Health-care shifts in the United States and internationally aimed at preventing diseases instead of just treating them put psychologists in a position to demonstrate how they benefit both patients and the industry's bottom line, says psychologist David H. Barlow, PhD, of Boston University.
In new collaborative roles, psychologists are working alongside physicians treating patients in traditional medical settings, such as oncology clinics, and developing chronic disease-prevention and management programs, such as smoking-cessation initiatives, which benefit the health of the public at large, says Barlow, who in 1996 published an influential American Psychologist (Vol. 51, No. 10) article on psychologists' shifting and expanding roles in health care.
Moreover, Barlow says, there's a growing awareness among employers, insurance companies and legislators that psychologists can fill such disease-prevention and management roles in general health care.
"In an era of evidence-based practice, psychological treatments have been shown to be the equal of or to be superior to alternative medical or pharmacological treatments," Barlow says. "As their benefit to the public's health and well-being is accepted, these treatments are finally being promoted by health-care policy-makers, creating a huge opportunity for psychologists."
Even as the trend toward growing roles for practitioners takes shape, much work remains in fully integrating psychological services into health-care service delivery and reimbursement systems, according to APA Executive Director for Professional Practice Russ Newman, PhD, JD. Newman offers the example of disease management, where it costs additional dollars to add psychological services where they did not previously exist to achieve better outcomes.
Convincing health insurers to make the investment is challenging, Newman says: "Payers seem less focused on how the added services will improve health than they are on how much money the added services will cost, or who is going to pay for the added services in the short run."
Still, there are signs of progress. Newman points to one recent development in reimbursement that helps facilitate practitioners expanding their roles beyond traditional mental health services delivery. In 2002, a series of new "health and behavior assessment and intervention codes" involving psychological services for patients with physical health diagnoses came into effect. The new codes enable reimbursement for psychological services provided to people with physical health problems in the absence of a mental health diagnosis. Now all Medicare carriers, except those in Florida, and as many as 16 private insurance carriers accept and pay for claims with the health and behavior codes, according to the APA Practice Organization, which continues working to gain more widespread acceptance of these codes.
The shift toward new roles for practitioners doesn't mean that professional psychology is losing contact with its roots in psychotherapy and assessment, but rather that there are opportunities to serve patients by expanding into new practice areas, says Newman.
Some of those opportunities will come in traditional health-care settings, such as interdisciplinary primary-care clinics, where physicians and psychologists work side-by-side to solve health problems, says psychologist Margaret Heldring, PhD, co-chair of the APA Presidential Task Force on Health Care for the Whole Person, established by APA President Ronald F. Levant, EdD. Such primary-care psychologists see patients on-site, consult with physicians on diagnoses and treatments and teach health-care colleagues how to think and act with awareness of psychological principles.
"Collaborative care can and should take place at all levels of health care," says Heldring, who is president of the Washington, D.C, universal-health advocacy group, America's Health Together. "Outpatient, inpatient, long-term, emergency, pediatrics, it fits in everywhere."
Ideally, psychologists should be based in the same building as physicians, Heldring says. For example, when patients come to their primary-care physician saying they "don't feel like themselves," the physician can actually walk them to the psychologist's office and make an introduction. That's an experience that makes the patient more receptive to the therapist and more likely to show up for the crucial first appointment, she adds.
Psychologists fulfill another role in collaborative care just by being present, Heldring says.
"It creates opportunities for different disciplines to have lunch together, do case presentations together and to understand more about each other and their patients," she says. "The psychologist starts to learn more about the medical issues, and the physician starts to learn about the psychological issues, and the whole environment becomes much richer and better at targeting patients' true problems."
Teaching "just happens" when a psychologist is present in a setting to answer questions, ask questions and consult, says psychologist Dana Brandenburg, PsyD. Based in Smiley's Clinic, a community health setting that serves a diverse group of patients in Minneapolis, Brandenburg spends half her time treating patients the clinic has referred to her and half her time teaching medical residents how to be more psychologically minded.
At Smiley's, psychologists shadow medical residents and provide insight on how to spot a mental health problem lurking below physical symptoms, says Brandenburg, also an assistant professor in the University of Minnesota's department of family practice and community health. For example, Brandenburg says she watched a resident remove stitches from a man's arm and suggested that she and the resident inquire further about the origins of his injury.
"It turned out that the patient had injured himself while drinking, that he had a drinking problem and needed to be hooked back into a treatment and prevention program," says Brandenburg, who was able to connect him to the services he needed.
Through the combined roles of practitioner and teacher, Brandenburg says, "I get to feel like I'm having an individual, positive impact from working with patients and, at the same time, I'm getting to have a system impact by making a difference in how medical care is provided."
Beyond treating psychological problems and educating others about them in traditional health-care settings, psychologists also have a role to play in public health through chronic-disease treatment and prevention programs, Barlow says.
"The natural extension of psychological interventions is chronic-disease prevention," he says. "The truth about chronic disease is that it's often caused by behavior problems like smoking, eating too much or lack of exercise, and there are enormous emerging roles for psychologists to organize interventions."
Indeed, psychologists' scientific training and behavioral, clinical and interpersonal skills qualify them to develop such interventions, says psychologist Catherine Davis, PhD, assistant professor of pediatrics at the Medical College of Georgia's Georgia Prevention Institute.
Davis herself is conducting one such scientific study: Overweight elementary school children are participating in structured after-school exercise activities, such as basketball games, for 20 or 40 minutes a day, she says. Researchers are tracking factors like the children's body mass and blood sugar to compare them with a control group. Early results show that children's amount of activity might relate to their ability to think and reason, as well as to weight and fitness, Davis says.
The research might also shed light on what kind of behavioral interventions make long-term improvements in child and adult lifestyles, Davis adds.
"When we ask doctors what should be done about health, they say 'exercise and eat better,'" Davis says. "But psychologists understand how to actually get people to exercise and eat better. That's the specific expertise we provide and why we're so valuable to health care as a whole."
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