Practicing psychology in the era of managed care: Implications for practice and training.

Beginning with the HMO Act of 1973, managed care, a system for controlling health care costs, rapidly expanded and gained influence as the main vehicle for health care delivery in the United States. Implementation of managed care principles in the mental health arena has generated much debate, particularly with respect to issues of quality of care. The authors briefly trace the development of managed care and evaluate its impact on the practice of psychology. The extant literature is reviewed with specific attention to issues of quality of care, confidentiality of patient information, and shifting practice patterns of clinicians. Finally, the future of professional psychology within the context of managed care is examined, and the implications of newly created mental health roles for practitioners, training programs, and organized psychology are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Emerging trends in mental health policy and practice

The continuing deinstitutionalization of patients in public mental hospitals and the growth of managed care are fundamentally altering mental health practice. Managed care provides opportunities for achieving parity of insurance coverage between mental and physical illness, but serious problems persist in integrating mental health, substance abuse, and general medical care and assuring an appropriate range of services and programs for persons with serious mental illness residing in community settings. Hospital and community care are poorly coordinated, and hospital care needs to be integrated into a more balanced system of services. Important new roles are emerging for purchasers, patient advocates, and mental health authorities.     

Managed care or mangled care?: Treating eating disorders in the current healthcare climate.

The challenge of treating patients with eating disorders, together with the increasing intrusion of 3rd-party payers into the healthcare system, presents a dual dilemma for mental health clinicians. Although there are potent treatments for patients with anorexia nervosa and bulimia nervosa, most therapies require substantially more than a brief number of sessions in order to be effective. This article provides guidelines to clinicians who treat patients with eating disorders under the constraints of managed care. Practical suggestions for treatment approaches as well as strategies for negotiating with 3rd-party payers are offered to assist clinicians in providing efficient, effective, and compassionate care to patients with eating disorders. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The clinical nurse specialist as expert practitioner in the obstetrical/gynecological setting

The role of the advanced practice nurse (APN) continues to evolve in specialty areas while healthcare systems seek solutions to issues of cost-containment, equity in access, and quality care. APNs have a significant role in facilitating the positive outcomes of clients utilized as measurable indicators in a managed care environment. The CNS as expert practitioner in the obstetrical/gynecological hospital setting integrates specialty knowledge and demonstrates specialty skills when working with childbearing and perimenopausal women and their families. Maintaining a holistic orientation to practice and keeping comprehensive documentation of activities facilitate achievement of quality outcomes for patients in this specialty field. Competencies essential to successful implementation of the expert practitioner role include: clinical expertise, effective communication skills, critical thinking and analytical skills, and a theoretical orientation to problem solving. The Roy Adaptation Model is an effective framework that can be used by the CNS in the obstetrical/gynecological hospital setting to promote, maintain, and restore health, as well as facilitate positive patient outcomes.     

Confronting health care realities: A reply to Sank (1997).

The author responds to L. I. Sank's (1997) proposal that an effective way to oppose the continuing growth of managed behavioral health care is to lodge professional ethics complaints against licensed behavioral health professionals acting as case managers. The author argues that this is not only a patently ineffective strategy, it also ignores the obvious—that no amount of effort by behavioral health professionals can turn back the clock and reimpose the fee-for-service system apparently favored by a majority of professionals in independent practice. It would behoove psychologists and other mental health professionals, then, to acknowledge the contributions of managed care to clinical and fiscal accountability as well as the problems arising from managed care models and methods of implementation. More important, they should consider what they can do to influence the shape of the service delivery systems of the future. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Managed mental health care and independent practice: A challenge to psychology.

Suggests that the rapid development of managed mental health care systems has created serious problems for psychology. Addressed are several issues that are inherent in the manner in which psychology responds to the development of these systems, particularly whether effective psychological treatment must be compromised in such systems. A model of managed mental health care is described. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Isolation and characterization of nisin-producing Lactococcus lactis subsp. lactis from bean-sprouts

Knowledge of the basic economic factors underlying managed mental health care directly impacts the clinical practitioners' ability to make constructive changes in the system. To aid understanding this article introduces the managed care marketplace model, the interactive relationship between medical necessity and patient co-payment, and demand management economics. The author encourages practitioners to develop strategies to overcome specific economic obstacles that prevent the promotion of group psychotherapy.     

Mental health and managed care: Training for the 21st century.

Discusses some of the difficulties future clinicians may encounter as they make the transition from graduate training to clinical work, and suggests that many traditional pre-doctoral psychology internships inadequately prepare trainees for the prospective practice of psychology in the era of managed mental health care. Graduate training programs need to integrate clinical work in a managed care setting during internship training utilizing the scientist-practitioner model to (1) more effectively prepare trainees for future work in managed care, (2) expand professional psychology's unique contributions to mental health treatment, and (3) apply the research methodology of psychology to evaluate clinical efficacy and treatment outcomes within the managed care environment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The mental health care revolution: Will psychology survive?

Managed mental health care, which encompasses a wide variety of approaches, is a response to precipitous increases in health care expenditures, particularly as they relate to mental health care. The shift from what seemed certain to become a national health insurance program only 15 years ago to the profit-driven corporate health care industry of today is truly revolutionary. These profound changes are beginning to have a major impact on the independent practices of psychologists. In this article, psychologist practitioners are exhorted to recognize this new development in the marketplace. Data are cited that show the rapid shift from free choice care to various forms of managed care, and practitioners are urged to participate in shaping the changes that are now in process in order to develop a humane and effective system of mental health care. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychological consultation with primary care physicians: Obstacles and opportunities in the medical setting.

This article discusses the relationship between psychologists and primary care physicians and describes the training and practice of physicians in the areas of mental and behavioral health care. Issues affecting the relationship between psychologists and primary care physicians are then reviewed. Different models of psychological consultation are discussed, and an integrated behavioral systems model of psychological consultation is presented as a potentially effective model for consultation with primary care physicians. This model provides a framework for psychologists to function as coproviders of primary health care services. Practical strategies to enhance collaboration between psychologists and primary care physicians in private practice are discussed. The need for more research on primary care and for the inclusion of psychologists in managed care and health care reform are also highlighted. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Considerations for ethical practice in managed care.

How does one maintain an ethical practice while facing the requirements and limits of a health care system that is dominated by managed care? Psychologists are increasingly raising such questions about ethical issues when working in or contracting with managed care organizations. The authors review the process involved in ethical decision making and problem solving and focus on 4 areas in which ethical dilemmas most commonly arise in a managed care context: informed consent, confidentiality, abandonment, and utilization management-utilization review. The need for sustained and organized advocacy efforts to ensure patient access to quality health care is discussed, as is the impact of managed care's competitive marketplace on professional relationships. Hypothetical examples of typical dilemmas psychologists face in the current practice environment are provided to illustrate systematic ethical decision making. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

In vivo perfusion measurements in the human placenta using echo planar imaging at 0.5 T

This paper alerts practitioners and administrators in correctional healthcare settings to a variety of issues of concern when advising or negotiating with state or county governments on the provision of managed behavioral healthcare. The participation of the mental health practitioner or administrator involved in determining the quality and appropriateness of behavioral managed care contractual services is an essential component of an overall healthcare service in a correctional setting. Several crucial elements are outlined relative to correctional settings, including the interface between custody and treatment providers, crisis intervention for incoming detainees or inmates, and provision of services for longer term "no parole" inmates in correctional settings. A number of considerations are reviewed, including (1) staffing, (2) drug formularies, (3) levels of service, and (4) "hidden costs," that may influence contractual negotiations as well as service provision by managed behavioral healthcare companies in correctional settings.     

Home healthcare nursing in the managed care environment. Part II. The impact on clients and professional nurses

Part I, published in last month's issue of Home Healthcare Nurse, provided information about managed care and health maintenance organizations (HMOs). This article, Part II, presents an overview of the history of home healthcare nursing, the results of a purposeful sample, and interviews of home care nurses. Interviews were conducted to determine how nurses perceived the impact of managed care on their clients and nursing practice. Conclusions are presented in terms of emergent categories gleaned from the interviews. Recommendations for the continued growth and advancement of professional nursing in the context of managed care are given.     

Directions for clinical research and genomic research into the next decade: implications for informatics

Managed care continues to revolutionize the provision of mental health services in the United States. Long-term, open-ended therapies have been replaced by short-term, highly focused interventions. Increasingly, managed care organizations rely on standardized preferred practice guidelines to give direction and focus to social work and other therapeutic interventions. Critics argue that changes effected by managed care, particularly the use of treatment guidelines, depersonalize the client-worker relationship and significantly reduce the role of empathy in the therapeutic process. Moreover, these critics suggest that overall client satisfaction with mental health services has deteriorated. This article presents a study that examined clients' perceptions of empathy and overall satisfaction with managed behavioral health care when the clients were in unstructured individual therapy or in time-limited standardized group therapy. The results reveal no significant difference in the clients' perception of empathy or of their overall satisfaction regardless of the type of treatment they received. This article describes the rationale and design of the study, presents the results, and discusses the implications for social work practice.     

Psychologists' reactions to Medicaid managed care: Opinion and practice change after 1 year.

How do psychologists adapt over time to a new managed care program? Reactions of Iowan psychologists to a managed mental health care program for Medicaid recipients were examined. The program was generally perceived negatively, although perceptions improved over time. Psychologists in private practice decreased the proportion of Medicaid patients they treated. Psychologists who continued to treat Medicaid patients reported decreased levels of job autonomy and satisfaction. A new managed care program presents psychologists with difficult ethical decisions, in which the quality of care provided to clients must be weighed against the negative aspects of participating in a managed care program. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

How expensive is unlimited mental health care coverage under managed care?

OBJECTIVES: To study costs, access, and intensity of mental health care under managed care carve-out plans with generous coverage; compare with assumptions used in policy debates; and simulate the consequences of removing coverage limits for mental health care as required by the Mental Health Parity Act. DESIGN: Claims data from 1995 and 1996 for 24 managed care carve-out plans; all plans offered unlimited mental health coverage with minimal co-payments. OUTCOME MEASURES: Probability of care, intensity of care, and total costs broken down by service type and type of enrollee. RESULTS: Assumptions used in last year's policy debate overstate actual managed care costs by a factor of 4 to 8. In the plans studied, costs are lower owing to reduced hospitalization rates, a relative shift to outpatient care, and reduced payments per service. However, access to mental health specialty care increased (7.0% of enrollees) compared with the preceding fee-for-service plans (6.5%) or free care in the RAND Health Insurance Experiment (5.0%). Removing an annual limit of $25000 for mental health care, which is the average among plans currently imposing limits, will increase insurance payments only by about $1 per enrollee per year. Children are the main beneficiaries of expanded benefits. CONCLUSIONS: Concerns about costs have stifled many health system reform proposals. However, policy decisions were often based on incorrect assumptions and outdated data that led to dramatic overestimates. For mental health care, the cost consequences of improved coverage under managed care, which by now accounts for most private insurance, are relatively minor.     

New therapies for cytomegalovirus retinitis

Advocates of inpatient managed care employing clinical pathways are confident that this patient management strategy reduces cost while promoting optimal patient outcomes. Other health care professionals are concerned that cost reductions place patients at higher risk for adverse health events. Research is needed to demonstrate the true impact of cost-containment strategies on clinical outcomes. The article describes a study in progress comparing patients conventionally managed by their physicians with similar patients whose overall management involved a nurse case manager. This study explores the issue of resource costs that can be linked to clinical and financial outcome measures.     

Optimizing cardiothoracic surgery information for a managed care environment

The rapid change occurring in American healthcare is a direct response to rising costs. Managed care is the fastest growing model that attempts to control escalating costs through limitations in patient choice, the active use of guidelines, and placing providers at risk. Managed care is an information intensive system, and those providers who use information effectively will be at an advantage in the competitive healthcare marketplace. There are five classes of information that providers must collect to be competitive in a managed care environment: patient satisfaction, medical outcomes, continuous quality improvement, quality of the decision, and financial data. Each of these should be actively used in marketing, assuring the quality of patient care, and maintaining financial stability. Although changes in our healthcare system are occurring rapidly, we need to respond to the marketplace to maintain our viability, but as physicians, we have the singular obligation to maintain the supremacy of the individual patient and the physician-patient relationship.     

Managed care, brief therapy, and therapeutic integrity.

A major cost-containment strategy of managed mental health care is the mandating of short-term psychotherapy via session limits, dollar caps on mental health benefits, and utilization review mechanisms. It is argued that while brief therapy is a widely useful treatment modality, when it is mandated by a 3rd party it violates the fundamental integrity of the therapeutic relationship. The construct of therapeutic integrity is defined, and the parameters vulnerable to managed care intrusions are identified. The author examines the implications of this analysis for (1) the practice of brief therapy, (2) training in brief therapy, (3) managed care, and (4) organized psychology. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Mental health services in managed care: quality questions remain

Primary care physicians are often the professionals to whom older patients turn for advice about medical coverage in Medicare managed care health plans. To assist in this dialogue, these authors outline current characteristics and financial arrangements for psychiatric and mental health services in Medicare managed care. Advantages and disadvantages of Medicare managed care for enrollees with mental disorders are outlined. Mental health "carve-out" and "carve-in" models are defined, and questions are raised about the number of psychiatrists and other mental health care providers needed to provide appropriate care for a plan's enrollees.