Professional Point

Many changes have occurred in this country's health-care system during the last decade. Most of them have been the result of a health-care transformation that began more than 30 years ago. A combination of structural changes in the industry, significant economic forces and, most recently, information technology advances, have stimulated considerable changes in health care. This combination of forces has had, and continues to have, a tremendous impact on our profession and the way we practice.

Structurally, the last generation of health care has witnessed the evolution from a fragmented cottage industry to an increasingly consolidated one, dominated by large health-care corporations. Integrated delivery systems have replaced many stand-alone hospitals, clinics and small practices. The rise of self-insured employee benefit plans, governed by the Employee Retirement Income Security Act, has put much of health care under spotty centralized federal regulatory control and made many state laws irrelevant. Employers, as well as other third-party payers, increasingly have been able to arrange for many different services to be provided by a relatively small number of contracts with large integrated delivery systems, even when the services are to be delivered in multiple states.

The effects of the increasing consolidation of health care have been profound. Hospitals have been replaced by health-care organizations that offer a wide range of services, including inpatient treatment, outpatient treatment, residential care and partial hospital services. A prior emphasis on specialty care has given way to reliance on primary care. Employers have become dominant as payers and purchasers of health-care services. And purchasers of health-care services have taken advantage of a "one-stop-shop" orientation that has evolved.

Simultaneous to these structural changes, economic forces also have been reshaping the health-care system. The realization in the early 1990s that health care was consuming almost 14 percent of the gross national product triggered a cascade of events.

A failed effort at legislated comprehensive health reform gave way to aggressive private market reform in an attempt to stem the tide of spiraling health-care costs. Attempts to bring business efficiencies to the health-care system turned into "big business" in health care. For-profit, investor-held health-care companies emerged and typically paid more attention to Wall Street than to patients. Regulatory controls were relaxed in the private sector to stimulate market-driven health care and increase competition, all of which was intended to control costs. Managed-care techniques to contain costs by limiting services, techniques which had been around since the early 1970s but were little used, became a popular method for employers and insurers in the context of private market reform.

The public sector also has been buffeted by economic forces. Cuts in government funding have led to decreased availability of health-care services. And efforts to privatize parts of the public sector, along with the use of managed-care techniques, have had a significant impact on health professionals and consumers.

More recently, information technology advances have begun to exert influence on the health-care industry, arguably the most information-intensive industry today. Technology-assisted delivery of services and technology-based efforts to increase administrative efficiency in health care are multiplying, as is the dissemination of health information to consumers.

The result of these forces is that we now have an integrated, primary health-oriented, market-driven, employer focused, information technology-assisted, health-care delivery system. This result underscores for practicing psychologists a need to diversify, particularly into primary-care settings, and to deal with the realities of an employer-dominated health-care marketplace. Importantly, psychologists are increasingly offering services beyond traditional psychotherapy and assessment for mental health patients. Sports psychology, forensic psychology, executive coaching and gerontology, for example, are areas into which many psychologists have expanded their practices; group practices comprised of a variety of specialty areas offer the prospect of providing a wide range of services in a marketplace that values diversification.

Consistent with diversification, psychologists are increasingly practicing as comprehensive health professionals and collaborating extensively with primary-care physicians. The growing societal attention to the effects of lifestyle and behavior on health and illness is creating important roles for psychologists in prevention, health promotion and disease management. These roles utilize existing research, knowledge and skills within our profession. As these trends continue, psychologists will be increasingly called upon as experts in behavior to solve behavioral problems, whether occurring with individuals, groups, organizations, systems or even the population at large.

The changing face of psychology practice will be vibrant and diverse, is built on the profession's rich heritage, and stands to position the profession not just as an important participant but as a leader in health care for the 21st century.