At various sites around the country, a major paradigm shift is occurring in primary care that will greatly expand the role of the psychologist. Nowhere is this paradigm shift more dramatic than at Kaiser Permanente of Northern California. Northern California Kaiser has embarked on a new strategy for offering primary care services. Essential to the strategy is the psychologist "Behavioral Medicine Specialist" (BMS). A BMS will function on each primary care unit as an integral part of a multidisciplinary team.

Two psychologists, Kirk Strosahl, PhD and Steven Tulkin, PhD , have played dominant roles in the redesign effort within Kaiser. Both were presenters in a recent interesting APA symposium. Drawing upon his experience at the Group Health Cooperative of Puget Sound, Dr. Strosahl is serving as a consultant in Kaiser's efforts to implement the "integrated care" model. Dr. Strosahl noted that research suggests that a staggering 70% of all primary care visits are driven by psychological factors.

Dr. Tulkin, the principle Kaiser psychologist on the redesign committee, reported that of the medical visits driven by psychological factors, the following concerns were common: depression, anxiety, somatization, chronic pain, job/family problems, and miscellaneous concerns (borderline personalities and substance abuse were mentioned).

According to Corine Giantonio PhD, the first Kaiser BMS in Northern California, research has shown that much of the treatment for depression and other behavioral health difficulties already occurs in primary care. Among the reasons for this is that many patients are reluctant to accept a referral for psychiatric services, and so their medical doctors attempt to manage them as best they can.

Where Group Health and Kaiser have included BMSs in primary care, psychological disorders have been identified and treated earlier, at times saving significant costs and providing services in a manner much preferred by many patients. While Dr. Giantonio believes that health psychology training is the best preparation for the BMS role, she also noted that Kaiser has not been able to find enough health psychologists, leaving positions unfilled.

Just as the primary care provider (PCP) may refer to an orthopedist or neurologist, the BMS may refer to a behavioral health specialist. For example, Lee Lipsker, PhD, works with chronic pain patients at Kaiser, one of the specialty areas to which a BMS can refer. He stated that having a psychologist on the primary care team makes his job easier because he receives more appropriate referrals for his chronic pain program, and the patients who are referred have been worked up more thoroughly.

According to Roger Johnson, PhD, MBA, a Kaiser consultant/psychologist, a major obstacle to successful implementation of the BMS role is the adjustment that psychologists themselves must undergo in order to work successfully in a primary care setting. The pace is much more intense, and providers must act more like a consultant than therapist. Skills in making quick, accurate assessments and offering easily digested, practical suggestions are at a premium.

Surprisingly enough, this paradigm shift was not driven by psychologists seeking to gain inclusion in primary care, but rather by business considerations. Kaiser believes it can offer superior, yet less expensive, primary care by inclusion of BMSs. Being an HMO, Kaiser is better positioned to do this than are traditional fee-for service systems. Dr. Johnson noted that in Sacramento, where Kaiser also offers Behavioral Medicine classes and groups in addition to the presence of BMSs, 30%-40% reductions in medical visits are common.

Integrated primary care is a revolutionary practice model. It has a strong basis in research, and could fundamentally alter the future course of our profession. When a paradigm shift occurs, some solutions are offered, while many new questions are generated. That will almost certainly be the case here.

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