At the Institute for Chronic Pain, we believe this lack of attention to coping is a mistake. It’s a mistake because it leads to poorer health and greater costs. Let’s explain how a significant lack of attention to coping leads to these unfortunate outcomes and then review what we might do about it.
A healthcare delivery system
For the most part, we have a healthcare delivery system. I mean this statement quite literally. The predominant way in which we provide healthcare in our society is that when something ails us we seek a healthcare expert who provides or delivers to us a procedure or therapy or medication that makes us well. The standard name for this type of healthcare is the ‘acute medical model’ of care. In such care, health is brought about by the healthcare provider. The provider has a certain expertise in what ails us. As patients, we lack this expertise and so rely on the provider to use his or her expertise in order to do something therapeutic to us. As such, healthcare providers do things to us to make us well, as long as we do what they recommend. Patients don’t have much role in the acute medical model, besides being compliant and patient with the recommended therapies and procedures and medications. The real power lies in the provider who provides healthcare. In this way, we come to healthcare providers in a state of ill-health and health gets delivered to us. As stated, we have a healthcare delivery system.
The acute medical model is all well and good, especially if we have cures for what ails us, or at least the ability to keep us alive in a medical emergency. When having an acute appendicitis or a heart attack, it usually pays to be compliant with the emergency room provider’s recommendations. In such situations, we become the passive recipient of the intellectual and technical expertise of a healthcare team that delivers us from a state of poor health and danger to a state of relative better health and safety. We can think of any number of acute health conditions for which this model of care is well suited and can produce dramatic, life-changing, indeed life-saving, results.
Perhaps it’s because the acute medical model can produce such results that it has become the predominant model of providing healthcare in our society. Whatever the reason, it has become the paradigm by which we conceptualize healthcare. By it’s terms, we understand the roles of providers and patients – those who provide healthcare and those who receive it. We use it to understand what we are supposed to do when being unwell – we rely on our healthcare providers to make us well. We use it to understand the healthcare system itself – we have a healthcare delivery system.
The practical consequences of the predominance of this way of understanding healthcare are numerous. Because the procedures, therapies, and medications of the acute medical model are valued in our society, they are typically reimbursed well. They are also reimbursed readily – they tend to have few obstacles to payments. As such, it’s largely how hospitals and clinics make money to pay salaries and other expenses and to make a profit. It’s largely how healthcare providers earn their living. It’s how the pharmaceutical and medical technology industries pay employee salaries and create value for shareholders. It’s also largely what patients want. Who doesn’t want a cure?
The predominance of the acute medical model can also lead to some unfortunate consequences, particularly when it comes to the role of the patient. As patients, we tend to believe that the acute medical model can deliver on its promise of making us well more often than it can in actuality. We might acknowledge that it can’t cure us of everything, but surely, we tend to think, it can keep us well enough. As such, the focus on healthcare in our society tends to remain on what healthcare providers and their technical expertise can do for us. Power and responsibility remain with the healthcare providers, even in cases where their power to make us well is not so great. This subtle form of dependency on the healthcare system to deliver wellness can therefore become increasingly problematic: it’s fine in the cases of acute appendicitis or acute heart attack, but not so fine in conditions where there is no cure.
Chronic health conditions are the bane of our society, generally, and of our healthcare delivery system, specifically. Conditions such as chronic pain, heart disease, type II diabetes, obesity, asthma, and others have become ubiquitous in our society. Whereas our grandparents, we might say, lived in an age of infectious illness (think influenza at the beginning of the twentieth century or polio in the early to mid-twentieth century), we live now in an age of chronic illness. Such chronic health conditions are what now burden us. Despite the magnitude of this problem, the healthcare delivery system isn’t particularly well-suited for this challenge even though, as a society, both as patients and healthcare providers, we tend to look to it for the solutions. It has no cures, to be sure. However, it can’t even keep us all that well. At best, it maintains the status quo of the current less-than-healthy state of the patient. Management and stability of pain, blood pressure, cholesterol, and blood sugars become the goal. Patients, in this model, are to remain compliant with the medication and other therapy regimens in order to keep their numbers within some acceptable range of poor health. Notice how patients remain subtly dependent on the delivery of healthcare in this system and yet the healthcare that is delivered is not so great.
Because of these factors, chronic conditions are also the main financial drain on our healthcare system. Chronic health conditions constitute 86% of the cost of our healthcare delivery system and are the leading cause of disability (CDC, 2015). Acute medical emergencies notwithstanding, for this devotion of healthcare dollars, our system of delivering healthcare fosters a subtle form of dependency in exchange for chronic, mediocre states of health and outright disability. Obviously, we don’t get a lot of bang for our buck.
The role of the patient in coping with health problems
So, what’s missing in this picture? It’s the lack of emphasis on what patients can do for themselves in responding to their own chronic health conditions. In the predominance of the acute medical model of delivering care, both patients and providers forget that patients themselves have a role to play in their health. We call it coping.
We might define coping as our cognitive, emotional and behavioral responses to a problem, such as a health condition. In acute health conditions, the typical coping response is the following: cognitively, we don’t know what’s going on and we need answers in the form of a diagnosis and treatment plan; emotionally, we’re concerned, if not alarmed and frightened; this emotional alarm is helpful because it motivates us to act and seek the help of those who do know what to do; and so, behaviorally, we seek healthcare providers who have the requisite expertise to do something to make us well again. This is what good coping looks like in acute medical model healthcare. If, however, as we do in our society, we continue to apply this model of healthcare to chronic conditions we don’t fair so well: cognitively, as patients, we remain lacking the requisite expertise to adequately respond to our condition; emotionally, we remain concerned, if not alarmed, by our on-going state of health and so remain motivated to continue seeking help from those who are supposed to deliver us out of our state of poor health; behaviorally, then, we continue to seek acute medical care – its procedures, therapies, and medications, which simply maintain the status quo. Lack of knowledge or expertise, emotionally alarmed, and dependent – these are not the characteristics of good coping, at least not in the context of chronic health conditions.
What’s lacking when we allow the acute medical model to predominate in our healthcare system is the capacity to:
- Cognitively, teach patients what they have, how it develops and why it continues on a chronic course; how to tolerate an understanding of the patient’s own role in these causal factors; and how they can respond to it.
- Emotionally, empower them so that they remain both confident in their own expertise of how to self-manage the condition and motivated to do so over the long-term.
- Behaviorally, coach patients on how to make meaningful, productive and sustained changes in their lifestyle so as to improve their state of health and well-being.
The acute medical model simply fails to provide these kinds of help, as it’s not designed to provide it.
Nonetheless, outside the acute medical model, in what’s called the ‘rehabilitation model of care,’ we have healthcare providers who assume this role of using their expertise to teach, empower, and motivate patients to cope well with chronic health conditions. They are health psychologists and other rehabilitation providers. You find them in chronic pain rehabilitation programs, cardiac rehabilitation programs, diabetes education programs, and, increasingly, cutting-edge interdisciplinary primary care clinics where you can see both a primary care physician and a primary care health psychologist.
Notice that the number of such providers and programs pale in comparison to the procedures, therapies, and medications of the acute medical model. As a society and as a healthcare delivery system, we continue to value external, technological procedures and pills over internal coping and lifestyle change, even though the latter is oftentimes more effective. Healthcare providers continue to refer patients to acute medical model care despite the option to refer them to rehabilitation, or coping-based, care. Patients continue to seek the former more than the latter. Insurance companies too continue to reimburse procedural- and pharmaceutical-based care at exponentially higher rates than education and counseling-based care.
It seems our priorities are out of whack when it comes to the greatest health needs of our society. In the case of chronic care, we don’t need more acute medical care, but more educational-based care.
A healthcare educational system
So, what if in addition to a healthcare delivery system we also had a healthcare educational system? What would it look like? Beginning with primary care, it would involve clinics that have not only primary care medical providers, but also primary care health psychologists. So, for example, type II diabetes patients would obtain medication management and nutritional counseling, as they do now, but also meet with a health psychologist to focus on the following:
- Tolerating and accepting greater degrees of ownership and responsibility for their diabetes and overall health
- Understanding the role that patients play in the development and maintenance of the condition
- How to make incremental lifestyle changes to improve their diabetes and overall health
- How to sustain these changes over time
In the limited number of primary care clinics that operate in this manner, the focus of such care is not to deliver well-being to patients, but to educate them, empower them, and motivate them to improve their well-being themselves. As a result, patients no longer remain in the afore-mentioned subtle dependency on the expertise of their healthcare providers. Through a healthcare educational system, patients become experts themselves.
Health psychologists, thus, operate under the principle that knowledge is often insufficient for sustained meaningful change. In our current acute medical model, the education and counseling that medical providers engage in typically ends with the provision of information: information, such as that smoking is bad for you; that you should lose weight; that you should exercise more; that you should learn to manage your stress; and so on. However, who doesn’t know these things? Simply knowing these things isn’t typically enough to successfully quit smoking, lose weight, start exercising or manage stress. Information is therefore insufficient for successful lifestyle change.
As such, we typically need someone to sit down and go over how to apply this information in ways that lead to long-term successful lifestyle change. However, no one, in our current healthcare delivery system, sits down with patients and actually goes over how to cognitively tolerate and accept such information or how to understand the individual’s role in achieving these goals; no one sits down with them and shows how to become empowered, confident and motivated to pursue and maintain these health goals; no one sits down and clarifies how to actually make incremental behavior changes that can successfully meet these lifestyle goals; no one develops a trusting relationship over time in which these often sensitive discussions can be had, as a coach has with the athlete that he or she trains; and no one can meet with patients on a periodic basis over time, with extended appointment times that last anywhere from fifteen minutes to an hour. No expert healthcare provider performs this role, except for the health psychologist.
What would it be like to have a trusting relationship with someone in your primary care clinic in which you can have up to an hour appointment, without the sense of being rushed, to discuss sensitive issues about how your health affects your life, but also how your life affects your health, to learn and grow, and to become a healthier and happier person, despite having some chronic condition? You’d become an expert at coping with your chronic condition and as such you'd know how to manage it so well that it would no longer disrupt your life in any significant way: what occupies your time, attention and energy would be your job, family and other life pursuits – not your chronic pain, diabetes, or heart disease.
Outside the primary care office, a healthcare educational system would also have specialty clinics. They would be interdisciplinary in nature, such as chronic pain rehabilitation programs, cardiac rehabilitation programs, diabetes education programs, and the like. Patients would seek care in these clinics in order to obtain advanced education and training in the self-management of their respective conditions. The function of these programs is typically two-fold. First, their intensity allows patients to take the next step in developing their expertise, which is to actually start reducing their dependency on the healthcare delivery system. By participating in these programs, patients get so good at self-managing their condition that they are able to reduce the amount of medications they take. Coping, in the form of healthy cognitive, emotional and lifestyle behavior changes, comes to be able to substitute for some of the medications that patients have heretofore relied on to manage their condition for them. Second, the intensity of these programs allow patients to learn and regain the confidence that they can return to some type of meaningful work.
Of course, a healthcare educational system wouldn't replace a healthcare delivery system. There is a time and place for acute medical model care. Medical emergencies occur and the acute medical model is best suited to respond to such cases. Even in the acute phases of what might turn out to be a chronic condition, there can be a role for the acute medical model. So, for example, patients can often benefit from acute medical model pain or cardiac management in the early phases of these conditions, even when the conditions subsequently later become chronic.
However, the vision we are entertaining involves a re-setting of priorities or emphasis when it comes to the roles of both the healthcare delivery system and a healthcare educational system. Patients and healthcare providers wouldn’t continue to repetitively seek acute medical model procedures and therapies long after a condition has clearly become chronic. Rather, everyone involved would see the point of switching the emphasis away from vainly attempting to deliver well-being to patients and towards educating, empowering and motivating patients to successfully improve their own well-being. In so doing, as a society, we would have to modify the value we place on the acute medical model, seeing that it has high levels of value in only certain contexts, and we would have to increase the value we place on rehabilitation-based care.
An important and essential part of this re-evaluation of our healthcare system would be the role of the reimbursement arm of our system – health and disability insurance companies and government institutions. They too would have to modify the value they place on each of the respective types of healthcare. Currently, reimbursement rates for acute medical model procedures and therapies are exponentially higher than rehabilitation, or coping-based, therapies. This system of valuation cannot but influence what type of care gets provided. To be sure, it's one of the reasons that the acute medical model predominates in our healthcare system.
What if, though, the reimbursement rates for medical providers were the same whether they provided education and counseling or a procedure? What if the health psychologist’s cognitive behavioral therapy was reimbursed at the same rate as medical providers’ education and counseling, or medical providers’ procedures? What if nutritional counseling and physical therapy were reimbursed commensurate to these other therapies as well? If the reimbursement rates of all these therapies were at least within the same ballpark, even if they weren’t exactly identical, we would have a very different healthcare system. Healthcare providers would stop being incentivized to provide acute medical care to conditions that are clearly chronic and they’d be incentivized to take the time to sit down with their patients and have the lengthy, oftentimes sensitive, discussions about how to cope with a long-term health problem.
Specialty care would significantly change too. In the vision we are entertaining, the value that we place on acute medical care would be commensurate with the value of coping-based care. Reimbursement rates for interventional procedures and surgeries would no longer be astronomically higher than interdisciplinary rehabilitation programs. To acknowledge that there may be a time and place for such former procedures, suppose that reimbursement rates declined only as they were repeated over time for the same condition. So, patients and providers might pursue interventions and surgeries, especially in the acute phases of a condition, but their value would decline as they get repeated long after it is clear that the condition is chronic. The reimbursement rates of interdisciplinary rehabilitation care would then start to become commensurate with acute care, especially when it comes to care for chronic conditions. In so doing, we’d stop incentivizing healthcare providers to deliver acute care to chronic conditions. The result would be that as a healthcare system we’d come to start valuing the right treatment for the right condition at the right time. We’d all obtain better care at a lower cost.
Whether you’re a patient, a provider or a representative of an insurance company, maybe it’s time to start demanding a healthcare educational system that focuses on coping-based care.
Center for Disease Control. (February 3, 2015). Chronic disease prevention and promotion. Retrieved from http://www.cdc.gov/chronicdisease/.
Date of last modification: April 12, 2015
Author: Murray J. McAllister, Psy.D.