Journal of Pediatric Psychology, Vol. 29, No. 1, 2004, pp. 61-63
© 2004 Society of Pediatric Psychology; all rights reserved
Commentary: We Can Make Our Own Dime or Two, Help Children and Their Families, and Advance Science While Doing So
Rainbow Babies and Children's Hospital and Case Western Reserve University School of Medicine
All correspondence concerning this article should be addressed to Dennis Drotar, PhD, Division of Behavioral Pediatrics and Psychology, Rainbow Babies and Children's Hospital, 11100 Euclid Avenue, Mather 230, Cleveland, Ohio 44106-6038. E-mail: dxd3{at}po.cwru.edu.
Rae (this issue) has called our attention to a critical and daunting set of issues that face pediatric psychologists and the children and families with whom they work: the financing of pediatric psychology services in a managed care environment. This commentary extends relevant discussion to consider the following issues: (1) strategies for economic survival and program development in a managed care environment, and (2) implications for the future of pediatric psychology, including training.
Strategies for Economic Survival and Program Development in a Managed Care Environment
Strategies for Income Generation
I share Rae's confidence that despite the challenges of managed care, pediatric psychology will survive, if not flourish, but not without extraordinary work and innovation. Perhaps at no time in the history of pediatric psychology has the entrepreneurial spirit of the field's founders, such as Salk (1970)
and Wright (1967), been more needed than it is now. But to what directions should such entrepreneurial energies be put? Rae (this issue) has outlined some excellent suggestions, and I present some others here. As shown in Table I, it may be useful to consider a broad-based strategy for income generation to include the full range (clinical care, research, and teaching) of activities that are conducted by pediatric psychologists in academic health centers and other settings.
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For example, with respect to clinical care, it is sometimes possible to negotiate with managed care companies and appeal decisions in order to provide greater coverage for specialized psychological services for medically involved children under different fiscal arrangements, such as under medical benefits. Such efforts are more likely to be successful if supported by data concerning efficacy and/or consumer satisfaction (Drotar & Zagorski, 2001
).
Another strategy for funding is to develop contracts with schools to provide specialized services (e.g., behavioral management of children with complex problems such as autism spectrum disorders [Drotar, Palermo, & Barry, 2003] or attention deficit hyperactivity disorder [Evans et al., 2003]). Pediatric psychologists also need to assume initiative in securing support from foundations and private donors, some of whom may be very interested in helping to fund innovative services for children (e.g., the Lance Armstrong Foundation's support for programs for cancer survivors).
Yet another option is to negotiate with hospitals to subsidize a component of the services that are provided by pediatric psychologists. Rae (this issue) likened such appeals to potentially demeaning requests for charitable donations. However, consider an alternative view of such requests: Many pediatric hospitals provide services such as medical care to indigent families or parent education and support programs that are regarded as essential to the mission of the hospital but are not fiscally self-sustaining. To the extent that hospital leadership considers such programs essential, they may be moved to assume some of the responsibility to find a way to pay for them through private donations, etc. I would argue that pediatric psychologists should advocate for funding for some (not all) of their services (e.g., participation in programs for children with chronic conditions) that are deemed essential to the mission of hospitals, including children's hospitals, but cannot be subsidized by fees for clinical service.
Other relevant sources of income generation include grants for teaching and training, including institutional grants for predoctoral and postdoctoral training. While training grant funds generally do not support faculty or staff salaries, they can enhance the overall fiscal health of pediatric psychology departments by funding talented, energetic students and fellows who make significant contributions through service provision and/or research. In this regard, it is instructive to note that one third of the clinical training in graduate psychology education programs in the first federally funded training program devoted exclusively to psychology (Title VII of the Public Health Service Act) focused in some way on the delivery of pediatric psychology services (Murray, 2003).
Finally, research funding can enhance the development of pediatric psychology services in creative ways, such as by providing resources to develop and evaluate innovative interventions (e.g., to promote adherence to treatment in children with chronic health conditions) and by funding staff to conduct them. Depending on specific institutional policies for recovery of indirect costs, research grants can also be used to develop research programs, including research on service delivery.
Strategies for Advocacy to Enhance Reimbursement of Pediatric Psychology Services
Ideally, strategies for income generation should go hand in hand with advocacy efforts to change policies concerning reimbursement, some of which are shown in Table I. Rae (this issue) underscored the American Psychological Association's efforts in developing new codes to promote reimbursement (Foxhall, 2000). In addition, a comprehensive advocacy agenda also might include parity of reimbursement for mental health services and, dare I mention it, health care reform (which may be a way off, though some hearts continue to beat with hope) (Newman, 2003), as well as funding for training and research.
Over and beyond advocacy at the national level, strategies to advocate for reimbursement of services should occur locally with department heads and administrators to educate them concerning the importance and relevance of pediatric psychology services. It is a sad but true reality that many hospital administrators and pediatricians in positions of authority still do not know very much about what pediatric psychologists do, let alone their special skills. For this reason, as Rae suggests, we need to educate hospital administrators and pediatric colleagues as to the human worth, potential cost-offset value, and contributions of pediatric psychology services, including how they can conserve physicians' time and emotional energies in dealing with such troubling problems as noncompliance with treatment regimens for chronic physical illness.
Finally, advocacy efforts should also be extended to managed care companies to document the value with respect to consumer satisfaction and efficacy of pediatric psychology services. In general, efforts are most effective if tied to departmental and hospital-wide negotiations for insurance contracts, which is possible in some but not all settings.
Implications for Training and the Future of the Field of Pediatric Psychology
One area that has sometimes been neglected in the mobilization of pediatric psychologists' response to the managed care revolution is that of the implications for training future generations of pediatric psychologists. To the extent that mentors are engaged in "survival mode" strategies, they may not have much surplus energy to devote to educating trainees concerning the most effective strategies to manage managed care (Roberts & Hurley, 1997). But students and fellows need our support to develop and sustain their careers in the current fiscal climate. Pediatric psychologists are now entering the field at a time when managed care has hit with full force. To my mind, this is both an advantage and a disadvantage: One obvious disadvantage is that our trainees will never know the halcyon, pre–managed care days when many psychologists roamed free in a field of dreams of liberal reimbursement for their services. But let's get real, it is 2003.
On the other hand, one salient advantage is that current students and fellows will now have the opportunity to be trained to be much better prepared than their mentors were to deal with the realities of managed care and learn effective strategies to ensure the fiscal viability of their services, training, and research programs. But this is by no means an easy task, and the anxieties of future pediatric psychologists are palpable. For example, I ask all incoming graduate students to pose questions about the future of our field. In recent years, prospective students' questions have reflected their concerns about the potential survival (not the growth) of the field in the current fiscal climate, such as: "Will I have a job after I'm finished with graduate school?" "Aren't job opportunities shrinking in response to managed care?" "How can I possibly practice what I am going to be trained to do in this program when I can't be reimbursed for it?" (ouch!); "Will pediatric psychology survive in the current economic climate?" (double ouch!)
So what do we say to the future generation of pediatric psychologists who pose such penetrating yet troubling questions? Do we say: "The future is so bright you will have to wear shades"? (this is probably too optimistic a message), or: "At least pediatric psychology will do a little better in the near future than most Internet companies, Enron, and Martha Stewart"? (this is not especially inspiring). Clearly, there are no easy answers to our students' and fellows' penetrating questions about the future of the field of pediatric psychology. Nevertheless, mentors have both the opportunities and the responsibility to model effective entrepreneurial strategies to generate funds for the economic survival of pediatric psychology and to provide comprehensive models of training in research, clinical care, and teaching that have helped to develop the field to where it is today (Spirito et al., 2003).
But what is my answer to the question, Will pediatric psychology survive the current managed care environment? It is an emphatic Yes. Why am I so optimistic? One reason is that the professional activities and collective vision of pediatric psychologists are not now and have never been defined by the limits of managed care. We have a broader professional mission, which is to provide effective services to children and families, develop science, and train the next generation of professionals, in close collaboration with our pediatric colleagues.
A second reason for my optimism relates to the extraordinary talent and professional commitment in our ranks and the outstanding students who are waiting in the wings. Will this work be easy? No; but then again, it never has been. With the inspiration of those who helped to found pediatric psychology (Salk, 1970; Wright, 1967), we will also need to be both creative and enterprising in developing and sustaining funding for our work and in advocating for the needs of children and their families.
Received April 14, 2003; accepted April 15, 2003
References
Drotar, D., Palermo, T., & Barry, C. (2003). Collaboration with schools: Models and methods in pediatric psychology and pediatrics. In R. Brown (Ed.), Handbook of pediatric psychology in school settings (pp. 21–36). Mahwah, NJ: Lawrence Erlbaum Associates.
Drotar, D., & Zagorski, L. (2001). Providing psychological services in pediatric settings in an era of managed care: Challenges and opportunities. In J. N. Hughes, A. La Greca, & J. C. Conoley (Eds.), Handbook of psychological services for children and adolescents (pp. 89–107). New York: Oxford University Press.
Evans, S. W., Glass-Siegel, M., Frank, A., van Treuven, R., & Lever, N. A., et al. (2003). Overcoming the challenges of funding school mental health programs. In M. D. Weist, S. W. Evans, & N. A. Lever (Eds.), Handbook of school mental health:Advancing practice and research (pp. 73–86). New York: Kluwer Academic/Plenum.
Foxhall, K. (2000). New CPT codes will recognize psychologists' work with physical health problems. Monitor on Psychology, 31, 46-47.
Murray, B. (2003). Graduate training grant winners. Monitor on Psychology, 34, 74-77.
Newman, R. (2003). New congress, old health care problems. Monitor on Psychology, 34, 23.
Roberts, M. C., & Hurley, L. K. (1997). Managing managed care. New York: Plenum.
Salk, L. (1970). Psychologist in a pediatric setting. Professional Psychology, 1, 395-396.[CrossRef]
Spirito, A., Brown, T., D'Angelo, E., Delameter, A., Rodrigue, J., & Siegel, L. (2003). Society of Pediatric Psychology Task Force Report: Recommendations for the training of pediatric psychologists. Journal of Pediatric Psychology, 28, 85-98.
Wright, L. (1967). The pediatric psychologist: A role model. American Psychologist, 22, 323-325.[Medline]
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