Psychology and Medicine: A Partnership for the Future
Donald McAleer, Psy.D.
As we talk of health care we hear that "the times they are a changin". Several years ago, Nick Cummings cautioned us about the massive changes to clinical practice and delivery of service in the era of managed care. Among other things he predicted the demise of solo practice and suggested that clinicians need to develop alternate methods of service delivery, including interdisciplinary group practice models. At the recent convention of the Pennsylvania Psychological Association, Dr. Nancy Boyd-Franklin, in her keynote address, echoed the call for such multidisciplinary collaboration. We are attempting such a collaboration. Our attempt, however, goes further and involves the full partnership of psychology and medicine.
Our group consists of five psychologists joining a group of seven physicians (four neurologists and three physiatrists) in a multidisciplinary partnership. The purpose of the partnership ranges from the practical (sharing of costs) to the philosophical (the development of a neuroscience based group) to the aspirational( serving our patients while meeting the challenges of managed care)
History of the initiative
Recent changes related to managed care, especially cost cutting have caused health care facilities to look more carefully at staffing patterns. Hospitals within our area are no exception. The five psychologists in our group are employed across three hospitals , two of which are sister facilities owned by a national rehabilitation company. Within the two rehabilitation hospitals, we went from a combined staff of 10 psychologists, four psychological assistants and one part-time consultant to four psychologists and three assistants over a four year period. Psychological care in the other hospital has eroded over the same time span to include an increased use of licensed and unlicensed masters level practitioners with only one doctoral level psychologist available for consultation. Clearly the writing was on the wall. Although psychology was well integrated into the running of the two rehabilitation facilities and well appreciated at the other hospital, as a discipline we were at risk. Proper health care is labor intensive and cost cutting decisions always look for methods to reduce staffing patterns. As a group we made the decision to begin to investigate an alternate service delivery plan, one which provided for increased autonomy and professional direction.
At the same time, in a similar cost saving measure, the two rehabilitation facilities planned to spin off the physiatry group consisting of four physiatrists (specialists in physical medicine and rehabilitation). This physiatry group joined with a preexisting group of four neurologists, creating a dual specialty partnership.
Because of the nature of our specialties within psychology (those of neuropsychology, rehabilitation and behavioral medicine), we had developed rapport and professional contact with a variety of physician groups, particularly this group of neurologists and physiatrists. As they were aware of our interest in leaving employment, we began to discuss of joining their partnership as full partners.
Structure of the Group
The practice group is envisioned as a general partnership with three divisions: Neurology, Physiatry and Psychology. It differs from an IPA in that it is a fully integrated group. An IPA is a collection of individuals or independent practices who join together for a common purpose, such as marketing of their combined services. Within an IPA there is no mixing of assets. Our idea is that of a more integrated group. Each individual is a full partner with a fiduciary obligation to the group and derives benefit from the affiliation in terms of its size and resources. Expenses are divided at the individual level, the divisional level and the partnership as a whole. The group is directed by an executive or steering committee made up of one member of each division. Decisions are made on a one person - one vote basis with some decisions requiring a simple majority for passage while others require a "super majority" of 2/3.
The division of Psychology would function much as any other psychology group practice with each member sharing in common expenses, providing coverage, and bringing a "book of business" to the partnership. Strength is gained from the larger partnership in terms of stability of referrals, financial resources and access to the other sources of referral afforded a medical practice.
Goals / Philosophy
The partnership, with its emphasis in neurology, neuropsychology and rehabilitation, aims to become the premier neuroscience and rehabilitation practice within our geographic region. Philosophically, the group embraces a holistic approach with mind and body integrated and evidenced in both brain-behavior relationships as well as the illness/wellness behavior continuum. Psychology also brings a unique perspective to the partnership, that of behavioral health and preventative care. This overall model fits well with the interface of medicine and psychology. Perhaps nowhere better can the interface be seen than in the realm of neuropsychology and rehabilitation.
With brain injury, individual lives are changed in an instant. Typically there are a host of multi-systemic complications displayed not only in the form of neurological deficits but respiratory, orthopedic and developmental problems as well. The neuropsychologist can also address similarly critical issues of behavior change and management, social/ psychological sequelae, and cognitive components, both in terms of assessment and remediation.
Although the physicians within the group recognize the role of lifestyle and behavioral patterns in the genesis and maintenance of illness, they often do not have the time nor the training to intervene. Psychology, with our training in behavior change and our knowledge of lifestyle factors that give rise to or maintain disease is ideally suited for such a partnership. We are able to focus on illness behaviors as well as the issue of preventative care and healthy lifestyles. Consultation that addresses assessment and coping with the crisis of acute illness can stabilize a patient and his/her family and improve the patient's receptiveness to medical care during an acute inpatient stay. Brief treatment approaches, targeting self regulation and coping models of care, are appropriate for many patients who are dealing with the short and long term effects of chronic and acquired diseases. Behavioral management, cognitive retraining, and familial coping address issues integrated with acquired brain injury and maximize its outcome. Working closely with the physician, psychologists can intervene early to address the lifestyle components of such diseases as headache, diabetes, heart disease, hypertension and stroke. All of the psychologists within the group are cross trained, although each has their own area of expertise and specialty. The cross training allows for strength in redundancy while the specialty, such as one in pediatrics, adds to the diversity of depth within the group and to the market in general.
Managed Care Strategies
Managed care seems to be moving in the direction of what can be called disease management. For any given disease or illness, decisions are made regarding what types of services are required, who can or should provide them, what resources are required, what is the typical time frame, and what dollars should be allocated for the resolution of the usual presentation of the disease. For example, within medicine, managed care has decided that certain diseases can be effectively managed by the primary care physician (PCP). The PCP receives a listing of procedure codes for illnesses that the managed care company includes in the capitated services provided by the PCP. The cost of these procedures is computed by the managed care company and reimbursed to the physician under a capitation and management agreement. Referral to a specialist is thus controlled by the PCP and costs are contained.
One strategy of our multidisciplinary group is to enter into the provision of clinical disease management, for illnesses within the neuroscience area such as Dementia, Multiple Sclerosis, Neuromuscular Diseases, Head Injury and Stroke. Our intent is to deal directly with the managed care organization (MCO), offering to clinically serve the patients within certain disease categories. Thinking specifically of Dementia, Pennsylvania has the second largest per capita population of elderly in the United States behind Florida. It offers to the MCO a one-stop shopping model in making decisions about care for their subscribers.
Another strategy is networking with IPA's and regional service providers to provide a comprehensive specialty referral in the area of neuroscience. Physicians, particularly PCP's, are developing larger practice networks to acquire patient care contracts directly from the insurance carriers. Sometimes these PCP networks are looking to affiliate with select specialty groups to further improve their patient care and to enhance their marketability to the insurance carriers.
Developing markets independent of the managed care spectrum also becomes viable. An adaptive strategy is to seek sources of income independent of the health care dollar. Although we intend to compete within the health care arena, the diversity of the group could allow us to approach Auto Insurers and Workman's Compensation carriers directly to provide a comprehensive spectrum of professional care.
Making it Work
Although the group is currently in its early stages, we continue to be hopeful. It is an approach which embraces an emerging role for psychologists and one which offers much for our patients and our profession. We are currently struggling with early development issues such as building referral networks, adequate office space, support personnel etc. We have completed the transition plan from employment to private practice yet there is much to be done.
Making an endeavor like this work is a lot like conducting any dynamic group. It requires perseverance and a shared vision or goal. It also requires an equality of commerce. This is to say that all parties must feel that they are equal in the value of their services and that there is a balance of give and take. This is not limited to money. Each must feel that the other provides a unique and needed component to the partnership.
As in any group there is also a requisite trust. It requires a trust in the clinical responsibility and skill of each member and a trust in the individual responsibility of each to the group.