Designing the Future of Professional Practice

1. Designing the Future of Professional Practice Robert E. McGrath Fairleigh Dickinson University

2. Even if you are on the right track, you’ll get run over if you just sit there. -- Will Rogers

3. Sources of Concern • Managed care • Competition • Healthcare reorganization • Devaluing of psychological services

4. Managed Care • Correlates of managed care involvement • longer working hours • larger caseloads • less participation in supervision, greater stress • higher rates of premature termination • reduced flexibility • greater pressure to compromise quality of care • Implications of national healthcare --Chambliss, Pinto, & McGuigan, 1997; Cohen, Marecek, & Gillham, 2006; Gold & Shapiro, 1995; Murphy, DeBernardo, & Shoemaker, 1998; Rothbaum, Bernstein, Haller, Phelps, & Kohout, 1998; Rupert & Baird, 2004

5. Competition • Still unmet need (Thomas et al., 2009) • Shift to master’s level

6. Healthcare Reorganization • Medical home • Episodic vs fee-for-service payments • Silo-based versus integrated care

7. Devaluing Psychological Services • 1996-2005/2006: • Number of patients increased (19.3-36.2 million) • 1996-2005: Proportion receiving ADPs doubled (5.8-10.1%) • Proportion receiving psychotherapy declined (31.5-19.8%) • Shift to master’s-level providers --Olfson & Marcus, 2009; Soni, 2009

8. Responding to the Challenge • Stasis • Primary care psychology • Prescriptive authority

9. Stasis • Short-term growth likely • Relative decline • Eventual retraction

10. Primary Care Need: Mental Health • Primary care is the most common site for treatment of mental disorders • Some studies find > 50% of PC patients meet DSM criteria • Number treated per year in CHCs for MH/SA problems quadrupled 1998-2003 --Kessler et al., 2005; Luoma, Martin, & Pearson, 2002; Mauer & Druss, 2009; Spitzer et al., 1994; Toft et al., 2005

11. Primary Care Need: Behavioral Health • Behavioral factors in physical disorder • Obesity • Diabetes • Asthma • Infectious disease • Addiction issues • Management of emotional/family components of disease

12. Models of Psychological Involvement in Primary Care • Relationship between providers (Blount, 2003) • 1. Coordinated care • 2. Co-located care • 3. Integrated care • Comparison • 1 is modal • 2 is common, higher rate of follow-through • 1 and 2 are traditional MH services • Difficult for psychologists to carve a niche in 1 and 2

13. Health vs PC Psychology • Acute versus chronic care • Individualized versus programmatic treatment • No diagnosis targeted --Blount, 2003; Gruber, in press

14. Role of the Psychologist in Integrated Care • Assessment/diagnosis • Consultation • Emergency service • Behavioral intervention • MH screening • Referral for MH services/targeted services • Program evaluation/outcomes assessment • Research protocol design

15. Challenges and Obstacles • Clinical training • Familiarity with PC settings • Same-day billing • Problems with CPT codes • Demonstration that MH screening has a medical cost offset • Startup costs • Competition from master’s level providers • No single driver in healthcare

16. Prescribing Need • 96% of U.S. counties demonstrate an unmet need for MH prescribers (Thomas et al., 2009) • For psychologists, the “need” often has to do with • Unprescribing • Improved monitoring • Avoiding polypharmacy • Considering contextual factors/alternatives to meds • Enhancing patient empowerment

17. Models of Pharmacopsychology • Collaborative • 60% of psychotropic prescriptions written by PCPs • > 60% of family medicine residencies offer no formal training in clinical pharmacology • Diagnosis of complex cases • Interpretation of research --Bazaldua et al., 2005; Mark, Levit, & Buck, 2009

18. Models of Pharmacopsychology • Prescribing • Indiana, Guam, New Mexico, Louisiana, U.S. military, U.S. PHS; U.S. IHS?; Oregon? • Infrastructure • Designation of programs • Practice guidelines • Licensing exam • Taps into existing funding streams/medical roles

19. Roles of the Prescribing Psychologist • Share on-call duties with psychiatrists • Fill positions formerly reserved for psychiatrists • Provide voluntary care to the indigent • Provide administrative services in state agencies • Serve as officers and even owners of hospitals • Become involved in state policy • Participate in pharmaceutical research --Ally, 2009

20. Benefits to Psychology • An area where competition is restricted • Taps into an existing funding stream • Dramatic increase in number of opportunities • Dramatic increase in potential to affect the system

21. Challenges and Obstacles • Resistance within the profession • Diffusion of identity • Two classes of psychologists • Resistance outside the profession • Licensure of psychologists required 30 years • Tension between two agendas

22. Complementary Agendas • Both are extensions of traditional roles • PC psychology draws on traditional tools for new populations • RxP psychology draws on new tools for traditional populations • Enhance diversity of opportunities • Improved status of psychologists; status of psychological interventions • Greater involvement with needier populations

23. Designing Our Future • Each has advantages but also significant pitfalls • On-going discussion within psychology www.rxpsychology.com