Keeping the "care" in managed care: the importance of the therapeutic relationship and psychosocial factors in the managed care setting.

From the earliest Greeks to contemporary medicine, the importance of the "mindbody connection"[1] has been recognized. The significant prevalence of psychosocial problems in both primary care and inpatient medical settings is well-recognized. The presence of depression can be expected in 5 to 25 percent of patients in outpatient medical settings and in 17 to 42 percent of patients in the general medical hospital, with some subgroups, such as oncology or dialysis patients, demonstrating even higher rates of depression.[2] It is further recognized that 50 percent of all mental health care is provided in the primary care medical sector rather than through mental health specialists.

Psychosocial factors have been shown to affect on health care delivery and costs in significant ways. Wells and colleagues[4] reported that, of 11,242 medical outpatients, those with depressive symptoms or a depressive disorder had worse physical, social, and role functioning; worse perceived current health; and greater complaints of pain.

Psychosocial factors have been related to mortality and morbidity in medical patients. For example, social isolation has been shown to approximately double the chances for recurrent myocardial infarction.[5] High levels of stress combined with social isolation may result in a four-fold increase in cardiac mortality at three years.[6] Depressed patients are reported less likely to resume premorbid activities after stroke compared to nondepressed patients.[7]

Individuals with significant emotional distress are acknowledged to be high or overutilizers of medical services.[8] Evidence exists that psychosocial interventions can reduce medical overuse and provide significant cost savings. For example, a program of screening for psychological distress in elderly hip fracture patients resulted in savings of $166,926 and $97,361 for the two hospitals involved.

Psychosocial Factors and the

Therapeutic Relationship in Managed

Care Systems

For many reasons, the impact of psychosocial factors and physician-patient relationships on the nature of health care as described in traditional systems may be even more critical in managed health care. In fact, many of the influences already described have been extensively examined in managed care environments. For example, Follette and Cummings[8] reported that psychological treatment of medical patients' emotional distress resulted in a decline in medical service use, that the decline was maintained after psychotherapeutic treatment was terminated, and that the decline produced savings that were not simply shifts to psychological costs.

While some work has suggested that savings from psychological services to medical patients may be more pronounced for the inpatient medical sector,[10] others have reported" that psychological treatment yielded decreases in outpatient visits, days hospitalized, prescriptions written, emergency department visits, and diagnostic studies ordered. Goldensohn et al[12] compared medical utilization rates before and after psychotherapy services were provided to medical patients. They found moderate decreases in the number of family physician visits and specialist visits, and a significant decrease in the number of x-rays and laboratory tests ordered.

In a recent overview, Cummings has concluded: "The evidence thus far suggests that psychological services can reduce the inappropriate utilization of expensive medical care among the "worried well" and improve medical management and behavioral outcomes among the chronically ill."[13]

There is no reason to assume that psychosocial factors will have any less impact on morbidity and mortality within managed care than has been demonstrated in traditional care. Further, Wells[14] reported no difference in the prevalence or severity of depressive problems in prepaid or fee-for-service systems. Outcome of treatment was also similar. In this same review of three large public policy studies, it was reported that more patients saw a general medical specialist for psychological care in a prepaid system (65 percent) in a fee-for-service system (50 percent). There was significantly less detection of depression in the prepaid setting (41.8 percent) than in the fee-for-service setting (53.7 percent) by medical physicians and significantly less treatment of the depression.

This is in line with general concerns about physician under-recognition of depression in medical patients. On the other hand, it has been shown that a greater emphasis on diagnosis and alerting physicians to the potential of a depressive disorder can significantly improve diagnostic accuracy.[15]

While managed care approaches emphasize outpatient treatment and prevention, implications of data on the psychosocial effects on inpatient medical treatment also have relevance.[1] Additionally, psychological reactions that may begin or be exacerbated by hospitalization for medical illness can extend into discharge and outpatient care. It has been reported[16] that, while 50.7 percent of patients undergoing open-heart surgery manifest an adjustment disorder at the time of the operation, 30.6 percent will still exhibit emotional impairment at six months. Another example is the report by Feibel & Springer[7] that the prevalence of depression in stroke patients is still 26 percent at six months post-stroke. These are patients and problems that will be seen in the primary care setting.

The foundation for much of the nature of psychosocial impact is the quality of the doctor-patient relationship. While it has been noted[17] that the doctor-patient relationship is often minimized as "placebo," the placebo effect is real and powerful. It is a special interpersonal relationship, dynamic, and intimate in nature, and built on a foundation of trust. A well-developed and healthy doctor-patient relationship provides unique understanding of the patient's situation, allowing more accurate diagnosis of problems, awareness of the relative contributions of physical and psychosocial factors, and greater effectiveness in affecting both physical and psychological needs.

The quality of the relationship can affect morale and motivation, behavior change, symptomatic relief, and even medicinal effects. The influence of the therapeutic relationship is so powerful that Balint[18] has described physician behavior and influence as a "drug" in terms of its effect on the patient.

Yet, concern has been consistently raised about the quality of the doctor-patient relationship. In traditional settings, patient surveys rarely find complaints about technical expertise; routinely found, however, is disenchantment with the "human element" of the relationship.[19]

More specifically for managed care, it has been suggested[17] that systems that "objectify" patients lead to decreased compliance, increased recidivism, increased cost, and increased litigation. Further caution has been raised that some patients in managed care settings are critical of reduced access to "their doctors," use of physician extenders, and reassure on physicians to see increased numbers of patients. Dissatisfied patients seek to change caregivers and systems.[19] Others[20] have written that litigation results not so much from the perception of technical incompetence as the breakdown of the patient-physician relationship, especially where "suit-prone patients" interact with "suit-prone doctors."

Given that most medical care, and now most psychological care, will be focused in the primary care sector, suboptimal therapeutic relationships can have profound consequences. In addition, the quality of the doctor-patient relationship can affect every aspect of care from diagnosis to treatment and outcome.

Problems can develop not only from lack of training or awareness of the patient's psychological status, but also from the physician's failure to be aware of personal emotional reactions to the patient, especially the difficult patient.[21] Such reactions can lead to emotional rather than clinical diagnostic labeling or failure to diagnose (because of dismissal) organic problems.[22]

Goldensohn and colleagues[12] suggest that the reduction in diagnostic tests seen with the institution of counseling for medical patients in their study may have resulted from one of several situations, including the fact that physicians who are uncomfortable handling emotional aspects of patient care temporize with diagnostic testing. Counseling of patients reduced this need and discomfort on the part of physicians. It has been reported[14] that, when general medical physicians see patients for counseling, they rarely have a specific psychological treatment noted, other than psychotropic medication.

We believe an under-recognized factor in burnout in primary care physicians comes from the challenges of managing psychosocial issues in their practices. Years of experience and interaction with physicians has suggested that, when practices become predominantly psychosocial sounding boards, physicians feel they have drifted or been pushed too far from their "medical" orientation, and stress and dissatisfaction become problematic issues. This is especially true for primary care physicians who have not been adequately trained or do not receive ongoing training and education in managing psychosocial issues, have little interest, and/or receive little support in being involved in intervening with patients' psychosocial needs.

The importance of the availability of resources for referral for psychosocial interventions cannot be overemphasized. It is not possible to be an adequate "gatekeeper" and also provide maintenance/care for all cases. This notwithstanding, primary care physicians are capable of positively influencing physical and psychological care. In prepaid systems, mental health specialists see patients for an average of 10 sessions, compared to one session for counseling by medical practitioners.[14] Other work has suggested[8] that even one counseling session can positively affect medical care parameters.

Evidence now exists that ". . .well-developed psychological, educational and behavioral treatments generally have meaningful positive effects on the intended outcome variables."[23] Additionally, there is now empirical evidence that "listening" and emotional ventilation (as opposed to emotional suppression) do have salutary effects on medical patients (when done under the correct conditions of a receptive and trained listener.[24] Other more active interventions, such as those to promote coping with invasive diagnostic procedures (such as endoscopy) have also demonstrated to be effective in reducing patient anxiety and in increasing patient satisfaction.[25]

Conclusion

Several conclusions emerge regarding psychosocial factors and the doctor-patient relationship in managed care settings. * Psychosocial and therapeutic relationship factors affect health care costs. * Psychosocial and therapeutic relationship factors affect morbidity and mortality. * Psychosocial and therapeutic relationship factors affect patient satisfaction. * Techniques and strategies to successfully address these factors are available. * There is a need for physician awareness and skill enhancement in these areas.

It is to the advantage of managed care systems and their patients that this emphasis not be muted, minimized, or ignored. Experience has taught that these factors must be integrated by design, because they will not develop by default. Promoting psychosocial intervention and the therapeutic relationship in managed care is not a medical nicety but a medical necessity, one that is even more pronounced if ultimate outcomes are to be favorable to the patient and cost-effective to the purchaser.

It will be incumbent on the primary care physician to understand the relationship of psychological and physical factors in health and illness, feel comfortable in the interface, and be effective in their treatment.

References

[1.] Asken, M., Florence, D. "Clinical and Cost-Effectiveness of Psychosocial Interventions in Health Care." Pennsylvania Medicine 97(11): 14-6, Nov. 1994. [2.] Katon, W. "The Epidemiology of Depression in Medical Care." International Journal of Psychiatry in Medicine 17(1): 93-112, Jan. 1987. [3.] Emerson, J., and others. "Personality Disorders in Problematic Medical Patients." Psychosomatics 35(5): 469-73, Sept.-Oct. 1994. [4.] Wells, K., and others. "The Functioning and Well-Being of Depressed Patients." JAMA 262(7): 914-19, Aug. 18, 1989. [5.] Case, R., and others. "Living Alone after Myocardial Infarction: Impact on Prognosis." JAMA 267(4): 515-19, Jan. 22-29, 1992. [6.] Ruberman, W., and others. "Psychosocial Influences on Mortality after Myocardial Infarction." New England Journal of Medicine 311(9):552-9, Aug. 30, 1984. [7.] Feibel, J. and Springer, C. "Depression and Failure to Resume Social Activities After Stroke." Archives of Physical Medicine and Rehabilitation 63(6):276-7, June 1982. [8.] Follette, W., and Cummings, N. "Psychiatric Services and Medical Utilization in a Pre-Paid Health Setting." Medical Care (5): 25-35, May 1967. [9.] Strain, J., and others. "Cost-Offset from a Psychiatric Consultation-Liaison Intervention with Elderly Hip Fracture Patients." American Journal of Psychiatry 148(g):1044-9, Aug. 1991. [10.] Mumford, E., and others. "A New Look at Evidence about Reduced Cost of Medical Utilization Following Mental Health Treatment." American Journal of Psychiatry 141(10):1145-58, Oct. 1984. [11.] Rosen, J., and Wiens, A. "Changes in Medical Problems and Use of Medical Services Following Psychological Intervention." American Psychologist 34(5):420-31, May 1979. [12.] Goldensohn, S., and Fink, R. "Mental Health Services for Medicaid Enrollees in a Pre-Paid Health Plan." American Journal of Psychiatry 136(2):160-4, Feb. 1979. [13.] Cummings, N. "Arguments for the Financial Efficacy of Psychological Services in Health Care Settings." Handbook of Clinical Psychology, in Medical Settings. New York, N.Y.: Plenurn, 1991. [14.] Wells, K. "Depression in General Medical Settings: Implications of Three Health Policy Studies for Consultation-Liaison Psychiatry." Psychosomatics 35(3):279-96, May-June 1994. [15.] Moore, J., and others. "Recognition of Depression by Family Medicine Residents: The Impact of Screening." Journal of Family Practice 7(3):509-13, Sept. 1978. [16.] Oxman, T., and others. "Frequency and Correlates of Adjustment Disorder Related to Cardiac Surgery in Older Patients." Psychosomatics 35(6):557-68, Nov.-Dec. 1994. [17.] Smith, T., and Thompson, T. "The Inherent, Powerful Therapeutic Value of a Good Physician-Patient Relationship." Psychosomatics 34(2):166-70, March-April 1993. [18.] Balint, M. The Doctor, His Patients, and The Illness. New York, N.Y.: International Universities Press, 1973. [19.] Meichenbaum, D., and Turk, D., Facilitating Treatment Adherence. New York, N.Y.: Plenum, 1987. [20.] Bernstein, L., and others. Interviewing: A Guide for Health Professionals. New York, N.Y.: AppletonCentury-Crofts, 1974. [21.] Stern, T., and others. "Autognosis Rounds for Medical House Staff." Psychosomatics 34(1): 1-7, Jan.-Feb. 1993. [22.] Hendler, N. and Kozikowski, J. "Overlooked Physical Diagnoses in Chronic Pain Patients Involved in Litigation." Psychosomatics 34(6):494-501, Nov.-Dec. 1993. [23.] Lipsey, M., and Wilson, D. "The Efficacy of Psychological, Educational, and Behavioral Treatment." American Psychologist 48(12):1181-209, Dec. 1993. [24.] Azar, B. "Research Plumbs Why the 'Talking Cure' Works." APA Monitor 25(11):24, Nov. 1994. [25.] Gattuso, S., and others. "Coping with Gastrointestinal Endoscopy. Self-Efficacy Enhancement and Coping Style." Journal of Consulting & Clinical Psychology 60(1):133-39, Feb. 1992.