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Keynote speech to 2003 State Leadership Conference
Despite the time that has past since the 9/11 terrorist attacks, the past year has continued to be influenced by those events. Growing problems with this nation’s healthcare system have hardly been priorities in a Congress whose agenda is understandably preoccupied with national security, terrorism, enemies abroad, and war. Add to that, an economic climate marked by corporate scandal, a persistently declining stock market, the increasing possibility of a “double-dip” recession, employee layoffs and a hiring slump described recently in the New York Times as the worst in 20 years. In turn, state governments are grappling with their own economic woes, a situation more likely to result in resources being taken away from healthcare than it is to produce creative solutions for an already ailing healthcare system. On top of all this, and much closer to home, the tragic death of Senator Paul Wellstone in October added another layer of uncertainty to the prospect of improving healthcare in this country. With Paul’s death, psychology lost a friend and one of it’s strongest advocates in Congress. To state the obvious, it’s been a difficult year. Last year’s State Leadership Conference focused on psychology’s challenge to help people cope with trauma and build their resilience in the wake of 9/11. Attendees may recall the important role for psychologists that we discussed -- to act as guides for the psychological journey of individuals, and indeed our Nation, to find meaning in what otherwise were senseless acts of terror. We were challenged to use our knowledge, our research and our clinical skill to help turn “personal tragedy into triumph and turn (our) predicament into human achievement”, as Victor Frankl would describe it (Frankl, 1959). In the past year, we have definitely taken steps to that end. The focus of this year’s conference is perhaps best described as more attentive to our own resilience in the wake of many challenges and uncertainties. Non-profit organizations everywhere are finding it difficult to grow or even to maintain membership and revenue levels as the tight economy closes in around us. And psychology is certainly not immune from this. In fact, if we assume that our practitioner members measure the value of their membership by visible and concrete progress towards fixing the broken healthcare system, we face an even greater challenge than many other non-profits. In these fluid, challenging and uncertain times, it is natural to begin wondering what we as a profession need to be doing differently, or how we need to be changing to respond to current circumstances. Yet, in times like these, adopting strategies to change course may not be the best approach. It may actually be that in our uncertain times, staying the course we have charted in recent years is a far more effective strategy. The theme of the conference was specifically chosen to reflect a stance of resolve and confidence that we as a profession are headed in the right direction. That is not to say we should be without self-reflection and self-evaluation. Yet, in our roles as leaders of the profession, we must demonstrate both perseverance and resilience in the face of significant challenges. More about that later. Since last year’s State Leadership Conference, a major milestone for the advancement of our profession was reached in 2002 when New Mexico became the first state in the country to enact a law authorizing appropriately trained psychologists to prescribe. Some of you will recall just one year ago – in 2002 -- the New Mexico law had passed the House and the Senate and awaited the Governor’s signature, something that was far from certain until the 11th hour signing—literally—just as a veto was about to occur. While we can celebrate that victory, our work on this agenda is far from over. The New Mexico law is in a continuing process of regulatory implementation. The huge boulder that our New Mexico colleagues have pushed up the hill is still a millimeter short of the top plateau. We must sustain our efforts in New Mexico, and even increase them if necessary, before we can relax. To be sure, considerable effort is being brought to bear on the prescription privileges agenda across the country. Georgia, Louisiana, Illinois, Texas, Wyoming, Oklahoma, Tennessee, Oregon, and Florida have all been a pursuing legislation. What is perhaps the most telling feature of the prescription privileges movement is that for the entire period from 1986 to 2002, a total of 13 states had filed legislation, usually no more than one or two a year. In 2003, we have 12 states simultaneously pursuing legislation. As important as it was to get that first state law passed, it is equally important to get the second law enacted. Organized psychiatry continues to cling to the argument that New Mexico was a fluke, an anomaly, and that no other state would repeat this “mistake” by the New Mexico legislature. We need to remove this misconception to which they cling by making new laws a trend rather than an isolated event. While the prescription privileges agenda is not without concerns from within our own profession that need to be addressed, I continue to be impressed by the optimism about psychology’s growth and future that I hear in those states where prescriptive authority efforts are occurring—something we cannot overlook at a time where much else in healthcare is pessimistic and at a standstill. In the wake of the Columbia Space Shuttle tragedy, we are reminded of the critical role pioneers, such as the astronauts, play in the growth and development of our country and our future. I do not believe it an overstatement to say that those of you working on prescription privileges for psychologists are the 21st century pioneers of our profession. Our growth, our development, and our future will be benefited by your work. On a related note, organized psychiatry’s increasing desperation in attempt to stop prescription privileges for psychologists is evident. Through sheer persistence, the New York State Psychological Association succeeded this year in enacting strong scope of practice language as a part of a now much improved psychology licensing law in New York. The law now defines psychology’s scope of practice, something the prior statute did not do, and includes explicit language authorizing psychology to diagnose and treat mental disorders (2002 N.Y. Laws 676). Because the previous law had no scope of practice language, psychiatry routinely argued that psychologists were not qualified to diagnose and treat mental disorders. During the legislative debate, psychiatry appeared panicked that prescribing psychologists were behind every tree and around every corner, despite the fact that the legislation did not seek prescriptive authority. As a result, the psychiatrists forced language into the bill which stated the obvious—nothing in the law authorized psychologists to prescribe, or to perform surgery, something NYSPA was quite well aware of since it was not advocating for prescribing power, or surgery for that matter. After the bill became law, psychiatry unbelievably claimed a national victory for having stopped New York psychologists from getting prescription privileges. According to a January issue of Psychiatric News: “New York psychiatrists can boast of a unique legislative victory. They reached an agreement with the State’s psychologists to back a bill that specifically bars the psychologists from being able to prescribe psychoactive medications…The psychologists agreed to a legislative compromise…in which they gave up their pursuit of legislation that would grant them prescribing privileges in return for (psychiatry’s) support for the scope-of-practice bill.” (Hausman, 2003) Psychiatry’s master spin job aside, congratulations to the New York State Psychological Association for staying the course on their licensing law. Another good example of an association sticking with an agenda and getting the job done is Georgia Psychological Association’s handling of the masters level mental health practitioners continuing challenge to psychology’s doctoral level licensing in the state. After years of stalwart defense against challenges to the doctoral-level license in psychology, licensure of non-doctoral individuals as professional counselors was developed to put a successful end to the problem. Georgia now joins South Carolina, Kansas, Oklahoma and Tennessee who have found similar solutions for non-doctoral individuals. In Virginia, a multiyear effort by the Virginia Academy of Clinical Psychologists to improve the State’s confidentiality protection came to a successful close this past year with passage of a law increasing confidentiality and prohibiting lawyers in custody cases from getting access to psychotherapy records. Any increased protection of mental health records in this day and age is an achievement, but when you are able to stop lawyers from getting access to records, you’ve really accomplished something. Speaking of the Virginia Academy, their lawsuit against Blue Cross/Blue Shield of the National Capital Area is another good example of staying the course. Filed in 1998, the lawsuit is now on its fourth different judge, has survived a motion to dismiss, a summary judgement motion, court-ordered mediation, motions to exclude all the evidence, two aborted trial dates, a motion to split the trial into two trials, and three motions challenging the Virginia Academy’s standing in the case. The fourth attempt by the defendants to eliminate VACP from the case is currently pending. The best news, though, is we are set for trial next month. As always, we are indebted to VACP and the individual plaintiffs for their courage and persistence, and thanks to all those who have contributed financially to this case. Battling the insurance and managed care industries is an expensive proposition, but a battle we can ill afford to forgo, even if that fight continues into the appeals court after trial. Also on the state front, the Psychologically Healthy Workplace Awards Program continues to grow. Twenty-eight state associations have now engaged their respective business communities around the awards process and, in doing so, have increased that community’s level of understanding of psychological issues and the value of psychological services. Awardees were diverse companies which ranged from Kitchen Distributors in Arkansas, to Redwood City in California, to Discover Financial Services in Delaware, to BellSouth of Kentucky, to Children’s Hospital of Philadelphia, to Southwest Airlines in Texas, to Catholic Social Services in Alaska, just to name a few. Newspaper, and even television, coverage of the awards has been an invaluable way to increase the public’s perception of the utility and value of psychological services. As an extension of the Psychologically Healthy Workplace Awards Program last year, the APA recognized 5 companies specifically for their actions taken with employee’s in the wake of 9/11. Those companies receiving Resilient Workplace Honors were Banc One, Dow Chemical, Intel, Pitney Bowes, and Ford Motor Company working in conjunction with the United Auto Workers. Resilience was also a major focus of the Public Education Campaign this past year. The launch of the Road to Resilience Campaign occurred in September with the Discovery Health Channel airing of “Aftermath: The Road to Resilience” on the anniversary of 9/11, and with a special community forum we held in conjunction with the Maryland Psychological Association, Discovery Health, Comcast Cable and the Mental Health Association of Montgomery County. Since the launch, over 1,000 resilience toolkits have been requested by psychologists for grass roots use. (Materials can be obtained by logging on to http://www.apa.org/practice.) Close to 80 confirmed public outreach resilience forums have been conducted by psychologists across the country and in Canada. Thirty-one state and provincial associations have conducted training or have otherwise promoted the resilience initiatives to their members. Close to 100,000 brochures have been disseminated to the public. Unlike the Warning Signs Campaign which has “ready made” forum audiences in schools around the country, some additional creativity is required with the Road to Resilience Campaign. Fortunately, there is no lack of creativity within our community. Information on resilience has been distributed, for example, as a part of an anger management program at a county jail in California, a 9/11 remembrance program in Orlando, at a resilience workshop for more than 50 journalists at the Chicago Headline Club, at a 9/11 commemorative concert and memorial service in Des Moines, as part of an organized response to the Washington, DC area sniper attacks, at a resilience forum during a Regional Safety Managers’ Conference in Missouri, at a health and wellness conference in Las Vegas, during a resilience training for health teachers in New York, at a forum for a diabetes support group in Pennsylvania and at a resilience workshop for professionals in health services and disaster recovery workers during a conference entitled, “Flood, Crud and Mud: Dealing with the Northwest Minnesota Floods”. Many of you will recall that the Road to Resilience campaign grew out of what we heard from the public after the terrorist attacks of September 11th. People were not so much interested in “coping” or “dealing with” or just “living with” the chronic and increasing uncertainty. They identified that they were interested in being able to be resilient in the face of these challenges. Neither the experience of uncertainty or the need for resilience has abated since last year. In fact, both appear to be increasing. As a result, we are continuing to develop additional materials for the Road to Resilience Campaign, particularly related to resilience for children, resilience in a time of war, in the event that such an approach is needed, and, even more specifically, resilience for children in a time of war. We are exploring a possible partnership with Time Magazine for Kids in this latter area. We also look forward to incorporating additional new material into the Campaign that might be contributed by Dr. Ron Levant’s Board of Directors Task Force on Resilience in Response to Terrorism which is accumulating psychological information relevant to a variety of specific populations. On a related note, the aftermath of the terrorist attacks has generated enormous interest in our Disaster Response Network. Psychologist members of the DRN have made numerous presentations during the year based on their experience and insights with disaster response. And this was in addition to the DRN’s continuing work actually responding to disasters such as tornadoes in Ohio, Tennessee, Alabama and Maryland, flooding in West Virginia, the D.C. area sniper shootings, a train derailment in Maryland and a plane crash in Minnesota. While the uncertainty of terrorism or impending war understandably overshadows organized psychology’s professional uncertainties, the current level of uncertainty in this country’s healthcare system is not without significance. According to longtime healthcare champion Senator Ted Kennedy: (America’s) successes in the science of medicine must not blind us to the glaring failure of our healthcare system to make quality health care available and affordable for all our people. We lead the world in medical research. We lead the world in our ability to cure and treat the most complex and deadly illnesses. But we lag behind every other industrialized nation in the world in guaranteeing all our people access to the best health care we can offer. And every year we delay, the crisis worsens. (Kennedy, 2003) While the problems of increasing numbers of uninsured and rising healthcare costs are clear, there is no clear or agreed-upon solution to these problems anywhere on the horizon. That is not to say there are no proposed solutions. In fact, there are reform proposals starting to pop up. According to Senator John Breaux, “clearly tinkering around the edges cannot stop, let alone reverse, the trends at work in healthcare today. In short, the healthcare system we depend on is plagued with inequities and collapsing around us. Not since the early 1990s have such dire circumstances challenged us to consider bold new ideas to overhaul our nation’s healthcare system.” While these various proposals are quite diverse, they seem to fall on a continuum of healthcare reform fixes ranging from completely overhauled, publicly funded single-payer systems on the one end, to solutions heavily reliant on private market reform on the other end. A politically and practically feasible method of reform is most likely to be some combination of the approaches found across the entire continuum. One common thread running through many of the proposals for reform is the desire to have consumers play a bigger and more central role in their healthcare decisions. Not coincidentally, this thread is appearing at a time marked by an abundant supply of health information available on the Internet and an increasing influence in the healthcare system by Baby-Boomers who have followed the path of empowerment virtually all of their lives. As Ron Bachman and Newt Gingrich jointly wrote in an Atlanta Journal Constitution Op-Ed, “Baby-boomers…have driven the economy for the past 50 years. As the Boomers are hitting age 50, they are hearing for the first time diagnoses from their doctors about cancer, heart disease, and diabetes. What will happen,” Bachman and Gingrich ask, “when the ‘Me Generation’ needs to access the healthcare system? Like their popular SUVs, Boomers will want to drive.” (Gingrich & Bachman, 2003) Consider, for the moment, one particular version of a plan with a more empowered consumer, referred to as “consumer-directed healthcare” (Bachman, 2003). Under this plan, members receive an annual allocation of available funds from their employers, ranging from $1,000 to $2,000, to be paid out only as used. These funds, sometimes called a Personal Healthcare Account or PHA, can be used to pay for plan deductibles, copayments, for IRS-qualified healthcare expenses, or to purchase other health insurance coverage, including even long-term care coverage. Unlike traditional Flexible Spending Accounts, unused funds can be rolled over into future years and added to an annual PHA allocation consistent with IRS guidelines issued this past June. When PHA funds are exhausted, a plan member is responsible for expenses up to the deductible amount for a catastrophic type plan. Services considered by the plan to be preventive, such as physicals or mammograms, are covered by the plan in total, at any time. Plans can also provide “credits” to the members Personal Health Account for the purchase by patient’s with chronic diseases of services which are consistent with appropriate disease state management of those diseases. This is, no doubt, an overly simplistic portrayal of a consumer-directed health plan, and my citing it is not intended to be an endorsement. Yet, it serves to illustrate a basic attempt to find a solution to the current state of affairs by influencing employee and employer incentives, as well as incentives for health professionals. A consumer-directed health plan is intended to give employees greater choice and more control over decision-making. Managed care and gatekeeping are not a part of the PHA; these are replaced by Internet-based support tools that provide information about services and healthcare professionals to the employee and by vesting power in the individual consumer to make decisions about his or her own healthcare. It is assumed that when armed with information and choice, consumers will make good healthcare decisions in their own best interest. Employers, theoretically, are incented by the opportunity to lower their premiums and administrative costs with consumer-directed arrangements. In turn, it is believed that small employers that cannot afford to fully fund even low-cost insurance will be better able to provide their employees with pre-tax dollars to be combined with employee funds and used to pay for premiums, current healthcare services, or saved for future use. There are also some incentives in this type of arrangement for healthcare professionals who can offer their services to consumers free of managed care’s restrictions on type of treatment, length of treatment and amount of reimbursement. It is estimated that one and a half million people are presently enrolled in a consumer-directed health plan of some type. And some analysts predict that this type of coverage could account for 20 percent of the health insurance market by 2005 and as much as 50 percent by 2007 ( *). But according to a Health Affairs study the jury is still out as to the effectiveness of consumer-driven plans (Gabel, Merrill & Rice, 2003). For starters, good information on quality of health services is often not yet available, particularly for individual healthcare providers. Many consumers are not prepared to use information on the Internet, which is the most common source of information for these plans. And the psychological literature on consumer information processing tells us that decision-making is highly complex and not necessarily straightforward. For example, according to the “principle of information-processing parsimony”, consumers seek to process as little information as possible in order to make rational decisions quickly (Rudd & Glaz, 1991). One important implication of this principle is that consumers may not engage in extended information searching and processing when making health-related decisions. In other words, we just don’t know yet if consumers really do make healthcare decisions in their best interest when given increased information and choice. Of course, consumer-directed health plans that pool employer and employee dollars do nothing to address the problem of the unemployed uninsured. For that, at least an improved and expanded publicly funded health system is a must. Other ideas for healthcare reform are beginning to spring up from the likes of Senator John Breaux, Senator Joseph Lieberman, and Congressman Jon Conyers, to name just a few. The January issue of the American Journal of Public Health has looked at lessons for universal healthcare reform to be learned from Canada, Britain, France, Germany, Brazil, and South Korea (International Perspectives Forum, January 2003). Even Paul Ellwood, often attributed as being the founder of managed care, is proposing a new concept for health reform called “Heroic Pathways”, designed to, in his words, “restore the power of patients, assure consistent quality, increase productivity and ensure coverage for all.” (“Pioneer of managed care”, 2003) It is virtually impossible to know which, if any, of these ideas will gain traction beyond partisan posturing in advance of the 2004 presidential elections. The best news in all of this, though, is the apparent increase in energy and discussion of comprehensive reform for a health system recognized by virtually all to be in crisis. Incremental “tweaks” to the system are now seen as holding little hope of successfully fixing the healthcare system, particularly when legislative efforts to hold managed care companies accountable—a critical component of incremental change—are currently being overshadowed by medical malpractice reform. The most salient question for us, given the uncertainty of healthcare reform is: What is the best strategy for organized psychology? It won’t come as a surprise to any of you at this point that we in the Practice Directorate believe the best strategic option is to stay the course that we’ve worked in recent years to chart. How does this strategy translate for us? First, we must continue to press for mental health parity. We have certainly seen this continue at the state level over the past year with New Hampshire, West Virginia, Alabama and South Carolina either creating or expanding parity for mental health. And at the federal level, irrespective of what reform plan moves forward, we must ensure that people with mental health disorders are no longer the target of insurance discrimination, in either the public or private sectors. Second, we must continue our efforts to educate decision-makers (and the public as well) about the important role of psychological services in preventive care. No small number of health problems in this country can be influenced through preventive lifestyle and behavior change—cardiovascular disease, diabetes, obesity, HIV and some cancers are but a few examples. Whether it’s consumer-directed healthcare which provides first dollar coverage for preventive services or a publicly funded, single-payer approach to coverage for prevention, our goal is that psychological services be included as an important part of prevention. Third, mental health and psychological services cannot continue to be kept so separate from physical health services in our healthcare system. We heard from the public, in our public opinion research as early as 1995, that people overwhelmingly recognized the link between psychological health and physical health, and yet, with relatively few exceptions, our health-delivery system refuses to recognize it. No mater what reform proposals emerge as real contenders, we must work to ensure that psychological health services are fully integrated with physical health services. In fact, although perhaps an ambitious goal, I can image a time when the public’s current understanding that good psychological health is an important part of good physical health is replaced with the reverse—the recognition that good physical health is actually part of good psychological health. Fourth, we must continue to press to hold managed care companies accountable for their actions, accountable for their decisions and accountable for their choice to put profits before patients. Although some versions of reform would eliminate managed care altogether, to the extent that it remains it must be held accountable. But perhaps more to the point, any market-driven approach to healthcare must have accountability at its core or the system’s concern for quality will not keep pace with its concern for cost. Fifth, we must continue to assure that the value of psychological services is recognized by policy makers, as well as the public. Not only is this recognition necessary to be certain that psychological services are included in any reform that occurs, but it is critical for preserving adequate reimbursement rates for psychological services of all types. Sixth, our profession must do better in the area of political giving. Currently, by one measure, practitioners who pay the special assessment give, on average, only $2.75 per person per year. This level of giving—or should I say non-giving—puts Psychology at the near bottom of the rankings of the health professions’ political giving performance. As Ron Fox, Chair of the Association for the Advancement of Psychology, recently observed, if each of the 40,000 special assessment paying psychologists contributed $45—less than a dollar a week—psychology could be the second largest healthcare PAC behind medicine. More importantly, we could increase the scope and amount of our average contributions to Members of Congress by enough to make the difference between getting a call back as opposed to getting a polite note of thanks; or to make the difference between having access to the Chief of Staff, or even the Member, as opposed to talking to a staffer. Seventh, and last, we must remain flexible in our ability to apply these objectives to whichever reform plans emerge as politically and practically viable proposals. My crystal ball is no better than anyone else’s, but I would predict that while many proposals for reform will be raised and some even debated by Congress, definitive action over the next two years is unlikely. Rather, a more likely scenario is that healthcare reform will play a role in the upcoming Presidential campaigns and election. Perhaps healthcare reform will even play a defining role in this process much as it did in the 1994 election of President Clinton. During this process, we would be ill advised to tie ourselves to any single version of reform. That is not to say we should be without voice as to what we believe is necessary for effective reform. But we must be prepared to ensure that psychological services are treated as an integral part of any reform plan. It might seem, at first blush, that this type of flexibility would fly in the face of the recommended strategy of staying the course. Yet, I would remind us that flexibility is among those behaviors we know to be associated with resilience. More to the point, flexibility and staying the course are not mutually exclusive strategies. Consider for a moment the description of the “Hedgehog Concept” by Jim Collins in his book, Good to Great, a study of why and how good organizations become great organizations (Collins, 2001). Adapted from Isaiah Berlin’s famous essay, “The Hedgehog and the Fox”, Collins writes: The fox knows many things, but the hedgehog knows one big thing. The fox is a cunning creature, able to devise a myriad of complex strategies for sneak attacks upon the hedgehog. Fast, sleek, beautiful and crafty—the fox looks like the sure winner. The hedgehog, on the other hand, is a dowdier creature, looking like a genetic mix-up between a porcupine and a small armadillo. He waddles along, going about his simple day searching for lunch and taking care of his home. The fox waits in cunning silence at the juncture of the trail. The hedgehog, minding his own business, wanders right into the path of the fox. ‘Aha, I’ve got you now!’ thinks the fox. He leaps out, bounding across the ground. Lightening fast. The little hedgehog, sensing danger, looks up and thinks, ‘Here we go again. Will he ever learn?’ Rolling up into a perfect little ball, the hedgehog becomes a sphere of sharp spikes, pointing outward in all directions. The fox, bounding towards his prey, sees the hedgehog defense and calls off the attack. Each day, some version of this battle between the hedgehog and the fox takes place, and despite the greater cunning of the fox, the hedgehog always wins. (pp 90-91) How does this apply to companies or organizations that go from “good to great”? Collins found that what distinguishes the great organizations was that they had adopted the approach of the hedgehog. They identified a single, central, organizing principle based on what they could be the best in the world at, and simply stuck to it. It was not necessarily what they wanted to be the best at but what they could be the best at. It was also what they were deeply passionate about and what drove their economic engines. For organized psychology, I would offer a Hedgehog concept that focuses on working to identify and magnify for all to see the utility of psychological services, the effectiveness of psychological services, the value of psychological services, and working toward the elimination of barriers to accessing psychological services. I dare say we can be the best in the world at this; I hope we are passionate about it; and to the extent we are successful, the public benefits, practitioners (and practitioner’s pocketbooks) benefit and our organizations benefit. The Hedgehog concept applies whether our focus is the public, the media, the courts, legislatures, the business community or the Congress. This concept applies whether healthcare reform involves the public sector or the private sector, whether it is single payer or market driven, and whether it is employer focused or consumer directed. It applies along with the changing demographics of our society and psychology’s efforts to assure that our services meet the needs of diverse communities. Over the years, we have developed a remarkable infrastructure to support these activities which we can be the best in the world at. We have a Federal Advocacy Coordinators Network that runs a grass roots machine that is second to none in healthcare. We have an impressive Public Education Campaign Coordinators Network that knows how to get the message out to the media and the public. We have a vibrant Business of Practice Network which has zeroed in on a method and message to educate the business community. We have state, provincial and territorial associations, practice divisions and a graduate student organization all working together towards a common purpose. And, most recently, we have elevated our information technology capability and launched the practitioner portal in an effort to further strengthen the sense of community among practitioners. What we are trying to accomplish for psychology is not easy, not without obstacles, and not without challenges. It will take time for us to get from here to there. But the course has been charted and the means to travel the course effectively built. I urge us to stay that course and continue leading psychology forward. References · Frankel, V (1959). Man’s search for meaning. Boston, MA: Beacon Press · Hausman, K. (January 17, 2003). Psychologists sacrifice claim to prescribing privileges. Psychiatric News. · Kennedy, E.M. (2003) Quality, affordable health care for all Americans. American Journal of Public Health, 93, 14. · Gingrich, N. & Bachman, R (January 30, 2003). Boomers will revitalize an aged, ineffective system. Atlanta Constitution Journal, p. 17. · Price Waterhouse Coopers (2002, September). Consumer directed health care: An overview. Atlanta, GA: Author (Ronald Bachman). · Rudd, J. & Glanz, K. (1991) How individuals use information for health action: Consumer information processing. In Health Behavior and Health Education: Theory, Research and Practice. San Francisco: Jossey Bass. · Gabel, J., Merrill, J. & Rice, T. (2003). Consumer driven health plans: Are they more than talk now? Health Affairs, 22, 9. · International Perspective Forum (2003, January). American Journal of Public Health, 20-51. · Pioneer of managed care proposes next generation of health care delivery (2003). Bureau of National Affairs Health Care Policy Report, 11(5), 167 · 2002 N.Y. Law 676. · American Psychological Association (1996). Survey of public perceptions of the value of psychological services. Washington, DC: Author. · Collins, J. (2001) Good to great: why same companies make the leap, and others don’t. New York: Harper Business. |
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