Skip to main content
Markkula Center for Applied Ethics

Ethical Tensions: Ambiguity

Ambiguity About the Appropriate Disciplinary, Institutional, and Community Locating of Mental Health Services.

Mental health care is currently in a period of institutional transition, within a health care system that itself is the subject of wide social debate. Unresolved political debates about the health care financing system, and concerns to address challenges of access, cost, and quality, impact insurance access and models of care available to both patients and providers. 

Three widely endorsed goals challenge contemporary mental and behavioral health practice: 

  • Improving integration of mental and behavioral health with primary care; 
  • Improving integration of pharmacological, talk-based, and behavior-modification- based treatment modalities; 
  • Developing value-based reimbursement strategies. 

American health policy is in the midst of a reaction against perceived overspecialization of care and resulting “silo-ing” of different aspects of patient care. A variety of policies and changes in medical education seek to improve patient access to primary care and to spur better coordination of care between primary care providers and specialists. One strategy is the development of “patient-centered medical homes,” primary care clinics that combine primary care with coordination of ancillary services. The Affordable Care Act of 2011 included goals of improving foundational primary care. 

Efforts to improve primary care providers’ and clinics’ support of mental health include the development of primary care screening tools for depression, trauma, substance abuse, and other mental health challenges, and encouragement to use those screening tools routinely. They also include efforts to develop communicative networks between primary care providers and webs of specialist providers.33,34,35 In medical education, there is renewed attention to training primary care providers to recognize and to treat common mental health challenges, and to diagnose and refer serious mental illness to the most appropriate specialists expeditiously. 

At the same time, within mental and behavioral health there are increasing efforts to better integrate pharmacologically-based treatments such as medication for depression, anxiety, mood swings, and substance abuse with talk-based therapy and/or psychological behavior modification strategies. Mounting evidence suggests that for many mental and behavioral health challenges, integrating these modalities improves outcomes. However, many kinds of practitioners are trained almost exclusively in one or the other, and may or may not have established cooperative networks with alternately trained providers. 

Both cost pressures and quality incentives contribute spur a broad movement within American medicine to increase “value-based” care. Value-based care seeks to tie pricing and reimbursement mechanisms to tangible improvements in health, and to evaluate relationships between treatment approaches and outcomes. As part of a “value-based” health care, there are evolving efforts to define outcome metrics for mental health and best practices to support them. However, these definitions are challenging both because good outcomes in mental health may be hard to measure quantitatively, and because many patients have complex bundles of mental health issues and other chronic diseases. In the absence of consensus on value-definition, insurance plans adopt a wide variety of policies on reimbursement for mental health treatment, influenced by cost-containment concerns as well as by still-incomplete information on quality assessment. 

Some commentators criticize aspects of integrationist and value-defining movements in mental and behavioral health. They worry these well-intentioned efforts can be distorted by cost-cutting pressures in ways that ultimately reduce patient-access to necessary specialist care, and that exacerbate current shortages of certain kinds of specialists, notably psychiatrists. 

As a result of these ongoing transitions in the health system, whether patients with mental or behavioral health challenges get treatment may depend on chance aspects of how they enter the medical system, the training of their initial provider-point-of-contact, and their insurance status, as much as on evidence-based medicine. Among both primary care and specialist providers, there is variation on the extent to which individual practitioners feel the patient population seeking mental health services from them is appropriate to their training. 

Return to Ethical Tensions in Mental and Behavioral Health