Psychological Practice and Managed Care
Results of the CAPP Practitioner Survey

Randy Phelps
American Psychological Association

Elena J. Eisman
American Psychological Association Committee for the Advancement of Professional Practice

Jessica Kohout
American Psychological Association

ABSTRACT

Practicing members of the American Psychological Association (APA) were surveyed regarding their work settings, activities, and greatest professional concerns in the managed care era. Results from 15,918 licensed psychologists indicated that half were full-time independent practitioners engaged principally in psychotherapy and assessment and another third were in part-time private practice. Four out of five reported a negative impact of managed care on their practices. Concerns about changes to practice and ethical dilemmas as a result of managed care policies were common to all settings. Relatively few differences were apparent between earlier and more recent generations.

RANDY PHELPS received his PhD in clinical psychology from the University of Utah in 1981. He is assistant executive director for professional issues at the American Psychological Association (APA) Practice Directorate.

ELENA J. EISMAN received her EdD in counseling from Boston University in 1975. She was a member of the APA Committee for the Advancement of Professional Practice (CAPP) at the time of the survey. She is executive director of the Massachusetts Psychological Association and is on the faculty of the Massachusetts School of Professional Psychology.

JESSICA KOHOUT received her PhD in sociology from the University of Denver in 1985. She is director of the APA Research Office.

WE APPRECIATE the support and assistance of Russ Newman, APA's executive director for Professional Practice, and members of CAPP, including George P. Taylor, CAPP chair at the time of the study. Additional thanks are due Anthony Chuukwu, Ricky Dodd, Marlene Wicherski, and R. Marchonie Auguste, without whose assistance the work could not have been completed.

Correspondence may be addressed to Randy Phelps, APA Practice Directorate, 750 First Street NE, Washington, DC, 20002-4242.
Received: July 1, 1997
Revised: August 11, 1997
Accepted: August 11, 1997

Although a substantial amount of conceptual and anecdotal literature regarding managed care's impact on psychological practice was available at the time the survey was commissioned (e.g., Lowman & Resnick, 1994 ; Newman & Bricklin, 1991 ), the study was needed because very little empirical data existed. Furthermore, the few existing research studies were based on small samples of limited scope. In those reports, managed care's impact was typically judged to be negative concerning practice patterns and the quality of care provided ( Bowers & Knapp, 1993 ; "BT Survey Results," 1987; "Fee, Practice and Managed Care Survey," 1995).

CAPP also viewed the survey as one of a series of initiatives by the Practice Directorate to promote two-way communication between the directorate and practitioner members of APA. As a result, the survey was sent to all of APA's licensed practitioner members instead of using sampling methods. On completion of the study, a brief overview of the results was mailed to them as well ("Practitioner Survey Results," 1996). The current article is a more complete report of the findings and focuses particularly on the results for various practice settings.

Table 1 reports the distribution of work settings grouped by category for the 91% of respondents who provided setting information. Over 50% indicated that their primary work setting was independent practice, either as a solo practitioner or as a member of a group practice. In addition, as the combined secondary and tertiary setting column in Table 1 shows, 29% of those who were not primarily in independent practice reported doing some part-time solo or group practice. Thus, it is apparent that about four of every five respondents were practicing to some degree in an independent practice setting.

For those respondents who were primarily in private practice, we examined secondary work settings in separate analyses. Results indicated that the majority (55%) worked only in independent practice, but the remaining 45% did report working at a second location as well. The most frequent of these secondary settings was medical (15% of the total group of independent practitioners), followed by academic (7%), government (3%), and other settings (19%), which included a broad range of sites, the most frequent of which was forensic settings (4% of all independent practitioners).

Professional Activities

Table 2 reports a breakdown of types of professional activities by primary setting. Psychotherapy was the principal activity for participants in all settings except academia, where supervision and teaching occupied the greatest portion of time. As would be expected, the distributions of activities varied considerably across primary work settings. For example, comparing the combined direct service activities of psychotherapy and assessment across settings revealed that more than three-fourths of the average independent practitioner's time was devoted to these traditional services, whereas these services occupied only a quarter of the time of academics and roughly half of the time of respondents in medical and government settings.

Impact of Managed Care

Participants were asked to respond to the question, "To what extent has your professional work been impacted by managed care?" with one of seven options: low, medium, or highly negative; no impact; and low, medium, or highly positive. Responses were collapsed into three summary categories, revealing that 79% of all respondents rated the effect as negative. Only 10% indicated the impact was positive, with the remaining 11% indicating no effect.

Again, there was considerable variability when we examined these ratings across settings. Figure 1 depicts the ratings for primary work settings. These ratings show that a greater proportion of independent practitioners and psychologists in medical settings were reporting negative effects as a result of managed care than their colleagues in academic or government settings, who were also much more likely to report no impact. Nevertheless, the majority of respondents in each setting rated the impact as adverse.

Professional Concerns

Table 3 reports responses to the professional concern items for the complete sample as well as by primary work setting. In each case, the table values reflect the percentage of respondents who cited the item as one of their top five professional concerns.

This table reveals considerable consistency across settings as well as some notable differences. The most frequently cited concern for every setting was the item "managed care is changing clinical practice," which ranged from a high of 68% of independent practitioners to a low of 43% of those primarily in academia. In addition, the item "ethical dilemmas created by managed care" was a significant concern for all practitioners. Inspection of the highest ranked items in the table by setting reveals its appearance as one of the five most frequently chosen items for every setting. However, private practitioners were substantially more likely to choose this item, with one out of every two citing it, as compared to about one of three working in academic, government, and medical settings.

Further examination of Table 3 for the most frequently reported items within a setting also indicates considerable similarity between independent practitioners and those in medical settings, although the proportions of respondents noting concerns about fewer clients, excess precertification requirements, and reduced income attributable to managed care were also considerably higher for independent practice. Other concerns were much more setting-specific. For example, academics were significantly more likely to mention reduced funding for research and for academic positions as well as a reduced job market for new graduates than were their practice counterparts. In a similar manner, those working primarily in government settings were significantly more concerned than other groups about reduced funding and lost positions in federal, state, and local facilities.

Measuring Outcomes

In response to the question about use of instruments or criterion measures for assessing clinical outcomes, 29% of the sample reported some form of outcome measurement as part of their clinical practice. There were large differences, however, between primary work settings, perhaps as a result of greater setting resources and support for the activity. Independent practitioners reported the lowest rates (24%), followed by respective rates of 34% and 35% for academic and government-based practitioners. The highest proportion, 40%, was reported by those working in medical settings.

A free-response question about the types of outcome measures used was content coded for a random sample of approximately 10% ( n = 1,600) of questionnaires. As indicated by Table 4 , there was little consistency in the type of measure or criterion used.

Year of Licensure

To explore differences between earlier and more recent generations of psychologists, we broke the sample into four cohorts on the basis of the year of licensure. Groups included those psychologists licensed through 1969 (10% of the total sample), those licensed during the 1970s (27% of the sample), those licensed during the 1980s (48%), and those most recently licensed during 1990-1995 (15%).

To provide an approximate gauge of the representativeness of the sample, we examined data on the year of highest degree for the 1995 special assessment payer population, because actual licensure year information was not available for them. These data paralleled the sample in that 11% of the population received the highest degree through 1969, 31% received the degree from 1970-1979, 36% from 1980-1989, and 6% from 1990-1995, with another 17% not specified.

Table 5 reports the distributions of selected variables for the licensure cohorts. Few substantial differences were apparent, although there were some trends in the data. Respondents within each group were most likely to be in primary independent practice, though the oldest and youngest generations of psychologists were proportionately less likely to be than their colleagues licensed in the 1970s and 1980s. Academia was the most frequent primary setting among psychologists licensed before 1970, but it declined in frequency across later cohorts. Medical settings were also the least apparent primary setting for the more senior group but increased in frequency with each succeeding generation to a high of 19% among recent licensees.

Although they are not reported in the table, additional analyses were performed for those independent practitioners who also worked in a secondary settings. Results differed by cohort, with those private practitioners working in two settings most likely to be from the 1980s' cohort (53%). The remainder were from the 1970s' group (26%), the 1990s' group (14%), and those licensed before 1969 (8%).

As Table 5 also indicates, managed care's impact on the participant's practice was judged to be negative by the majority of all groups, though the proportion was somewhat lower for the eldest generation. In addition, there was a good deal of consistency across cohorts regarding the most frequently cited professional concerns, all of which were related to managed care. There was a trend apparent for outcome measurement in that the more recent the license, the more likely was the participant to use outcome measures in clinical practice.

How should these results be interpreted? One implication is that despite external pressures to change and advice from professional organizations to diversify, a majority of private practitioners seem to be steadfastly adhering to a traditional professional identity. There is some indication that this may be the case in that the current findings are virtually identical to those of research about the roles of APA practitioners from well more than a decade ago. Regarding work settings, for example, Prochaska and Norcross (1983) reported similarly that 51% of APA Division of Psychotherapy (Division 29) members were in private practice in 1981. More recently, Kohout (1995) also found that 51% of APA's 1992 special assessment payers were in independent practice.

The current data also show little diversification by independent practitioners in other activities that psychologists are trained to provide, such as consultation, research, and teaching. In fact, the current study found that these psychologists were spending even more time in the traditional clinical activities of psychotherapy and assessment than previous research has indicated. Norcross and associates ( Norcross, Prochaska, & Farber, 1993 ; Prochaska & Norcross, 1983 ), for example, reported figures of 65% and 68% for these combined activities in their respective 1981 and 1991 samples of Division 29 members.

On the other hand, some findings mitigate against the interpretation that a large segment of the practice community is unable or unwilling to adapt to changes in the delivery system. Almost half of those in private practice worked in a secondary setting as well, although it is unclear from the data if this is a result of increasing financial pressures rather than diversification. Yet the largest group of those with two work sites had opted for roles in medical settings, perhaps to capitalize on growing opportunities for psychologists in the general health care system and to take advantage of the increasing availability of hospital privileges. Medical settings were also attracting new graduates more frequently than any other institutional setting. These changes may be indications of a gradual shift in professional identity from the traditional and more narrowly defined mental health provider to the broader health service provider role for which APA has actively advocated through association policy, marketplace initiatives, and projects demonstrating the value of psychological services in primary and tertiary care settings.

In this study, we unexpectedly found few generational differences, although those psychologists whose careers were established well before the advent of managed care were the least likely to be negatively affected by it. Proportionally more of them were academics, and they were less likely to be in private practice than colleagues licensed in the 1970s and 1980s. Nevertheless, their most frequently reported professional concerns were similar to those of other generations.

We expected new graduates to be the most concerned of all cohorts, given their recent entry into a job market where much of service delivery is dominated by various organized systems of care and where most panels are closed to new providers. Yet their concerns and responses to managed care were also quite similar to those of psychologists of previous generations. On a related note, APA's most recent Doctorate Employment Survey ( Wicherski & Kohout, 1997 ) found that new graduates felt they needed additional training to equip them for the changing health care system. Specific issues cited included information about marketing, the medical culture, alternatives to long-term psychotherapy, integrated delivery models, interdisciplinary teams, and the ethical and legal implications of managed care.

An important finding of this survey is that a profession so well-equipped through its training models and scientific traditions to conduct outcome research is doing so little of it in actual clinical settings. It is clear that the complexities of the task, logistical problems, and additional resource requirements make such an undertaking daunting in a supportive institutional setting, much less a solo practitioner's office. What is needed are outcome models that provide clinically meaningful data that inform the treatment process, can be practically and easily applied across diverse theoretical models and settings, and provide information that can be easily understood by consumers. Despite the complexities, demands from policymakers and the marketplace for accountability and demonstration of the value of psychologists' services make measurement of clinical outcomes an increasingly necessary activity ( Rainer, 1996 ).

Finally, because of the aggressive cost-containment policies of managed care, psychologists are increasingly facing clinical situations that have the potential for serious conflicts of interest. This study revealed widespread concern across diverse settings and cohorts about ethical dilemmas resulting from managed care policies, with greatest concern reported by private practitioners. Unfortunately, the survey provides no information about the specific situations encountered, the responses of practitioners to them, or how well the APA ethics code ( APA, 1992 ) offers guidance in these situations. Given the immediacy of the issues, APA should move quickly to identify the problems as well as to provide some form of guidance in the interim if revisions to the ethics code appear warranted.

Despite the difficulties facing the profession, psychology has weathered changes throughout its history, successfully redefining itself through battles over such issues as licensure, freedom of choice, mandates for mental health treatment, and hospital practice. As the health care delivery system becomes increasingly organized, psychologists will need to capitalize on their skills as change agents and work within their professional organizations to maximize the discipline's future role and stature.

References

American Psychological Association (1992). Ethical principles of psychologists and code of conduct. American Psychologist, 47, 1597-1611.
Bowers, T. G. & Knapp, S. (1993). Reimbursement issues for psychologists in independent practice. Psychotherapy in Private Practice, 12, 73-87.
BT survey results: The changing mental healthcare delivery system (1987, July 20). Behavior Today, pp. 1-2.
Fee, practice and managed care survey (1995, January). Psychotherapy Finances, 21, 1-8.
Kohout, J. L. (1995). Employment settings of psychologists. Psychiatric Services, 46, 1115.
Lowman, R. & Resnick, R. J. (1994). The mental health professional's guide to managed care. Washington, DC: American Psychological Association.
Newman, R. & Bricklin, P. M. (1991). Parameters of managed mental health care: Legal, ethical and professional guidelines. Professional Psychology: Research and Practice, 22, 26-35.
Norcross, J. C., Prochaska, J. O. & Farber,J. A. (1993). Psychologists conducting psychotherapy: New findings and historical comparisons on the Psychotherapy Division membership. Psychotherapy: Theory, Research, Practice, Training, 30, 692-697.
Practitioner survey results offer comprehensive view of psychology practice (1996, June). APA Practice Directorate Practitioner Update, 4, 1-4.
Prochaska, J. O. & Norcross, J. C. (1983). Contemporary psychotherapists: A national survey of characteristics, practices, orientations, and attitudes. Psychotherapy: Theory, Research and Practice, 20, 161-173.
Rainer, J. P. (1996). Introduction to the special issue on psychotherapy outcomes. Psychotherapy: Theory, Research, Practice, Training, 33, 159.
Wicherski, M. & Kohout, J. (1997). 1995 doctorate employment survey. Washington, DC: American Psychological Association.

Figure 1