keep them in the field.
Q: How would you suggest psychologists get involved?
A: First of all, check with your state psych association. Someone will be focused on these matters. Let them know you want to be involved.
Then, think about what parts of that you wish to be involved with. Maybe you are most concerned with attending to the health needs of children or women or older adults. For me, it happens I am a consulting psychologist so when someone is talking about transforming the way that primary care is delivered, those are matters where I have expert experience and can offer a fresh point of view. I happen to also understand behavioral science and so I can talk about how physical and behavioral health is integrated. I am doing what I want to do. There is plenty of room for people to pick something they are interested in.
Q: For all the discussion, do you think that we are going to see the changes that are needed?
A: I think we have a long way to go. We are taking steps in the right direction but we are going to have to be persistent and determined. And I see that among my colleagues on this task force. Everybody knows we are going to have to stay at this for years, not months, in order to assert our voice effectively and to begin to affect the dynamics of the change.
Q: Do you think these reforms are too mired in politics? If a new president in four years throws out the laws, will we be back to where we started?
A: I think that anyone with any expertise in health care knows we have to solve these problems. The status quo is not sustainable. $2.7 trillion a year, 17 percent of our gross domestic product, is spent on health care, and it’s spiraling. We have a whole generation of people who are aging and if they don’t adopt healthy behaviors and begin to self manage their health, we are going to be in terrible financial straits down the road. So I know there can be politics in it, but the economics of it are pretty clear.