Steps In The Evolution of The Health Care System

Healthcare in the 21st century is evolving on three paths: providing consumers with the incentives and tools to stay healthy, giving providers the incentives and tools to keep patients healthy, and creating and sustaining integrated health care institutions who maintain the health of the whole person. Often all three elements are necessary before there are measurable improvements in health and efficiency.

The health care delivery system is moving several fronts toward more intergraded systems of care driven in large part by changes in the way consumers and insurers choose sites of care and pay for that care. While most agree on the needed direction of change the evolution of the health care system is currently faced with a number of “chicken and egg” dilemmas: what has to happen first?

A representative example is the integration of primary care and behavioral health, specifically depression. A little under 10 percent of adults in the United States have symptoms of depression. Approximately 50% of people treated for depression receive treatment in primary care settings. However, studies have found that depression is often underdiagnosed and untreated in the primary care setting. Moreover, depression is often a comorbid condition for a wide variety of physical and behavioral health conditions and that depression often affects the success in treating those conditions or maintaining health. For example, individuals with depression and chronic conditions are almost twice as likely to fail to adhere to treatment recommendations for those chronic conditions.

The Affordable Care Act requires that all insurance plans cover at no cost to the consumer preventative measures that the U.S. Preventive Services Task Force (The USPSTF is an independent panel of experts in prevention and evidence-based medicine and is composed of primary care providers) has determined have scientific evidence of a high certainty that the services have a net benefit. Those measures include screening for depression.

However, the USPSTFs recommendation was that screening should be in “primary care settings when staff-assisted depression management programs are available”* That translates into an integrated system of care where behavior health providers are available to effective address the screened patient’s needs. A review of the scientific literature on depression screening in a stand alone primary care setting finds no evidence that patient outcomes are improved.* The authors of that review argue that depression screens should not be one of the recommended preventative measures. Other studies have found that cost-benefit ratios of depression screening depend critically on the cost of the screening, population being screened, and the access to appropriate care post-screening.

What that all means is that the inclusion of depression screens as preventative measures may be an important first step in providing patients, and providers with the tools necessary to cost-effective improve and maintain health, but its likely that it will only be show measureable improvements in health when provided in integrated systems of care.

*Thombs et al. BMC Medicine 2014, 12:13 accessed at:

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