Journal of Pediatric Psychology, Vol. 29, No. 1, 2004, pp. 55-59
© 2004 Society of Pediatric Psychology; all rights reserved
Commentary: Financing Pediatric Psychology Services: "Look What They've Done to My Song, Ma" or "The Sun'll Come Out Tomorrow"?
The University of Kansas
All correspondence concerning this article should be addressed to Montserrat Mitchell, Clinical Child Psychology Program, The University of Kansas, 2010 Dole Human Development Center, 1000 Sunnyside Avenue, Lawrence, Kansas 66045. Email: mroberts{at}ku.edu and montse{at}ku.edu.
A number of converging forces have compelled changes in the organization and financial arrangements in medical and mental health care. Some of the changes have been dramatic and imposing; others, relatively slow evolutions. At this point, the modern managed health care system appears to have a constricting effect on professional practice and on quality of care (Roberts & Hurley, 1997
). This situation has led to lamentations by many psychologists, including William Rae (this issue), whose refrain of "Buddy, can you spare a dime?" resonates with health care providers and consumers/patients alike. The "dime" that Rae alludes to can be seen as representing both the managed care reimbursement system and the apparent lack of recognition of the value of pediatric psychology services.
Pediatric psychology is a specialty that goes beyond traditional office-based care. Pediatric psychologists are prepared to be consultants and collaborators as well as direct interventionists in a wide range of settings, including hospitals, specialty medical clinics, and primary care centers, for a diversity of activities. However, most mental health coverage is dependent on coded diagnoses from the DSM-IV (Diagnostic and Statistical Manual, Fourth Edition, American Psychiatry Association, 1994), which does not include diagnoses for the psychosocial aspects of health and disease. Thus, pediatric psychologists are increasingly being put into ethical and professional dilemmas over how to provide services for treating the psychosocial concomitants of disease that are outside reimbursable practice parameters. The ethics of managed care have not been fully researched (cf. Buckloh & Roberts, 2001). However, one result is that "adjustment disorders" seem to be a rising "epidemic," as a new generation of children and parents are given this diagnosis in order to receive services (Rabasca, 1999). In summary, the changes prompted by the growing influence of managed care has been a difficult transition for all practitioners but have perhaps had a greater and more negative impact on the relatively new fields of health psychology and pediatric psychology.
Because of a push toward shorter, cheaper treatments, pediatric psychologists increasingly feel as though they must work harder for less money, while constantly bargaining with insurance companies to justify the worth of their services, and have become frustrated and angry at the apparent marginalization of their field. Hence, Rae's articulation of this perception has meaning, and this anger may be a useful tool to energize the field and inspire advocacy and research (DeAngelis, 2003). Consistent with Rae's musical theme, lyrics of other songs come to mind, like "Pack up all your cares and woe" and the more modern lament of Melanie Safka, "Look what they've done to my song, Ma," to describe our angst over how psychology's good works have become changed by what some have called "mangled care." In this commentary, we want to discuss the emergence of managed care plans and organizations, compare the U.S. system with those in Europe and Canada, and describe what we see as the accomplishments of pediatric psychology. Thus, we will close with what we see as a brighter future for the field of pediatric psychology, borrowing from the Broadway play and movie about the Depression era, Annie: "The sun will come out tomorrow."
Development of Modern Managed Care
In response to rising health care cost in the 1980s, managed care was developed to control costs, provide more flexibility for consumers, and spread cost risks among several providers (Bodenheimer, 1992a). Indeed, the original managed care plans were established to provide quality health coverage to populations that traditionally would not have been covered. In the early years, managed care organizations (MCOs), particularly those designed as health maintenance organizations (HMOs), accomplished what they intended. Patients under HMOs (networks of limited numbers of providers willing to accept lower fees in return for higher volume of business) were more likely to receive preventive health care than Americans under fee-for-service or Europeans or Canadians under socialized health care plans (Rubin & White-Means, 2001).
MCOs began changing dramatically when, during a period of economic recession, the larger insurance companies began looking for ways to reduce losses and increase their long-term viability. They began expanding into and adapting managed care concepts and were then able to undercut some of the smaller, regional HMOs, slowly taking over more and more of the managed health care insurance business. Currently, only a few insurance companies control the majority of the United States' insurance policies and are some of the world's largest corporations (Bodenheimer, 1992a). These companies have both the financial and political clout to dictate, or at least influence, national insurance policy to their fiscal benefit. Health care policy and legislation implemented in this way do not necessarily benefit the consumer and have been linked to rising health care costs (Himmelstein & Woolhandler, 1992).
In sum, managed care is not inherently damaging to clinicians and their clients. Instead, the current manifestation of managed care, as run by large corporations focusing on cost containment, is stifling clinical practice. Examining the Canadian and European health care systems can provide an interesting model of systems that are universal and government based, in comparison with the American system, which is employer provided and corporate run.
Europe and Canada: Is Socialized Medicine the Future for American Health Care?
In 1966, Canada passed the Canadian Medical Care Act, a federal law mandating the creation of a comprehensive and universal province-run, national health care plan. About 20 years later, Canada supplemented this system with the Canada Health Act, with an enforcement provision to withhold federal money from provinces that allowed doctors to "extra-bill" above negotiated rates (Navarro, Himmelstein, & Woolhandler, 1992). In the years since, Canada's health care costs have plateaued, while those of the United States have more than doubled (Sullivan & Mustard, 2001). At the same time, Canada has seen the health status of its citizens continuously improve. Because this type of federal insurance system insures an individual for his or her life span (rather than for only relatively brief amounts of time, as in the U.S. system), the Canadian system has a financial incentive to fund health promotion and disease prevention, which have long-term, rather than short-term, positive effects (Bodenheimer, 1992b). The same emphasis is found in the countries of the European Union, which have recently launched a political and media campaign with the phrase "There is no health without mental health" (Lavikainen, Lahtinen, & Lehtinen, 2000).
The benefits of a Canadian- or European-modeled system are balanced by some potentially contentious differences compared with the American system. Some of the less controversial cost containment techniques of the Canadian system include the absence of the advertising and marketing of health care services, which saves millions of dollars but can also be perceived as a reduction in informed consumer choice. Perhaps more controversial are the sacrifices in coverage for certain populations and specialized services and in the amount of money spent on research and technology. In 1985, for example, Canada spent less than half of what the United States spent on research (Navarro et al., 1992). Similarly, in 1990 the United States boasted 8.4 magnetic resonance imaging machines per one million people, whereas Canada had only 0.7 (Mossialos & Le Grand, 1999). The drive to produce new and better medical technologies, pharmaceuticals, and surgical/medical techniques is certainly fueled by the competitive health care industry in the United States, which is currently a world leader in the development and use of cutting-edge technological medicine. But it is not well established that Americans always need such an abundance of medical technologies.
The Current System of Managed Care
Despite the possible pros and cons of socialized medicine, the current trends in the insurance industry indicate that the United States will not be adopting a universal health care plan in the near future (Rice, 2001). Additionally, the continuing growth of the health insurance industry (and subsequently the industry's growing influence) suggests that it will be very difficult for pediatric psychologists to change their financial situation, also difficult, by simply bulking up the research base of clinical practice with empirically supported treatments.
An option for pediatric psychologists is to become more actively involved in tackling the problems created by the insurance monopoly through legislation and the court system. Unfortunately such legal approaches provide only slow and incremental changes. For example, despite the excitement over the recent Supreme Court decision upholding Kentucky's "any willing provider" law (which forces HMOs and other health care networks to allow their policyholders to seek services from any doctor, hospital, or other provider who agrees to the HMO's terms), questions have been raised as to the practical effect this decision will have on the current health care system (Walsh, 2003). Nonetheless, a long-term approach, which requires perseverance and patience in the face of powerful lobbies, may ultimately prevail and alter the developmental course of managed care arrangements. Because of the implications for the future of pediatric psychology, the resources used to create these changes may be a particularly good investment.
Additionally, it should be remembered that some of the financing difficulties arise not because of managed care, but because of the nature of clinical practice in pediatric psychology. Managed care reimbursement plans do not cover many of the specialty services that pediatric psychologists are trained to provide (i.e., consultation and interdisciplinary collaboration), but neither does (or did) the alternative, i.e., fee-for-service, which also rewards only direct clinical hours. Many such "ancillary" services were often covered through distributed funds from other hospital resources.
While the rise of managed care has constrained how much and how pediatric psychologists work and has caused many pediatric psychologists to complain about the changes, the current managed care insurance system has also induced pediatric psychologists to develop better, more efficient treatments—in effect, distilling treatments. The Empirically Supported Treatment (EST) movement (e.g., Holden, Deichmann, & Levy, 1999) has been heralded as a remarkable advancement for the field (Kazdin, 1997). Without the need created by managed care, the treatment-efficacy literature base may not have expanded so rapidly during the last decade, although it would be difficult to disentangle causes. In fact, the mental health experts in the European Union have begun to look at the American-based EST movement as a model of good treatment outcomes research. Additionally, it can be argued that managed care has allowed more people (from a wider range of socioeconomic statuses) to utilize mental health services. The shift has been to provide few services to many more people rather than many services to a few people.
The effect of these shifts on patient care and quality of services has not been well studied, often because of the methodological difficulties of self-selection of service providers and the wide varieties of diagnoses served (Roberts & Hurley, 1997). Despite the obvious fact that providing fewer services or sessions does not meet the needs of the more severely mentally ill or of those families experiencing numerous stressors (i.e., divorcing parents with a chronically ill child and another child whose acting-out behaviors are interfering with academic functioning), the available research suggests that overall, mental health outcomes do not differ significantly for clients using HMO plans and those using fee-for-service (Sanchez & Turner, 2003). In fact, perhaps it is a myth that long-term therapies are what clients prefer and would seek out if given the opportunity. For example, in an analysis of a pediatric psychology outpatient clinic, the majority of clients attended only one session, reporting high satisfaction with this visit (Sobel, Roberts, Rayfield, Barnard, & Rapoff, 2001).
Accomplishments of Pediatric Psychology
Researchers and clinicians should reflect on the history of pediatric psychology and give themselves credit for what has been accomplished in just a few short decades (and, interestingly, William Rae should be credited for early work in this area). At its beginning, for example, the field spent a lot of energy focused on teaching doctors and hospital administrators the necessity for child- and family-friendly hospital practices. Just 30 years ago, pediatric psychologists were fighting to allow more than 2 hours of parental visitation and to humanize hospitals (Ack, 1974/1993; Roberts, 1993). Getting the medical field to recognize that infants experience pain was another early battle (Franck, Greenberg, & Stevens, 2000). The field has clearly moved far beyond these issues, and a solid literature on hospital environment and pediatric pain, both medical and psychological, now exists. Additionally, Rae (this issue) bemoans the fact that pediatric psychologists are often forced to search out grants to maintain their salaries. However, these grants were not available in the past, and the inclusion of pediatric psychology in grant portfolios is a major step toward recognition of the potential scientific and clinical impact of the field.
Pediatric psychology continues to transform itself, as do other health care fields. Dentistry, for example, was established to treat tooth decay. Now with more focus on prevention and public health, the field of general dentistry has become primarily a provider of patient education and early intervention. Additionally, as the basic science of dentistry became more solid, dentistry branched into new fields such as orthodontics, cosmetic dentistry, and advanced periodontics. Similarly, the groundbreaking clinical work of the first pediatric psychologists is so accepted and well established that some of these activities are now done by social workers, nurses, and even paraprofessionals (e.g., hospital preparation). Child-friendly changes have been made in general hospitals, and training in psychosocial care is an essential component of medical school training. All 10 of the top 10 children's hospitals recognized by Child Magazine (Sangiorgio, 2003) have psychologists on staff, demonstrating the recognition that psychologists are an important component of "best care practices." Thus, although some activities of the pediatric psychology field are changing, pediatric psychologists should celebrate the accomplishments and take advantage of opportunities and change to look for new ways to expand the reach of the field.
A Bright Future?
Because the profitability of health insurance companies is more dependent on medical/surgical outcomes than quality of life or mental health outcomes, we believe that the future of mental health care depends on the ability of clinicians and researchers to challenge, through research, the mind/body dualism that seemingly pervades conceptualizations of health care held by MCOs. In fact, research linking positive mental health outcomes and reduced health care utilization has led several insurance companies to move in the direction of integrating psychologists into primary care settings (Sanchez & Turner, 2003).
Pediatric psychologists are well situated to provide research linking physical health to mental health. Pediatric psychology developed as a system-integrated profession, and pediatric psychologists have worked in integrated systems for the last several decades. Additionally, by continuing to refine research methodologies to examine the link between psychological and medical functioning, pediatric psychologists can become valuable links between health insurance companies and traditional, office-based clinical psychologists. Thus, instead of being pushed out by managed care, pediatric psychologists may soon find themselves experts in the future of competent and high-quality health care.
So, instead of disclaiming that we have entered a Depression era of our profession, we offer the more optimistic and hopeful song of Annie, the Depression-era moppet who was the embodiment of seeking a brighter future despite current setbacks: "The sun'll come out tomorrow."
Received June 27, 2003; revision received July 30, 2003; accepted August 12, 2003
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