PN: But wait a minute. Aren't there tremendous economic incentives to reducing physician visits by "carving in" mental health services as part of primary care?
Cummings: That's true, and that's why they have tried to do it, but they have found out that they don't know how. Look, the success of the managed care industry has been tremendous. In 1993, the Congressional Budget Office predicted that by 1998 health care expenditures would reach $1.7 trillion. In fact, in the year 2000, health care costs had reached only $1.3 trillion. Managed care has saved the United States somewhere between $350 to $400 billion last year alone! Congress, literally, balanced the budget on what they saved on Medicare and Medicaid by farming out the services to managed care. So the managed care companies don't want to change. They don't want to do something they don't know how to do. And most of all, they don't want to disturb a huge profit center unless they absolutely have to. How can I explain this? I mean, it's like asking the members of the chauffeurs' union to suddenly all become airline pilots. You're either a pilot or you're a chauffeur. It takes a lot to stop physicians from doing what they are trained to do. A patient comes in week after week with the same symptoms and the physician will repeat the same "standard" test--electrocardiograms, blood tests, X-rays--trying to chase down some physical disease. And when one physician has had it, there are always more doctors with whom to start off the whole process again. And unless the patient mentions a psychological problem, most physicians have not been trained to think of referring to a mental health specialist.
But the important thing to remember about integrated care is that it's not enough just to change a few components in an otherwise traditional medical system. That's like adding a few drops of red paint to a 50-gallon can of white paint. You have to approach every primary care problem by including attention to the behavioral care issue as well. That's true integrated care.
PN: If there is so much resistance within traditional medicine and from managed care companies satisfied with their current profits, where is the impetus for change coming from?
Cummings: The real impetus for integrated care is coming from the employer. By now, they are familiar with the medical cost-offset literature that has consistently found that 60 to 70 percent of visits to physicians are made by people who have no organic disease, but whose primary problem is that they are somatizing stress. They know that there are billions and billions of dollars to save on the medical and surgical side, if those people could be treated by mental health professionals instead. So employers are starting to pressure the companies out there to change the way they deliver health care, which will have a huge impact on therapists.