Bill Clinton’s 1992 presidential campaign was oriented around the phrase: “It’s the economy, stupid.” The title of this article is meant to embrace the spirit of this plea for staying focused on top priorities—without resorting to name-calling. But what does it mean in a healthcare context? We can offer a variety of solutions to healthcare problems, but the foundational issue is which clinical models are used for establishing those solutions.
We can launch that debate with a direct question about our models. Should we search today for new medications (the biomedical model) or should we be searching for new psychosocial solutions?
People in the U.S. have been trained to prefer biomedical solutions. If you have a problem, then you try to find a doctor who can provide the best medication or surgery. This is a wonderful model if you find yourself in the category that has such solutions. However, clinical leaders should be asking where the best solutions will emerge, and this is a clinical model question.
Determinants of health
People are complex in that there are biological, psychological and social determinants of their health status. If we largely emphasize the biological, will we not miss other important healthcare solutions that are potentially more safe and effective? The answer is, obviously, yes, and we may also miss solutions that cost consumers less money.
The economics of pharmaceuticals are quite different from the economics of psychosocial solutions. Much could be said about this, but the main point is that pharmaceuticals are expensive to develop and costly to the consumer, especially during the initial period as a brand name product. Psychosocial solutions are less expensive in development and generally less costly for consumers.
Both the top and bottom lines for the pharmaceutical industry are typically high each year, and one reason is the success it has in promoting its clinical model. Specific drugs will vary in terms of their contribution to a company’s finances, but the industry is unparalleled in its promotion of medicine as the dominant clinical model.
Pills save lives every day, and so perhaps we shouldn’t question the status quo. Yet, aren’t we saving lives with other interventions? Psychotherapy in general is remarkably efficacious. It has an effect size of 0.8, which is large in the world of statistics.1 Why is psychotherapy not being extolled on par with pharmaceuticals? There is no entity promoting the value of psychosocial solutions like psychotherapy, let alone one with the power and wealth of the pharmaceutical industry. Psychotherapists sit alone in offices offering effective services confidentially, and the addiction industry is by and large a collection of small, independent programs.
Let us move outside the silo of behavioral healthcare to explore a clinical problem generally treated within the primary care arena. People with chronic pain have been suffering for generations. Effective medications were not available for these patients for many years, and then it became acceptable for primary care providers to prescribe opiates.
The ascendance of this clinical model has progressively led to addiction, persistent pain and overdose for many patients. The Centers for Disease Control and Prevention recently estimated that 91 Americans die every day from an opioid overdose.
Research has shown that psychosocial interventions, such as cognitive behavioral therapy (CBT) and mindfulness-based stress reduction, are more effective than usual care with opiates. These findings are now being widely promulgated, but this clinical solution may be less important than the clinical model that produced it.
CBT and mindfulness have been successfully used for depression and anxiety for many years, but it required a commitment to identifying new psychosocial interventions for pain for these techniques to be tried for patients—who formerly relied solely on a succession of pain medications. Families across America are grieving the loss of loved ones who died from opiate overdoses, and they should understand that the primacy and the profitability of such medications blocked out the identification of safer and more effective psychosocial solutions.
Promoting the psychosocial model
Healthcare in the U.S. can be improved with advances in science and with the development of smart business strategies. Pharmaceutical companies have long paid attention to both the science and the business of healthcare. Marketing departments for the drug companies have never been concerned about the relative value of psychosocial interventions, but frankly this is not their issue.
The problem is that there is no marketing powerhouse for psychosocial solutions, and so patients find those solutions only haphazardly as they sift through a maze of biological promotions. The problem is the prevailing clinical model, not the available clinical solutions.
The promotion of a more holistic model, namely, a biopsychosocial model, would be a step forward, but this will not happen until there is consolidation within the psychosocial treatment world. This is beginning to happen, especially within the substance use disorder (SUD) treatment industry. The federal parity law of 2008 changed insurance funding for mental health and substance use disorders, and the more significant impact was on SUD programs since insurance funding was historically much more limited for SUD than for mental health disorders.