Integrated Care Vs. Co-Location: Or, “Integrated Care: No day at the beach!”

Perhaps one of the best measures that the integrated primary behavioral health care model is gaining wider acceptance is through a simple Google search. Typing in “integrated care” yields 82 million results, while a finer tuned search on “primary behavioral health integrated care” still stacks up over 5 million links.

The amount of information and chatter continues to swell every day. More data on enticing economic and clinical outcomes is starting to be easier gained, although one still needs to closely examine the perimeters and methods of the studies to extract true knowledge. Sample sizes, adequate study time, experimental/observational methods and other criteria should be considered as you browse through the data and reports – as you should any study you review.

However, one very common thread that I see in many of these reports and articles on integrated care tends to slightly bother me. Often, while extolling the virtues of an integrated approach, people will write that it is a way to beat stigma, that it will allow people to receive mental health treatment in a place where they are more comfortable such as in primary care. I guess in some sense that is a true enough statement. But it doesn’t tell the whole story. It’s sort of like saying that the beach is a great place to see beautiful models with sculpted bodies, and perfect families picnicking together under whimsical umbrellas. We’ve all been to the beach. Certainly there are gorgeous people and nice families, but there is also a whole lot of…well…”normal.” The statement about accessing mental health care in an environment where one is most comfortable should be received cautiously as it is loaded with caveats and “it depends” qualifiers.

And it all starts with how one defines “mental health treatment.” Many health centers have imported mental health clinicians into their practices; most often we see this as some sort of partnership where a therapist (typically a licensed social worker) is given some office space and sees patients based on a referral process in a co-located system. They might even talk of “warm hand offs” and “curbside consults.” Most often in these arrangements, however, they offer a traditional mental health approach meaning the therapist maintains a rather controlled schedule, receives referrals and sees the patients on a well-prescribed basis in 40-50 minute blocks. So yes, in this sense, a patient can receive mental health treatment in an environment of his comfort preference. But is that really integrated?

For that statement - integrated care can help people receive mental health treatment in a place where they are more comfortable – to be true, the organization needs to be practicing a rather complex model that offers real-time behavioral interventions based on a brief therapy approach to the total patient population. It should utilize highly-skilled behaviorists who function as primary care providers, and assist patients with emerging or current mental health issues, as well as disease management techniques. The idea should be to maintain as many of the patients as possible in primary care; but for those who require a higher intensity of care, access to more intensive services should be readily available. New roles such as consulting psychiatrists, population-based case managers, and primary care providers who are more comfortable dealing with behavioral issues are vital. Anything short of that simply isn’t truly integrated. In fact, one might even judge that an organization has become integrated when the staff stops talking about integrated care. Instead they just talk about healthcare.

Every primary care visit has a behavioral component. Each and every visit. Whether its a patient who needs to stop smoking, lose weight, change diets, take a pill every day, reduce stress, get more exercise, sleep better or manage a complex chronic illness – there is always a behavioral factor. To sell integrated care as simply a method where people can access mental health treatment in primary care is short-sighted, and almost a bait-and-switch. It is much, much more than that. It is true reform.

There is definitely a need to find ways to extend mental health services to those in need – and there is, without a doubt, a lot of need. However, sheltering a therapist who provides traditional mental health counseling in a primary care setting is simply not integrated care. It is a valuable service, no question; but it is not what we think of in terms of integrated care. Perhaps a better way to make the statement is “integrated care is a wonderful population-based healthcare model where people can access high-quality services from a variety of skilled providers, including mental health professionals.”

Just had to get that off my chest. Now, let’s clear this exam room for the next patient!

Saying “Yes,” the BHC’s the Best Tool: Or “Yes, I am not asking you to lunch ever again.”

At the core of a fully functioning integrated care team is a well-trained behavioral specialist. Some may call this position a Behavioral Health Consultant  (or Counselor, BHC), a Behaviorist, a Behavior Interventionist, or any other variety of titles. Sometimes there is some confusion in the role and duties, and it often starts with the position title; we’ve seen organizations refer to this position as the Care Coordinator, or Mental Health Consultant. That is akin to calling a zebra a horse, because, well, they sort of look alike. Making that mistake can lead to ongoing confusion and frustration with the role both by the person manning the spot, and the providers they work with.

So perhaps it is important to better define the role so that the titling of that position is much easier and more clear for all to accept. However, truly defining the skills, duties, and characteristics of an effective BHC is a far lengthier discussion than we can have in this forum. For now it is important to know that the BHC is an embedded member of the primary care team – not an adjunct to, or some sort of floating specialist that is co-located in the practice such as a podiatrist or nutritionist. The BHC is a member of the primary care team and functions as a primary care provider. Their interventions are in real-time, they help with issues that are both incident to a medical condition, or when emerging mental health issues surface in the context of a primary care visit. They function as generalists, and will often focus on patient resiliency, personal responsibility and assessment of readiness to change.

However, beyond all of that, one of their most important skills is their ability to say “yes.”

* Can you help this patient? She seems to be rather depressed.

* Can you pop into exam room three right now?

* This patient is having recurring headaches because her glasses are the wrong prescription but she can’t afford to go to the eye doctor. Can you help her?

* The adolescent in room 2 is having constant stomach pains and isn’t sleeping well, but I can’t find any physical or medical basis for the complaint; would you mind talking with him?

* The 60-year-old in exam 4 is hypertensive, diabetic and has coronary issues – she seems depressed and overwhelmed, can you help her?

The answer is always “yes.” Being positively responsive is about access and support. The success of the role of the BHC is inherently and entirely dependent on their accessibility to the providers in the clinic. Once a BHC sets a precedent of not being accessible, their effectiveness and importance to the providers begins to erode. One of our BHCs at Cherokee Health Systems, Dr. Suzanne Bailey, describes it as an invitation to lunch among friends. If one keeps asking the other to lunch and keeps getting denied – for whatever reason or excuse – she simply stops asking after a few times. The same holds true in our practice.

To do this, the BHCs need a cadre of tools, supports and dependable referral sources at their disposal. Take the lady who needed glasses in our example above. At most busy clinics the BHC may not have time to search through the community resources to find a local Lions Club or other charitable organization that can assist with providing new glasses. At Cherokee, we’ll often reel in one of our case managers from the “traditional mental health” side of the house to assist. They are typically well-connected to the assistance circuits in a community and can often make a few phone calls in a matter of minutes and have if figured out. In smaller and more isolated practices, we’ve seen where there is a front desk staff that can help with it. Whatever path of assistance they follow, it all started with the BHC saying “yes.”

We often hear of organizations who confuse the role of the Care Coordinator and a BHC. One of the key differences tends to be the populations they serve. A Care Coordinator will often work from a patient registry, often those with identified co-morbidities or high-utilizers. They may or may not provide direct patient care – if they do they often engage in coaching, group education sessions, and care navigation assistance (linkage, referring, following-up). Certainly a very valuable and important role in a well-functioning patient-centered medical home (PCMH) model. The BHC, however, is a generalist. They are embedded on the primary care team, tend not to work off a registry, and have been trained in behavioral interventions. Both roles are important in a PCMH setting; but it is vital that they are not confused. Avoid the temptation in a search for efficiency to combine the roles. It would be like combining the role of a second basemen and first basemen on a baseball team.

As you begin your implementation of an integrated model, and learn about the complexities involved, one of the key steps toward success is finding a potential BHC who can offer the easiest answer of all: Yes, I can.

Is The Behaviorist Enough, or Just a Good Start? Or “An architect, a researcher and a mayor walk into a bar…”

I’m sure I’ve referenced Daniel Burnham at least once, if not several times in this blog venue. The famous architect and urban designer directed the construction of Chicago’s 1893 World’s Columbian Exposition, and devised the urban plans for some of this country’s most beautiful cities like Washington D.C., Chicago and San Francisco. I find myself continually inspired by his words: “Make no little plans; they have no magic to stir men’s blood and probably themselves will not be realized. Make big plans; aim high in hope and work.”

Aim high in Hope and Work.

I found myself thinking about ol’ Dan again as I read Ben Goldacre’s “Bad Science: Quacks, Hacks, and Big Pharma Flacks,” a book that examines, well, bad science. Specifically Goldacre takes on dubious claims made by homeopaths, alternative education movements, vitamin salesmen, drug companies, “health food” shills, and other modern day snake oil salesmen. He provides a clear and raw lesson in skepticism and how to better analyze studies and research. Goldacre points out some obvious – but still glaringly ignored – facts about magic pills, quick-fix interventions, harmful diets and useless rituals, all seemingly backed by “research.” He continuously turns back to what is known: there is no quick fix and no magic pill to good health. Detoxifying cleansers, energy baths, exponentially diluted herbal treatments – all bunk that is wrapped in bogus science and designed to simply help lighten your wallet, not your body.

Goldacre discusses the 1982 Multiple Risk Factor Intervention Trial, a massive 7-year study of nearly 13,000 men that was meticulously designed and administered. The study tested a multifactor intervention program on mortality from coronary heart disease for high-risk men from 35-to-57 years of age. One group of men was given support and assistance to change their lifestyles and diet, while the control group was given no such support. The results, after seven years, showed surprisingly virtually no difference between the groups. Goldacre observes that even despite the intervention, the participants probably won’t change their diets as much as you need them to. He said that this is really a good indication of what happens in the real world – in your clinics and with your patients – people tend not to change their diets and lifestyles at the drop of a hat, especially for the long term. Goldacre speculates, as we all do, that dietary change – real change – requires a seismic shift in lifestyle, shopping habits, what is in those shops, how you use your time, the cooking equipment you have on hand, how your family relates to each other, changing your work style and on and on. He cites the North Karelia Project, a 1970′s experiment in Finland, where a public health movement set about changing an entire community’s behavior in terms of health; they worked with stores to change the food offerings, employed community educators and advocates, improved healthcare provision and other efforts. He compares these results with the interconnected health and socioeconomic disparities we see in our own country, specifically New York. Goldacre compares the incredible rates of poverty, obesity and chronic health conditions in the Bronx as to significantly different (read: better) rates of those same conditions in ritzy Manhattan.

So where does old man Burnham come back into this?

I wonder if the role of the Behavioral Health Consultant is enough. Are we Aiming High Enough in Hope and Work? As a board member of a local health center, I was recently involved in a strategic planning exercise. One of the things we casually discussed was the role of a community health center in a community. We talked about its role as a change agent, as a leader in population care, and as a pillar of civility. Those are some lofty expectations and obligations. But they have the power to stir the blood, don’t they? I wonder if we really invested enough thought and energy to these questions in our strategic planning. It should have been the driving force.

No, the role of the BHC is not enough. It’s a terrific start and a great template to expand on. But if we’re really to even help one person make substantial, meaningful change in their life, it is clear that we have to change our communities. This takes courageous leaders, strong advocates, solid data, collaborative efforts, and long-term investment. It is achievable. It is necessary. For all the talk of healthcare reform and debate swirling in the media and coffee shops today, we have yet to even address the real issues. When New York Mayor Michael Bloomberg set out to ban the sale of car-wash-bucket-sized soda drinks he was met with instant opposition and cries of infringement of rights. So how can this be done without trampling rights? Can it be done? Perhaps its not so much a question of limiting one’s rights to certain objects, but making the access to better options easier. Perhaps its not a question of “restrictions from,” but rather “a right to.”

Either way, our blood needs to be stirred. It doesn’t need to be detoxified, or electronically charged, or chemically enhanced with diluted herbs. Aim High in Hope and Work.

Same-Day Billing, an Avalanche of Claims: Or “This, and other popular urban legends.”

A few things have come up since our last blog, an entry that talked about some billing and coding issues that can either be opportunities or obstacles for the implementation of primary behavioral health integrated care practices.

It reminds me of a circumstance a few years ago when my company used to offer these monthly lunchtime seminars for business professionals and the general public called “Lunch and Learn.” We had done it for several years until one day we received a rather stern and ominous cease-and-desist letter from a law firm in Colorado forbidding us from using those three words in that specific order any further as it was trademarked by their client. Imagine that, a verb, coordinating conjunction, and another verb that make up a simple phrase being trademarked. I guess it’s no different than “Just Do It” or “March Madness.” So we started calling it “Learn at Lunch.” Silly.

However I wonder if I can’t profit from trademarking another phrase – one that has had plenty of play in Medicaid negotiations around the country. It seems whenever a primary care association or group of providers requests the ability to bill for two services in the same day – say, a primary care visit and behavioral health encounter – they are met with immediate dismissal. Palms are raised to halt the conversation any further. Oh no, they are told by the (insert payer), that will cause An Avalanche of Claims. We’ve all seen those videos on TV of a lone skier swooshing down a slope being chased by a monstrous avalanche of snow and destruction. Ski, little fella! Ski like the wind!

But often in those same discussions, plenty of lip service is paid to integrating care. “Oh, we’re very committed to that practice,” they’ll say. “We agree that mental and physical health are connected.” They’re just fearful of what will happen if they actually commit to it. People who run successful businesses will often tell you that the most dangerous place to be in business is the “mushy middle.” You kinda-sorta do something, but not really. Your message gets blurred, your mission is foggy and your goals face more forks in the road than an overturned catering truck. If you’re going to commit to integrating care, there are few things you must commit to doing:

1. Allow same-day billing for two different encounters;

2. Allow the use and access of the 96150 codes by psychologists and social workers.

3. Better yet, encourage the use of alternative funding mechanisms such as capitation rates, and fair sharing of cost savings.

Back to that potential Avalanche of Claims ©™, our experience in working with states and individual providers has been the opposite. Well, sort of. Check out this slide:

This is data provided us from one of our payers – an external source comparing our data to those of our safety net colleagues in Tennessee. You will see a slight (17%) Avalanche of Claims ©™ (Patent Pending) in the area of Primary Care Visits. In all other areas – read, EXPENSIVE AREAS – such as ER visits, specialty care and hospital care, you see a dramatic decrease in cost.

In fact, what you see in the aggregate is a 22-percent decrease in total cost. You would think payers would want to see more primary care/prevention/health maintenance utilization than all of those other expensive encounters. Now, what makes our model different? How are we finding efficiency?

Integrated Care. Real Integrated Care. Not any of this mushy middle nonsense either. Well trained behaviorists embedded on primary care teams that are likewise well-trained in the model. We use a consulting psychiatrist, technology, an electronic medical record, and are led by an experienced leadership team who knows how to assign value to our model and convey it to our payers and stakeholders. It is NEVER easy, though. Never.

This Avalanche of Claims ©™(Patent Pending)® is an urban myth. It is a blurry assumption based on skewed data and mismatched models. The best way to mitigate an avalanche is to fire a cannon and let it happen. But in this case, I’m not even sure there’s  enough snow on the slope to roll a snowball.

Healthcare Reform, not Payer Reform: Or “Has everyone lost they perfactuated mind?”

Back when I used to be a case manager I worked with a client whose mother was one of the most delightful people I’ve ever met. She was refreshingly rude, yet poignant; and brutally honest, often dishing truth without the hint of any internal filtration system. She was also challenged phonetically. She was an innovator of words, often introducing new ones on the fly; one of my favorites was “perfactuate.” The best I could figure is that it was when someone would twist facts to their own benefit; as in “when that boy go to the doctor, he perfactuate everything.” She couldn’t be bothered with conjugations or conjunctions, which often resulted in a jumble of words that likely have never been arranged as such in any sentence ever spoken by any man in the history of time. One that I’ve since used many times was when she was particularly frustrated; we were leaving a meeting with her son’s Supported Employment Counselor who was trying to explain a complicated disability work benefit called Status 1619(b), she blurted out “Has everyone lost they damn mind?”

I thought about her recently as I’ve read several articles about health care. One in particular that had me channeling Momma was Steve Brill’s 24,000 word, 30-some page feature in Time Magazine, “The Bitter Pill.” It might be one of the most blogged and tweeted about stories ever by this point. It is Time’s longest story in the publication’s history, so trying to sum it up succinctly is impossible. However, the point I think he makes is that ours is a system not so much of health care, as it is disease treatment, and that President Obama’s health care reform measures, while historical and courageous, only scratches the surface of true reform. The Affordable Care Act doesn’t do as much of care reform as it does payer reform. As in who’s getting “reformed” to pay a bill for a system that hasn’t “reformed?” (Brill, S., Time, “The Bitter Pill. Why medical bills are killing us.” 4 May 2013). About three pages into it I yelled “has everyone lost they damn mind?”

Healthcare blogger Chris Kresser addressed this broken system in an article back in 2010 when he talked about ours being a Disease Management system versus Wellness Care. He provides a neat chart that describes the differences (below).

Certainly no one will argue against that payer reform is a necessary component to improve our system. But Kresser hits the nail on the head in particular in describing how the human body is a complicated interconnected “whole”, but our healthcare system treats it as a series of separate parts. That is a better approach to maintain the car that transports us to the doctor than the care we should receive. Think about it – you drive past muffler shops, oil change garages, tire stores and brake shops on your way to your doctor; just like you pass the number of health specialists from oncologists, OB/GYNs, cardiologists, etc. How is our healthcare system much different than a system that uses such promotional standards as “rattle rattle thunder clatter boom boom boom – don’t worry call your Car-X Man?”

Treating the person as a whole has clear benefits. Nancy Shute addressed this in a recent story on a NPR blog that discussed the relationship between stress and physical health. She found that half of Americans who require help with stress and anxiety don’t get it from their normal providers of health care, while also pointing out that about a quarter of Americans also don’t have access to mental health care (Shute, N., NPR. “Stressed out Americans what help, but many don’t get it.” NPR.org, Shots, your health. 8 February 2013.)

So the evidence mounts, yet nothing seems to change. Or does it?

In an effort to get a better grip on what services are available to our safety net population – those without insurance, or underinsured, who often have serious and multilayered health challenges – I looked at the implementation of a certain CPT code (Current Procedural Terminology – a standardized code used by providers and payers) that is often utilized in truly integrated “whole health” models. There is a series of codes in the range of CPT 96150-96155 that “represent services offered to beneficiary who present with established illness or symptoms, the purpose of the assessment is not for the diagnosis or treatment of mental illness, and may benefit for evaluations that focus on the biopsychosocial factor related to the beneficiary’s physical health status” (CMS, “Coding and Billing Guidelines”, Effective Date 16 March 2010). Essentially this is the “incident to” code range that is often described in integrated care circles – where a behaviorist can be utilized to assist a patient with a variety of lifestyle and behavioral interventions that are incident to a medical condition. Think about a recently diagnosed diabetic who now has to make many changes in his life including diet, exercise and medication adherence. State Medicaid systems have a choice as to whether they will activate those codes or not – often referred to as “flipping the switch.” A quick study showed that only 29 states have those codes in place, including about ten of them that have them saddled with burdensome qualifiers that render them almost useless. There are other CPT codes that are useful in a population-based integrated care approach including the more traditional mental health codes of the 90801-90804 series. These are typically reserved for more thorough initial assessment and follow-up of traditional mental health issues often treated in community health centers such as depression and anxiety. The other complicating factor that often trips providers up is that individual states have an option of letting providers bill for two separate services in one day – say, a medical bill and then a mental health encounter, such as in the use of a 90801 coded service. About 34 states allow those multiple billings, but again, some are heavily qualified on the types of services that can be billed. Some in fact, allow same-day billing, but don’t allow the 90801 codes to be used.

Often people will throw up their hands in defeat if the “incident to” 96150 codes aren’t allowed. However, a quick peek at the “day in a life of a Behavioral Health Consultant (BHC)” at Cherokee Health Systems reveals that the 96150 code is actually used relatively infrequently. We looked at a typical day of a BHC, in fact, just a half day. We found that the BHC visited with nine patients in a four-hour period. The 96150 code was used in only three of the visits – a 12-year-old with unexplained abdominal pain, a 58-year-old female with fibromyalgia and insomnia, and a 13-year-old male with obesity and weight management issues. The other six were all under the 90801 scope. In Tennessee, we are able to use the 96150′s and can bill for two services in one day.

I talked to a colleague in another state, one that doesn’t allow the 96150 codes or same-day billing. She said that her state’s Medicaid Director is warming to the idea, but is fearful that it will create “an avalanche of claims.” We can provide evidence it doesn’t. In fact, what it does is create MORE primary care/prevention claims, and less emergency room and hospitalization claims. But in our fee-for-service, intensely managed and regulated world, change comes slowly.

It is up to us, then, to appropriately perfactuate the data to demonstrate the wisdom and benefits of an integrated approach.

The Mythical Integrated Care Manual: Or “a forehead spot on the conference room table.”

A few years ago I was involved in a project to redesign our company’s website. Let me preface this by saying that asking me to be involved – let alone lead – a website redesign project is like asking me to scrub in on an open heart valve replacement operation. Truth be told, I hate websites. Really do. They frustrate me and often create more questions than they’re supposed to answer. But they’re now a function of our every day life; is there a day you don’t have to access one? Anyway, during this process we’d have these endless meetings where techy people would talk their moon-man language about “stickiness” and bandwidth and whatnot, while I’d sit there with my forehead on the table wishing that a satellite would crash through the ceiling and we could all go home. Please don’t think that’s an exaggeration. There have been many a meeting where I’ve had to scrub forehead grease off a polished table before leaving and doing something productive.

After about five or six of these meetings I began to feel like a complete moron. I didn’t know half of the stuff that they were talking about, and more truth to be told – I’m quite sure most of them did not either. One person in the meeting, I kid you not, just that week had locked herself out of her office on Monday, out of her car on Wednesday, and on Thursday, the day of the meeting, spent 15 minutes looking for her glasses that were perched on her head. And she was opining about “click-throughs” as if she had come down from cyberspace mountain with the tablets of eKnowledge. We had mapped out the “landing page,” whatever the heck that meant – and it had about 22 “radio buttons,” a dozen drop-down lists, ambient music and a scrolling information bar. I go into a seizure when someone turns on CNBC with all that stock stuff and multiple screens and yakking heads, so this page – even when just drawn with a Sharpie on a poster board – made me seasick. When I get that way, instead of balling up into a fetal position and weeping, I just mentally go back to a simpler time, a time of Fisher-Price toys that needed two grenade-size batteries and made a couple of noises, and lit a couple of lights, and by God you were happy.

So that was my contribution to the meeting. I unstuck my forehead from the table, and while scrubbing away the oil spot with my sleeve said “a red button and a green button, that’s all we need.” Can’t we make it as simple as that, or is this some sort of passive-aggressive revenge on the world for us having to transition to an electronic medical record? Seriously, why are we making this so complicated?

Scott Case, CEO of the Startup America Partnership and a founding executive of Priceline.org (obviously a techy), said it best with his remarks to a group of midsize business leaders recently: “There are no instructions; that’s how the world works. Nothing comes with an instruction manual anymore.” The point being that no matter what product you sell or service you provide, it has to be designed for use without explanation (Build, The Catalog of Ideas. Fall, 2012. Mansueto Ventures, New York, New York.).

This comes to mind shortly after we at Cherokee Health Systems completed our second version of our 140-some page Behavioral Health Consultant Resource Guide, a sort of “how to”  to be a BHC. We provide it to our attendees at our twice-a-year BHC Academy. People frequently ask us for our policies and procedures, or program descriptions, and any other documents and tools we use. Sometimes they ask us to consult on their projects – which we’re humbled and happy to do – but really all they want is answers. We tend to ask a lot more questions. We encourage them to experiment, do Plan-Do-Study-Act (PDSA) cycles, and when you don’t have time for that, to practice “Ready-Fire-Aim” and see what happens. We’ve also found that there are a number of consultants out there who seem to have all the answers and are willing to spew forth for a few bucks. Duke University-based behavioral economist Dan Ariely sums it up pretty succinctly: “Companies pay amazing amounts of money to get answers from consultants with overdeveloped confidence in their own intuition. Managers rely on focus groups – a dozen people riffing on something they know little about – to set strategies. And yet companies won’t experiment to find evidence of the right way forward” (Build, The Catalog of Ideas. Fall, 2012. Mansueto Ventures, New York, New York.).

Integrated primary behavioral health care – even with all of its mysteries and complexities – isn’t that difficult of a concept. We get so wrapped up in “reverse integration” and electronic records, and informed consents that we’ve now complicated the landing page so severely to have rendered it useless. Start simply. Red button and green button. Pick a provider and a specific diagnostic set; screen for depression in patients with diabetes. Add complexity as you move forward – what you’ll find is that you’re not really adding more radio buttons or drop-down lists, but you’re just making the red button and green button bigger and easier to reach. There will be plenty of time to be frustrated and to problem solve – don’t try to do it all on the first day.

Now, I have to clean the conference table again.

Behaviorist-Patient-Relationships: Or “The myth of Wally Pipp and concussions today.”

Sometimes the old sportswriter in me can’t be contained.

While enjoying a terrific Thanksgiving Day weekend with family, food and football, it was hard not to notice a disturbing trend emerging in sports, particularly professional football. The previous weekend a number of starting quarterbacks were knocked out of games with concussions. To the NFL’s credit it has implemented cautionary measures that need to be administered before the player is allowed back onto the field.

This is where behavior and health meet again…or more descriptively, clash.

In particular, the case of the San Francisco 49ers’ Alex Smith. Smith was injured in a game in the second quarter against the St. Louis Rams in Week 10. The game announcers said it was obvious that “something wasn’t right” with Smith as he left the field, but he was allowed to return to take 12 more snaps including one that resulted in a touchdown pass. After that scoring play Smith complained of dizziness and blurred vision and was at that point removed from the game. Initially the team doctors said they didn’t believe Smith was concussed in the apparent helmet-to-helmet play, but rather a “quarterback sneak” before the touchdown pass.

Smith remained on the injured list throughout the next week and did not play in the game versus the Chicago Bears on Monday Night Football, a blowout San Francisco win led by second year quarterback Colin Kaerpernick. Smith was finally cleared by team doctors earlier this past week, but head coach Jim Harbaugh elected to start Kaerpernick again reporting that he felt that the former backup had the “hot hand.”

And before the name of Wally Pipp is evoked – let’s dispel that old folktale as a romantic spin. You might know the story of the former New York Yankees star first baseman who reportedly had a headache on June 2, 1925. The story goes that Pipp sat that game out and was replaced by a young kid fresh from Columbia University named Lou Gehrig who held that spot in the lineup for the next 2,130 games. It just ain’t true. Pipp, in fact, was slumping terribly, hitting only .243 for the seventh place Yankees. In the month or so before sitting the June 2 game out, his batting average had dropped over 80 points. In fact, the 33-year-old Pipp would play only three more seasons in the major leagues, all with Cincinnati where he had one more good year before trailing off and finally retiring. Miller Huggins, the Yanks’ manager replaced a number of slumping veterans that season with young players in order to evaluate their talent and shake up the lineup. All the more remarkable about Pipp’s career is what happened almost a month to the day after being replaced at first base, though. Pipp was taking batting practice from a hard throwing rookie who plunked him in the temple with a fastball. Pipp was knocked unconscious and taken to the hospital where he was vomiting blood and dazed. He suffered a fractured skull, but returned to play on August 7, 1925.

Back to Alex Smith. The 28-year-old might have more in common with Pipp than we believe, but not because of headaches, but rather in the decision making processes of their coaches. It’s hard to accurately compare Smith’s situation with Pipp’s though. Whereas one was a slumping veteran on a tanking team, the other is still a relatively young high-performer on a surging team. Smith was having a solid year at the time of his injury, throwing for over 1,700 yards, 13 touchdowns, and a completion rate of 70-percent through ten games. Many teams would love to have a quarterback with those numbers. Still, Harbaugh decided to stay with Kaepernick, a kid he picked as the 36th player selected in the NFL Draft the season before. NFL pundits and writers speculated that Harbaugh, a former NFL quarterback, was never enamored with Smith and liked Kaepernick’s ability to throw the deep ball, never a strength of Smith who many label as more of a “game manager,” the kiss-of-death of NFL quarterbacks.

OK, so what? A coach has every right – in fact an obligation – to put the players he feels are the best fit in positions to help give his team the best shot at winning. For his part, Smith has accepted the demotion with class, but said in an interview that he felt he hadn’t done anything to lose his job. He’s right. And so is Harbaugh. It’s just a tough situation for all involved.

The rub with all of this, though, is that Smith would still very much likely be starting had he not suffered that inconvenient (or convenient – whatever your perspective) concussion. His mistake was suffering the symptoms of the injury and reporting them. In all likelihood that cost him his job, and some speculate his roster spot on the team in the offseason. After the most recent game, a San Francisco road win over New Orleans, Harbaugh refused to address the quarterback situation stating that he will make a determination later in the week.

It’s a problem for the NFL that on one hand is working so hard to implement concussion standards and prevention steps, but on the other hand is more than any other sport sensitive to negative publicity. The perception, even as we know it to be based on a romanticized and erroneous story, is that Smith has been “Wally Pipped.” But even more a problem for the NFL is the message Harbaugh’s decision sends, right or wrong. Smith is under contract with the 49ers for three seasons, including 2012. He is guaranteed $8 million this season in salary and bonus options. His 2013 contract, worth $8.5 million is only guaranteed if he is still a rostered player on April 1, 2013. If he is cut, he is owed only $1 million. Players around the league watching Smith’s situation see about seven-and-a-half million reasons not to report concussive symptoms.

The league is continuing to search for ways to make the concussion assessments more objective. It’s certainly become a priority for the NFL due to pending litigation about concussions and their lifelong impact on former players.

You see the impact – so to speak – on health and behavior. The motivations people have in certain circumstances have a definitive influence on how and if they will seek treatment for their ailments. This phenomenon is not unique to the multi-million dollar world of professional sports. In fact, the relative stakes are the same for a welder who bangs his head on a beam or a mechanic who injures his back lifting a heavy part or a teacher who who is experiencing piercing headaches. The fear of lost wages, of being able to support a family, or losing their job completely are very real, and a very strong motivator to “tough it out.”

Behaviorists in primary care are quite aware of this and have to be sensitive to the competing influences in a person’s life. Assisting a person through the readiness to change (or accept aid) process is difficult, and one that should be approached with incredible delicacy. Simply sending patients down various chutes based on assessment scores is not enough; building a relationship with a patient and truly understanding his or her circumstances and situation is vital. It doesn’t happen in a quick, brief encounter, but often is the result of a team-based, patient-centered approach.

Like coaches who have to make tough decisions on what is best for their teams, Behaviorists are there to sometimes help patients make even tougher decisions on what is best for them and their families.