In the trenches: bolts of pain, rays of hope

The new health-care marketplace is changing everything psychologists are familiar with, from what they practice, to what they preach.

By Patrick A. McGuire
Monitor staff

An old friend from California phoned Ray Fowler, PhD, not long ago and told APA's chief executive officer she was reluctantly giving up her independent practice in psychology.

An expert in treating adolescents, she'd been referred the case of a teen-age boy who had made multiple suicide attempts. She felt she could help him, but the boy's managed-care company allowed her only four sessions--fewer than the number of times the teen attempted to take his life.

"I've got to get out of practice," she told Fowler. "I can't be put in a position of doing things that are unethical in order to maintain my practice."

By now, such cries of pain from the embattled field of independent practice have become common, as the shifting health-care marketplace continues to inflict insult and injury on the once stable world of professional psychology.

"I'm even starting to hear psychologists say they don't want their kids to go into psychology," says a subdued Fowler. "That really hurts."

Though psychology's practitioners bear the most obvious scars--treatment decisions are usurped, reimbursements are way down, fear has taken hold among many--ripple effects of the market's change have also touched on psychology educators and their students, psychological researchers and psychologists who advocate for the public interest.

While some of the effects are clearly negative--poor people have less access than ever to mental health services--others are viewed as positive. Research, for instance, will likely focus on projects with the potential to demonstrate psychological interventions are cost effective. And for many, the changes are providing a forced opportunity to flex creative muscles and develop niches they hadn't considered before.

But negative or positive, most observers agree that the marketplace is still shaping itself, and that until everything shakes out, nothing, not even managed care, is here to stay.

"The system is still changing and evolving," says Russ Newman, PhD, JD, executive director for practice. "We will not always be in a system that values only short-term, crisis intervention. The public is no longer primarily interested in saving money. They are interested in good care and increasingly demanding it."

This month the Monitor features a special section on just how market forces are impacting psychology, with each of APA's executive directors, as well as Fowler, devoting their columns to the dramatic changes that have affected the field.

"We're going to come out of it well in the long run," says Fowler. "But in the meantime many psychologists and those they care for are being hurt badly."

In fact, three out of five practitioners have seen their income fall in recent years by an average of nearly 20 percent according to a recent APA survey. The most frequently hit were those with five or more years of experience. Meanwhile, stories of colleagues losing half their income and beyond are heard recurrently.

'The managed-care effect'

Ironically, startling data show that a large majority of practitioners who admit they have been negatively impacted, are still clinging fiercely to their practices, loathe to change their approach.

Coinciding with this "managed-care effect" is the significant increase in the number of APA service-provider members who have let their memberships lapse. Over the years, providers have made up a steady 55 percent to 60 percent of APA's membership base--they had reached 63.2 percent as of 1997--and the annual rate of providers who let their memberships automatically expire each year has always been well below half that. For instance, in 1991 when providers made up about 58 percent of all members, they counted for only 28 percent of automatic resignations.

But that number increased in 1995 to almost 45 percent of automatic resignations, and had jumped again by 1997 to almost 59 percent--an increase of 600 provider resignations in six years, with many pleading financial hardship.

Those who stay, fear they will be driven out of the profession, fear the loss of control over treatment decisions, fear limits on the number of sessions with a patient. Supporting such concerns: a 1996 survey by Div. 42 (Independent Practice) showing the number of their patients covered under managed care steadily rising, from 10 percent to 50 percent in three years. While APA has initiated several strategies to deal with new market issues--including several ongoing initiatives in the Practice Directorate--APA Board Member Norine Johnson, PhD, argued recently for a more demonstrative show of strength. She proposed that APA make the effects of the changes in the health-care market an association-wide, explicit priority. The Board passed the measure unanimously, and also created a subcommittee--chaired by Johnson--to address the issue.

"I felt it important it make an explicit acknowledgement of the problem," Johnson says. "It's as if there were an elephant in the road--a huge roadblock to the American public's right of access to health care. And a huge barrier to psychology's ability to deliver services. I thought it was time we said, 'Hey, there's an elephant in the road' and that we said it all together."

That sense of togetherness, says Fowler, is the one bright note that has played out in the frequent discussions he's had with psychologists who are not practitioners. All have expressed personal concern for their colleagues.

"There's growing awareness that if your colleague is hurt, you're hurt too," says Fowler. "As long as it's bad for somebody else, it's bad for us all, because we are one profession."

And throughout that profession says Newman, it's important to understand that the market is still evolving and is likely to undergo more positive change. One reason is the unique tension, he says, that has come into play between the old market, rooted in patient care, while the new one is driven by the bottom line.

"Ten years from now there will be cost-containment efforts, but they won't look like what managed care looks like now," he says.

Another factor, he says is that research is beginning to show managed care is causing more cost shifting than cost saving. "Even to those who are interested in costs alone, managed care doesn't look so good now," says Newman.

Meanwhile, the tension between old and new values is not lost

on state legislatures--which have begun to address abuses in the system--or even Congress. Last year, Newman says, politicians on both sides of the congressional aisle showed a willingness to take positive action.

"We've been mindful of the need for cost containment," says Newman, "but at the same time we want to make sure we preserve the core values of the way psychology has approached health care. I think we can make changes without losing our integrity."

Among the many strategies Newman has employed is a one-two punch that uses the legislatures and the court system to fight violations to the core values of patient-first care, and that also helps practitioners become more diversified in the way they practice.

The two must be pursued together, Newman argues, for they are complementary goals that build on each other. He admits that some critics see the legislative and court options as a waste of time, while others see the marketplace strategy as a selling out of the old values.

"But if the market is being driven by market forces," he argues, "then to have maximum input means psychologists have to be participants. Our efforts intend to maximize the psychologists' ability to influence decision-making regarding health care. To turn our backs gives up one of the most currently potent tools to make an impact."

Inferior care

Ultimately, says Newman, the goal should not be merely to keep the quality of patient care from being sacrificed, but to improve that quality. In agreement is Henry Tomes, APA's Executive Director for Public Interest, who thinks marketplace changes have an especially heavy impact on consumers, especially the poor.

"I am not sure that this country is upset that psychologists may make less money," he says. "But they are upset that a lot of money is being spent and people are getting inferior care. Poor people have less access to health and mental health care than they've had before."

That need, he says, creates opportunities for psychologists who have not been quick to serve minority populations.

"I assume there will be a shift in that direction," he says. "Because right now a whole lot of practitioners are focused on a very narrow band of the population in need."

At the same time, he says, many psychologists who work in the public sector--in community mental health systems, clinics, state psychiatric facilities--are experiencing the kind of difficulties that people are experiencing in solo practice.

"In independent practice, as well as public practice, you have a situation where people who have less training become more in demand as providers of services than people who are fully trained," says Tomes. "They cost less."

In fact, what many psychologists call "The Masters Issue" is a significant part of the dilemma faced by doctoral-level practitioners. "There is stiff competition, huge competition," says Jessica Kohout, PhD, APA's director of research.

Consider, she says, that there are 73,000 doctoral-level practitioners in the United States, and that of the 4,000 new doctoral-level psychologists each year, about 2,000 continue to go into practice. But they face competition from more than 70,000 master's-level practitioners. In addition, says Kohout, psychology, education and social work each graduate annually more masters-level "providers" than graduate at the doctoral level in psychology.

Yet Kohout says she has seen also an improvement in the perceptions of the marketplace among new doctorates in just the last two years. Between 1989 and 1995, new doctorates who said the job market looked bleak increased from 2 to almost 10 percent, she says, while those saying the market looked excellent dropped from almost 12 to 3 percent. Yet in 1997, those who responded with bleak as an answer were at 5 percent and those responding with excellent were at almost 9 percent.

A more puzzling perception issue centers on the reaction of the overwhelming percentage of practitioners with negative opinions and experiences of managed care. Despite these views "the average solo practitioner for the most part did not show any real change in the way in which they practice," says Michael Murphy, PhD, former president of Div. 42, of their 1996 survey.

For instance, while nine out of 10 respondents said they'd seen no positive impact from managed care, and eight of 10 said managed care had taken control of aspects of care and treatment they as clinicians should control, almost half said they had not changed their practice structure at all. Less than a quarter anticipated joining a group.

Murphy--whose report called this lack of change in fundamental aspects of practice "remarkable"--believes the role and status of psychologists are still emerging. The same is especially true for students, says Jill Reich, PhD, APA's executive director for education.

"The marketplace is changing," she says, "and in education it requires us to go to the foundation of the discipline and to say 'What is it that our discipline and our profession is uniquely positioned to do?' The students drawn in now have to be the ones who say, 'I know this isn't going to be straightforward. I know I'm going to have to create my own job or career.' So you have a different set of goals for seeking a discipline."

Those new goals are not evident in all students now seeking their doctorates in practice-oriented psychology. The first type, she says, seems disinterested in the market-oriented courses and workshops aimed at bringing students up to speed with real-world business realities that are offered more frequently by schools.

"That's not what these students came to do," says Reich. "They came to help people. That, and the idea of a private practice and their own patients, that ideal of the 80s. The marketplace is changing, but that's not the marketplace they wanted to come for."

Yet a second type of student, says Reich "is much more savvy about the situation than we give them credit for. They're not saying this is an easy market. They're saying I know this is going to be tough."

The middle group

This continuum of students is comparable, says Board Member Johnson, to the continuum of practitioners she has spoken with during travels the past six months. And while that continuum includes those who have dropped out and those who have managed to click with the new marketplace, she describes what she calls a middle group.

"These are the practitioners who are struggling to keep their heads above water," she says. "I don't know if people are really aware of this group. They are more aware of those who have dropped out."

They feel alone, she says. "They feel the message they have been getting so far is that they should learn how to do business practice. But they feel they need more to be heard for what they are, for the skills they bring now."

One way to prove their value to a disbelieving health-care system, is through research, says Richard McCarty, APA executive director for science directorate. Research funding is "blooming," he says, which can only be good for practice. He noted a variety of research programs now ongoing that show financial savings when psychologists are included in an intervention.

"I think this is the wave of the future," says McCarty, "because you have to document the effectiveness of the intervention. And that's where research is crucial. And once the case has been made, then the practice opportunity starts to grow and flourish."

But there's a paradox, he adds. "At the same time managed-care companies are squeezing psychologists, many aspects of the medical profession are recognizing the value of psychology. You name any chronic disease and psychologists have an important role to play in care."

Newman agrees that practice will not flourish without research, but he cautions that research doesn't necessarily equate with opportunities "until we deal with what's happened to the system and the values of care. Even good research that is used in a market that continues to be profit driven, and not targeted toward promoting good care, will not solve the problem."

As he speaks, he forms a small circle with his thumb and index finger.

"Some people want to see the problem like this," he says, referring to those who view it only in terms of managed care. "When it's really this." Now he extends his arms into a large O. "The problem is a health system based on the wrong values with the wrong incentives."

What's needed now, he says, "is for us in psychology to recognize the piece each of us has to deal with. It will be an integrating of those pieces that will bring us together on this. The system is still changing and evolving. Our goal is to assure that 10 years from now the values upon which the health care system are based are consistent with the core values of psychology to provide quality care."

But the painful here-and-now is what Johnson's middle group of practitioners is concerned about. These are psychologists, she says, who entered the field before the major changes in the health care system, people who are not, by nature, entrepreneurs.

"I hear them say 'I'm ashamed to tell people what's happening to my practice,' she says. "But this is not a failing of individual psychologists, or a group of psychologists. This is societal change, in fact the major social change in the United States in the past 20 years. And there is a lot of hurt and fear."

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