Medicaid's quiet revolution: Merging the public and private sectors of care.

State governments have been quietly transforming the Medicaid program in efforts to contain its runaway costs. By shifting from a fee-for-service model to managed care in Medicaid, almost every state has begun to merge the public and private sectors of care. This change raises potential problems and opportunities for psychologists and for consumers. The private sector will be challenged to treat patients it has traditionally referred to the public sector. Psychologists will be challenged to work together in new collaborations with one another and with consumers to maximize quality of care. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Factors influencing survival after gamma knife radiosurgery for patients with single and multiple brain metastases

BACKGROUND: Significant changes are restructurng the U.S. health care delivery system. National health reform is now extending itself into the public sector. Increased health and medical costs by federal and state governments are forcing a reevaluation of major entitlement programs, especially Medicaid. METHODS/RESULTS: Because Medicaid is the single largest item in many state budgets, states are now enrolling Medicaid patients into managed and coordinated care arrangements as a means to control costs and increase access to care. HMOs are not only competing for private patients but also actively seeking the Medicaid population. Nationally, almost one-fourth of all Medicaid patients are now enrolled in managed care plans. Various models and approaches have been developed by individual states. CONCLUSIONS: Because managed care enrollment in the Medicaid program has increased substantially in recent years, selected services including vision care are no longer rendered by any practitioner willing to accept Medicaid fees. Freedom of choice is now restricted to pre-selected and panel practitioners participating with the managed care program. The rules, regulations, billing procedures, fees, and program requisites will differ under managed care programs. Private optometric practitioners must consider entering economic and organizational relationships and linkages that make them attractive to managed care organizations.     

Building Systems of Care for Children With Chronic Health Conditions.

Objective: To describe the leadership role that rehabilitation psychologists can play in improving the health care delivery system for children with special health care needs (CSHCN). Setting: Midwest academic health center and surrounding communities. Participants: Children with chronic health conditions and disabilities and their families. Intervention: A model research demonstration project designed to promote family-centered, comprehensive, coordinated, and community-based care for CSHCN. The project aims to enhance environmental supports for CSHCN and their families in 2 ways: (a) by improving the ability of primary care providers to deliver effective chronic care management and (b) by integrating this improved clinical practice into an enhanced Medicaid managed care service delivery system for persons with chronic illness and disabilities. Conclusions: Psychologists have the potential to improve the quality of life of CSHCN and their families by intervening not only through direct services but also by promoting positive changes in the larger health care environment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Roles for Psychologists in End-of-Life Care: Emerging Models of Practice.

Professional psychologists are increasingly likely to encounter opportunities to work with patients and families facing end-of-life issues. Psychologists can provide psychological assessment, intervention for patients and families, consultation with and support of health care team members, grief therapy, and program development and evaluation. Psychological services are useful for healthy individuals who wish to make thoughtful plans about their own future care, patients with life-limiting illnesses, families stressed by providing end-of-life care, bereaved individuals, and health care providers who face issues of burnout and strain. Several challenges for psychologists working in end-of-life care are noted, including training, development of clear roles, and reimbursement. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A monoarthritis model in rabbits induced by repeated intra-articular injections of lipopolysaccharide

In recent years, states have increasingly turned to managed care arrangements for financing and delivering health services to Medicaid beneficiaries. In 1996, approximately 40% of all Medicaid recipients were enrolled in some form of managed care. The rapid escalation of managed care in this population has been fueled by states' desire to slow the growth of Medicaid expenditures and by the trend toward managed care enrollment in the private health insurance industry. The effect of managed care on cost containment in the Medicaid program may be limited, however, because 85% to 90% of Medicaid managed care enrollees are women of childbearing age and children, who together account for 69% of Medicaid recipients, but only 26% of program costs. Nonetheless, the increase in managed care enrollment in this population may have a profound impact on health service delivery and health outcomes for U.S. children, approximately 20% of whom received health benefits through the Medicaid program in 1995. In the future, the proportion of Medicaid-eligible children enrolled in managed care will likely increase as a result of recent legislation that relaxed the requirement that states seek federal approval prior to mandating managed care enrollment for Medicaid beneficiaries. More states are relying on fully capitated arrangements as the preferred type of managed care for Medicaid recipients, despite the relative lack of experience many of these plans have in serving this low-income population. Moreover, managed care organizations have few incentives to enroll chronically or disabled children with higher-than-average expected costs. Without mechanisms in place that adequately adjust capitated rates to account for these higher-cost enrollees, managed care organizations may lose money, and children with the greatest health care needs may be underserved. As mandatory managed care enrollment for Medicaid recipients increases nationwide, states should carefully monitor changes in program costs and quality as well as implications for the delivery of pediatric health services and health outcomes.     

Psychotherapy research on Medicaid in Hawaii.

Describes the complex organizational and social conditions for conducting psychotherapy research in a state Medicaid program. Comparative data are offered on service delivery and utilization in Medicaid, the Civilian Health and Medical Program of the Uniformed Services, and the dominant employee health plan in Hawaii. It is suggested that the reporting of these data has led to extended coverage of psychologists under Hawaii Medicaid laws. The major overlap in types of procedures used by psychologists and psychiatrists and some indications of the impact of the extended coverage of psychologists on Medicaid health care costs are described. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Problems and limitations in using psychological assessment in the contemporary health care delivery system.

Psychologists report limitations on psychological assessment services and problems gaining authorizations and reimbursement for these services from third-party payers. Documentation and categorization of these problems and limitations is based on responses from well over 500 psychologists responding to a broad solicitation for feedback. This article explores the barriers to access for assessment services, including resistance to psychological assessment, difficulties in the preauthorization process, problems with reimbursement, the clinical decision-making process, and larger systems issues. The authors make recommendations for redress of these problems through work with the profession, other mental health professionals, managed care, and patients–consumers and through political action. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The sentinel effect in an outpatient managed care setting.

Psychologists who provide services under managed care must typically cope with session restrictions and time-consuming paperwork to justify session use. This process has been broadly challenged by critics of managed care. This study investigated the effect of allocating sessions in outpatient treatment on session use. Providers were authorized either 6, 10, or 19 sessions (benefit maximum), with additional sessions given without restriction. Results showed that doctoral-level psychologists in the 6-session, 10-session, and 19-session groups used up to 2.5 sessions more than the control group, whereas master's-level providers used up to 5.5 sessions more. Master's-level providers also had an 18% treatment dropout rate, compared with 7% for psychologists. On the basis of cost analysis, session management is financially warranted for master's-level providers but not for doctoral-level psychologists. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Medicaid's not-so-"quiet revolution": A call to action for psychologists.

Psychologists are research-based health care providers with much to offer to the development of programs for people with disabilities and chronic illnesses. An exemplar for psychologists' involvement in health care planning is Health Care Options Plus (HCO+), a prevention-oriented, Medicaid-funded program for people with disabilities. Contributions such as HCO+ will make a positive impact on the future of professional psychology and health care delivery models for people with disabilities. Psychologists must recognize the importance of Medicaid as well as their own potential for influencing public and private health care sectors in order to thrive in the current health care climate. (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)     

The evolution of health care: Implications for the training and careers of psychologists.

Congress failed to pass legislation in 1994, but the general principles guiding reform are clearly embedded in state-level legislation and the inexorable movement toward managed care in the private employer–insurer markets. These principles, legislated by statute or realized incrementally through private market reforms, present challenges and opportunities to psychology as a science and a profession. Psychologists must significantly modify the way they currently work, and university-based training programs must modify the way they educate future psychologists. The issues go beyond the dominant concern with benefit plan coverage and professional prerogatives and affect the very organizational structures in which psychologists work and the ways they get paid. Psychologists now share with every health-related science and profession the public's demand for research-based evidence of cost-effective solutions to individual and community-wide health problems. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The Employee Assistance Program: A Systems Intervention Model for Health Care Settings.

The August 1979 special issue of Professional Psychology on psychologists in health care settings covered activities of psychologists in a variety of such settings. The importance of a "life-space developmental frame of reference" is described by Donald Wertlieb (1979) in "A Preventive Mental Health Paradigm for Health Care Psychologists." We should like to respond to his argument for a preventive health frame of reference by drawing your attention to the employee assistance program as one such prevention and early intervention model for both the academic and nonacademic staffs of universities and colleges. The University of Missouri-Columbia Employee Assistance Program (EAP) is an example of such a program. We have recently completed our fourth year of operation and have provided services during these 4 years to over 500 faculty, staff, and their families. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Military health care providers' views on prescribing privileges for psychologists.

Selected military psychologists have been trained and privileged to independently prescribe psychotropic medications. To explore the attitudes of health care professionals toward prescribing authority, a survey of 395 military psychiatrists, psychologists, primary care physicians, and social workers was conducted. Psychologists, physicians, and social workers supported prescribing privileges and continuation of the training programs. Results suggested that support by physicians and social workers is based on improving access to comprehensive mental health care for their patients. Psychologists advocating prescribing privileges at the state level need to pursue the training and licensing authority to prescribe independently. The opposition of organized psychiatry seems assured. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Changes in health plans serving Medicaid, 1993-1996

To better understand the Medicaid managed care market during a period of rapid change, we developed a new data set that links Medicaid enrollment data with health maintenance organization (HMO) industry data for 1993-1996 to analyze Medicaid enrollment in full-risk health plans. Nearly half of the Medicaid enrollees in a fully capitated managed care arrangement were in plans in which Medicaid makes up at least 75 percent of the total enrollment. In addition, the number of Medicaid-only plans has more than doubled since 1993. Commercial-based plans participated increasingly in Medicaid managed care during the period, yet more than half of the plans entering the Medicaid market were newly formed.     

National study of the experience of psychologists with psychotropic medication and psychotherapy.

Psychologists have been involved in psychopharmacological research and practice since the 1950s, although this seems not to have been remembered. Biodyne data on 1.6 million mental episodes from 1988 to 1992 document psychologists' involvement in monitoring and managing psychopharmacological medications. A large percentage of patients presenting for mental treatment were already taking psychotropic drugs. Medication usage decreased dramatically as psychologists diagnosed their individual conditions and initiated psychotherapy in addition to monitoring and managing medication usage. Relevant training in psychopharmacology should be an integral part of training of psychologists providing health care. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Veterans Administration psychology: Six decades of public service (1946-2006).

Psychologists in the Veterans Administration (VA), now the Department of Veterans Affairs, have contributed 60 years of public service to the treatment of our nation's veterans, enhanced by their involvement in clinical research supporting that care. From the development of new mental health care programs following World War II to their role in today's polytrauma centers caring for severely wounded veterans, VA psychologists have not only provided distinguished service to veterans but also provided insights for the entire profession in the care of veterans. This article highlights some of their contributions to practice and research as VA psychology and its training program celebrate their 60th anniversary. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The impact of the Veterans Health Administration (VHA) reorganization on psychology programs: A survey of VHA psychology leaders.

Because the Veterans Health Administration (VHA) is the nation's largest health care system and employer and trainer of psychologists, changes in VHA psychology have implications for the rest of the profession. A national survey of 127 VHA psychology leaders (91% response rate) documented that many psychologists now are managed by a psychiatrist, deliver more outpatient services, and do less personality testing. In the context of a 10% reduction in psychology staffing, morale is rated lower than 2 years earlier. Diversified professional roles are associated with higher status of psychology and management support for mental health programs. Psychologists need to understand and respond adaptively to the organizational and economic forces affecting their practice. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Immature chemodifferentiation of Purkinje cell synapses revealed by 5''-nucleotidase ecto-enzyme activity in the cerebellum of the reeler mouse

Data from child and adolescent emergency mental health screening episodes prior and subsequent to privatized Medicaid managed care in Massachusetts are used to investigate the relationship between payer source and disposition and to compare the match between clinical need and disposition level of care. Having Medicaid as the payer in the post-Medicaid managed care period decreased the odds of hospitalization by nearly 60%. None of the clinical need variables that contributed to hospitalization for Medicaid episodes in the pre-Medicaid managed care period were significant in the post-Medicaid managed care period. Multiple forces shaping professional standards, decision making, and quality of care are described. Public sector agencies must lay the groundwork for comprehensive evaluation prior to the implementation of privatized Medicaid managed care initiatives.     

Tennessee's failed managed care program for mental health and substance abuse services

In July 1996, Tennessee initiated a managed mental health and substance abuse program called TennCare Partners. This publicly funded "carve-out" experiment started chaotically and soon deteriorated into a crisis. Many patients did not receive care or lost continuity of care, and the traditional "safety net" mental health system nearly disintegrated. This qualitative case study sought to ascertain the impact of the TennCare Partners program. It points out that the program's difficulties stemmed directly from a flawed design that spread funds previously earmarked for severely mentally ill patients across the entire Medicaid population. States contemplating similar reforms should strive to protect vulnerable patients by risk-adjusting capitation payments and by focusing resources on care for severely mentally ill persons. States should also minimize program complexity and ensure the accountability of managed care networks for their patients' behavioral health care needs.     

Medicaid policy: Psychology's overlooked agenda.

Although psychologists are recognized as autonomous providers under almost every major federal health care initiative, they are not federally recognized as such under Medicaid because of Medicaid's unique federal–state partnership. State-by-state information on the access to psychologists under state Medicaid regulations are presented. As the move toward national health care reform becomes increasingly evident in the 1990s, psychologists have the responsibility and the opportunity to design innovative, behaviorally oriented health care delivery models in response to the national concerns of adequate coverage, access, and quality care. To do this, psychology as a profession must gain formal recognition under the various state Medicaid plans, either on a state-by-state basis or by way of federal mandates (as it was achieved by professional nursing). (PsycINFO Database Record (c) 2010 APA, all rights reserved)