Many of you have read or heard about how managed care is reshaping health care to control costs. For psychologists in independent practice this has meant increased paperwork, restricted access to patients, and strong controls over the nature and length of assessment and treatment, all for less money. The economic goal of this change is maximal quality at minimal cost. In the West (i.e., western U.S.), this revolution is occurring at a rapid pace, and every practitioner associated with health or mental health care has been affected in some way. Some private practitioners in psychology and even medicine have reported reductions in annual income of 40% or more over the past 1 - 2 years. I promise not to whine about the death of the profession. Rather, I offer a hypothesis about the nature of this health care revolution based on principles of general systems theory - a description of transformation, not death. A corollary of this hypothesis is that it will affect all psychologists, not just practitioners.
First, a brief summary of relevant systems theory principles. Closed systems such as a card deck are neat and simple. Probabilities are initially fixed and each change (e.g., a new card uncovered) has a predictable effect on the probabilities of all other cards. Unfortunately, most human systems (e.g., economies) are open systems in which the effects of individual events are difficult to determine. This occurs because these systems exist within larger systems, all of which affect one another (e.g., family, city, state, country, world). A change will have ripple effects throughout the system that are not linear, but chaotic, multidirectional, and nonlinear. One key principle of open systems that provides predictability is the tendency of each system to retain equilibrium or balance. As a system moves away from balance, the whole system will react to re-establish it. The resulting pattern of change is constant motion, but in a predictable fashion around points of equilibrium.
The changes in the health care system in the West and other places in the country are not simple ripples within the U.S. economy, but part of a larger global social-economic whole system shift to a point of better equilibrium. The nature of the change is clearly systemic because of its rapid pace, pervasiveness, and the parallels in multiple industries and countries. The ultimate economic goal in all industries is maximal quality at minimal cost. This economic transformation has already been endured for more than a decade by the banking industry and many manufacturing industries involved in global trade. Even after all their corporate downsizing, merging, and restructuring, these industries continue to evolve in their structures to remain competitive. What is going on in health care is also well under way in the other industries and governments. Industries less affected to date, such as law will have their turns as well. Although the nature of the effects may differ, everyone in the system is affected because the forces driving this process are immense, global, and beyond economics. What is happening is probably on the order of magnitude of our ancestors' experience as they shifted from groups of hostile competitive clans of hunter-gatherers with decreasing resources to establishing interdependent trading communities with domesticated food, animals, and tools. The essential systemic shift is at the structural level of the global system from competitive autonomous units to cooperative interdependent units so the global economy can achieve a higher level of efficiency to meet the needs of the global population.
This structural shift from autonomous to interdependent units is precisely what is happening in health care - hungry fee-for-service providers (doctors, hospitals, psychologists, etc.) leaning to share resources, eliminate waste and reduplication, increase efficiency and quality, and reduce cost to provide health care to its customers. Some clinical psychologists around the country are just beginning to experience the belt tightening; other, especially in the West and several other states are headlong into the systemic shift. These changes are not temporary, but are more enduring shifts in the basic fabric of the world's economic and social structure.
The key to preparing for and managing this systemic change is to conceptually shift from the content level (area of professional specialization or expertise) to the process or structure level (the need to shift from autonomous to interdependence units in one's service delivery). During such systemic change, structural issues take priority and precedence over content issues as the system shifts to a new point of equilibrium. content issues generally regress during periods of systemic change to more basic human needs, such as personal survival and immediate concerns. These concerns will expand again as the global system develops greater equilibrium and balance.
To assist the conceptual shift from working as autonomous to interdependent units, let me share what is happening to delivery of psychological services. Solo private practice is disappearing and being replaced by cooperative ventures (group practices and large networks of practitioners). Professionals are struggling with professional boundaries, and need to acknowledge that overlapping skills have to shift to the cheaper provider (MD to psychologist, psychologist to masters level professional, etc.). Interventions now require direct relevance and practical application to clients (the system cannot afford long-term, open-ended, non-productive approaches to treatment). Clear and rapid communication is required to get information around larger, interdependent systems involved in providing health care. Clients, families, case managers, peer reviews, and other professionals require understandable, nontechnical language to comprehend assessment findings and intervention results. Assessment models are shifting from fixed lengthy test batteries to flexible ones directed at answering specific referral questions. Interventions must be state-of-the-art to achieve quality care with rapid, reliable results. Techniques substantiated by outcome studies will have greater approval and appeal.
My experience at Cedars illustrates a proactive stance at both the individual and institutional level to manage this systemic change. Cedars-Sinai Medical Center, because of its size, reputation, and financial stability, was initially buffered from the early upheaval that affected small community hospitals around the country by economic belt tightening and mergers. The restructuring process at Cedars has been occurring for a least two years. Psychologists were inordinately affected by the medical center by layoffs and program reductions or closures, perhaps because we occupy less central positions in the organizations (there never has been a central psychology department at Cedars). The medical center strove early in the process to define a role for itself in a capitated health care system (the next step in health care financing), in which insurers pay the "Cedars-Sinai Health System" a flat per person per annum rate for all their enrollees. Cedars becomes the executive provider of all necessary care to keep these individuals healthy. To do this, Cedars has reduced its be capacity from more than 1100 to a current target of about 550, is reducing and reorganizing the hospital structure, and is creating numerous alliances and new programs to provide a full spectrum of health care. Under a capitated system, insurers function more as brokers and the financial risk shifts considerably from the insurer to the provider. Psychologists in the Department of Physical Medicine and Rehabilitation have also experienced this shift in roles. Of four full-time equivalent positions two years ago, two half-time positions have been eliminated and two full-time positions have been reduced and are being transformed to contract positions, in which psychologists will also share the benefit and risks of the health system. The goal of the new system is to get persons to the least expensive level of care as quickly as possible to minimize cost, but t provide the best quality care possible, which is the incentive to draw new contracts form insurers and renew old ones. Health promotion and behavioral compliance issues will become paramount in new health care systems, a potential gold mine for psychologists who can provide these services in interdependent, contractual relationships.
Personally I remain the only full-time employed psychologist in our department. My position has shifted from provision of direct patient care and general team consultation to primarily team consultation and teaching, with direct service only to defined high priority patients. As of July 1, I and a postdoctoral fellow will provide services on an inpatient rehabilitation unit that was staffed two years ago by three psychologists and several trainees. What used to be routine psychological assessment and treatment is now being provided by other rehab staff in a less formal way or not being provided at all. I have trained speech pathologists to broaden their initial evaluations to screen for more complex neuropsychological functioning and continually guide their interpretation of findings. My own assessments are focused on targeted complex issues that others with lesser training cannot perform. I am also training all staff in identification of adjustment-related problems and provision of simple interventions that can facilitate minor emotional adjustment issues. My own interventions are either brief and focused (1-2 sessions) on a target issue or directed at difficult patients (e.g., character disordered or traumatically brain injured) with complex behavioral management issues. Readers with more traditional practices might be aghast, but this teacher/consultant/psychological expert role has replaced my traditional direct service professional role.
How does all this affect geropsychology? Medicare, the primary insurance for older adults has attempted to contain costs with the diagnosis-related groups payment mechanism for hospitals and the relative value scale payment mechanism for physicians, it is well behind other insurance companies in the move toward health maintenance organizations and capitated care. Medicaid is already undergoing transformation in many states to HMO or capitated care, and Medicare will probably follow suit in time. Clinical geropsychologists will ultimately face the same issues before the clinical psychologists dealing with managed care now.
Relative to psychologists in other fields, geropsychologists should fare well at content level during this era of change and transformation. As I mentioned above, during these major systemic shifts the content level regresses to immediate and practical needs. One growing practical reality facing our society into the next century is the ever increasing number of older adults. In order for society to meet these practical needs, geropsychological knowledge, skills, and application will be in great demand. Of course this will be though interdependent health care systems or other cooperative ventures that can contract to provide these services. Research developing and substantiating practical applications to older adults will continue to be necessary.
As I mentioned at the beginning of this article, the corollary of this hypothesis of global systemic change is that it will affect every individual in the system. Psychologists outside of health care practice also need to develop an interdependent orientation and flexibility address the demands of waves of change. I encourage other readers to respond with ideas and experience of your own in this Column.
To direct comments about the information contained in these pages, please write to marsiske@ufl.edu