Why Did Kaiser Change?

At the 1998 American Psychological Association National Convention in San Francisco, there was a symposium was "Health Psychology in Managed Care - An Opportunity for Creative Adaptation." One of the presentations was by Kirk Strosahl, a psychologist with the Group Health Cooperative in the Seattle area and a Kaiser consultant. His presentation was entitled "A model for integrating behavioral health and primary care medicine." He reported the following statistics:

• 90% of the ten most common complaints in primary care have no organic basis. Kaiser performed a ten year follow up study, and found that no organic conditions emerged after ten years to explain the somatized complaints.
• 70% of all primary care visits are driven by psychological factors.

Dr. Strosahl's statistics on the breakdown of these psychological factors in 25,000 patients was as follows:

• True Medical Difficulties - 30%
• Panic, Generalized Anxiety, Major Depression and Somatization - 35%
• Stress and Adjustment Disorders with Anxiety or Depression - 35%

It was also reported that:

• Psychologically distressed patients utilized health care at a rate of two or three times higher than non-distressed patients.
• Kaiser physicians see an average of 35 patients a day, and have difficulty identifying and managing psychological disorders.
• Kaiser estimates a 20% - 30% cost savings by integrating psychology into primary care.

Steven R. Tulkin, Ph.D. & Malcolm Gordon, M.D. (from Kaiser of Northern California) presented in the same symposium, and their presentation was called "Clinical Health Psychology in Kaiser's Redesign of Adult Primary Care". They "cut up the pie" a little differently. They reported that of the 70% of medical patients with primarily psychological concerns, the following breakdown of underlying psychological concerns was found:

• Pain/somatization - 25%
• Depression - 20%
• Anxiety/Panic - 20%
• Job Problems/Stress - 10%
• Marital/Family Problems - 10%
• Miscellaneous - 15% (Among the miscellaneous problems, borderline personalities and chemical dependency were also discussed)

According to Tulkin and Gordon, the role of the "behavioral health specialist" involved 1) diagnostic assessment of patients, 2) co-managing conditions with physicians using brief (15-30 minutes) and short term interventions, 3) consult with physicians regularly regarding patients, and 4) train staff about the role of psychological factors.

In the integrated primary care model, the psychologist is used to leverage physician time. This enables physicians to be more productive and effective in their interventions. Similarly, Kaiser is looking to psychological tests to leverage the psychologist's time. This makes possible an efficient diagnostic and treatment system. One of the psychological tests that Kaiser is using is the Battery for Health Improvement. Interestingly, although it was developed completely independently of the research at Kaiser, there a re a number of remarkable parallels. In particular, the BHI has a scale for each of the primary underlying psychological concerns reported by Tulkin and Gordon. This may make it especially useful in the triage process for integrated care patients.

In particular, the Northern California Kaiser implementation of Integrated Primary Care demonstrates an enviable integration between medicine and psychology. Perhaps it is not surprising that a recent Time magazine investigation rated Northern California Kaiser as one of the best HMO's in the United States. The professionals at Kaiser feel that integrated primary care is the future of both medicine and psychology. Overall, the patients like it, they get the care they need, they get better, and it saves a great deal of money.

It is a win-win situation.

It is a paradigm whose time has come.

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