Despite managed care, psychologists are committed to independent practice

Results of three studies reveal practitioners? frustrations as well as their dedication to providing care in traditional settings.

By Scott Sleek
Monitor staff

Most psychologists appear committed to remaining independent practitioners, despite the ethical and financial difficulties that managed care places on their work, three recent studies reveal.

Results of the surveys?which are the first attempts to scientifically weigh psychologists? sentiments toward managed care?reveal that most practitioners continue to work in traditional independent settings.

But the surveys also confirm what for years has been largely accepted as fact: An overwhelming majority of psychologists believe managed care has dramatically compromised quality of care and forces them into ethical dilemmas, particularly in the area of patient confidentiality.

The three separate studies appear in the latest issue of the APA journal Professional Psychology: Research and Practice (Vol. 29, No. 1, p. 29?51). The surveys collectively garnered about 17,170 practitioner responses. (Many practitioners may have responded to more than one of the surveys, since each study involved the same type of professional population, notes Jessica Kohout, PhD, director of APA?s Research Office.)

The surveys are among the first to go beyond the largely personal accounts and media reports about the profession?s experience with managed care, Randy Phelps, PhD, assistant executive director for professional issues in APA?s Practice Directorate, writes in an introduction to the reports on the studies.

?The literature within professional psychology has consisted largely of anecdotal reports, conceptual analyses and widespread condemnations of the system,? he says. ?The survey results attempt to provide a broad, systematic assessment of psychologists? attitudes and perceptions of managed care?s impact on their work.?

The psychologists who conducted the surveys say such data are needed to bolster efforts to reform the health-care system by providing empirical data to policy-makers and legislators who could change the industry?s objectionable practices.

Similar results

One of the reports in the journal is on a 1996 survey of more than 47,000 members that APA conducted at the behest of the association?s Committee for the Advancement of Professional Practice (CAPP). That survey drew nearly 16,000 responses?a 34 percent response rate. APA?s Practice Directorate reported the findings last year, but this is the first time they?ve been published in a professional journal.

Another is on a New Jersey Psychological Association (NJPA) survey, which yielded 812 responses out of the 1,647 licensed providers who were sent questionnaires. A third, conducted by an Indiana State University research team with funding from APA?s Div. 42 (Independent Practice), is a poll of 1,000 division members. About 440 people responded to this survey, representing a 44 percent return rate.

Although the surveys were all conducted independently, the responses yielded largely similar results. Most respondents reported significant increases in their dependence on managed-care contracts as a source of income, reflecting managed-care?s increased prevalence in the nation?s health-care system.

Many respondents in the surveys also reported that managed care has:

? Pushed them into ethical dilemmas, such as requiring them to report confidential patient information as a condition of reimbursement.

? Controlled aspects of patient care, such as the type and duration of treatment, that clinicians should oversee themselves.

? Left them with reduced income.

(Breakdowns of the results from each of the three studies appear in accompanying charts.)

Proportional woes

The New Jersey poll took a slightly different tack than the other studies by specifically inquiring about the size of each participants managed-care caseload. That study found that practitioners with the most managed-care clients reported lower morale, fewer covered sessions per client and greater ethical challenges in their practices.

NJPA also asked its members to rate 10 managed-care companies operating within the state on such factors as precertification requirements, the level of training of utilization reviewers and the number of sessions typically allowed. The results showed considerable variability from company to company in terms of the number of respondents reporting problems working with those organizations.

The information could be used by consumers as a report card on the quality of health plans available in the state, NJPA officials say. It can also help individual psychologists decide which managed-care panels are better to join compared with others, they add.

Despite the concerns reflected in the surveys, few respondents indicated plans to leave independent practice. Many respondents reported they want to preserve a traditional professional identity as providers, despite the external pressures to diversify into adjunct activities?such as teaching and consulting, psychologists who conducted the surveys say.

Michael Murphy, PhD, of Indiana State University, who led the Div. 42?funded study, says he was somewhat surprised at the 88 percent of respondents who said they remain in traditional solo practice, especially since APA has been encouraging practitioners to diversify into other professional endeavors, such as small group practices or adjunct consulting work.

But psychologists may be more able than many medical specialists to maintain an independent practice despite managed care?s blow to their incomes, Murphy adds. Medical specialists often have higher overhead, in the form of technical equipment and the support staff trained to operate it, that psychologists don?t incur, he says.

?If an oncologist were to experience a 20 percent hit to their income because of the managed-care contracts they?ve been compelled to enter, that person probably wouldn?t be able to stay in practice,? Murphy says. ?Many psychologists in independent practice, because their overhead is so much lower, can more easily take such a hit.?

Still, many practitioners who responded to the Indiana State poll indicated that they are repositioning themselves in the changing marketplace by joining medical staffs or integrated networks of providers.

Those types of practice settings are generally regarded as rich with opportunities for psychologists, staff in the Practice Directorate note.