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THE IMPACT OF MANAGED CARE ON
CAREER SATISFACTION AMONG PSYCHOLOCISTS

By

Brooke Livingston Stevens

A DISSERTATION
Submitted to
Michigan State University

in partial fulfillment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY

Department of Counseling Psychology

1997

ABSTRACT

THE IMPACT OF MANAGED CARE ON
CAREER SATISFACTION AMONG PSYCHOLOGISTS

BY

Brooke Livingston Stevens

Managed care and third party payors have brought about substantial changes in
the delivery of psychological services. This study examined the relationship between
managed care or third party payor variables and career satisfaction among
psychologists.

A measure of career satisfaction and a survey addressing the practice of
psychology were mailed to 700 randomly selected practitioners from the general
membership of the American Psychological Association, of which 155 were returned
and completed.

The results indicated that psychologists have an average level of career
satisfaction. Compared with prior research using a similar sample pool, the results
suggest a downward trend in career satisfaction among practitioners. The study
identified six demographic variables related to General Satisfaction on the Minnesota
Satisfaction Questionnaire: gender, family income, percentage of white collar clients,

worktime performing non-reimbursable tasks, worktime involved in utilization review,

and work setting. In addition, the study also found that General Satisfaction was
significantly related to six predictor variables: reporting family or couples therapy as
individual treatment; selecting a treatment approach to conform with third party
reimbursement guidelines; third party payors’ influence over treatment decisions; third
party payors impact on the treatment relationship; the availability of case managers;
and the Iicensure status of utilization review personnel.

The data supported the conclusion that increased involvement with managed
care was associated with a decrease in General Satisfaction. The study also found that
Intrinsic Satisfaction was significantly higher than Extrinsic Satisfaction among the

psychologists in the survey.

ACKNOWLEDGMENTS

As with all successful endeavors, this project has many parents. I would
especially like to recognize the following individuals, without whom this journey
would not have been completed:

Dr. Nancy Crewe, her guidance and unwavering support, and for helping me
in my hour of need; Dr. Robbie Steward, for the original idea, and for her warm spirit
and understanding; Dr. Betsy Becker, for her leadership in navigating the shoals of
statistical analysis, and staying with the project when the topic changed; Dr. Donald
Stanton, for his insight into the realities of managed care practice, and for his
flexibility; Dr. Louis Primavera, for his patient tutorial in the basics of applied statistics,
and for his generosity; Dr. Karen Strom, for her kind permission to use her dissertation
research in developing the Practice of Psychology Study instrument; and Bob
Ewbanks, for his steadfast friendship and moral support.

And finally, to my wife, Leslie: without whom this project would never have
been started or finished, for your perspective and balance, for your patient support

and inspiration, thank you with all my heart.

TABLE OF CONTENTS

List of Tables viii
List of Figures x
Introduction 1
Summary
Statement of the Problem 9
Chapter 1 Literature Review
Health Maintenance Organizations
Historical Background 1 0
Current HMO trends
HMOs and the Profit Motive 12
HMOs and Cost Containment 12
Managed Care
Historical background 1 3
Managed Care Strategies
Reducing the Cost of Services 1 7
Reducing the Utilization of Services 18
Limiting access to treatment 18
Limiting treatment 1 9
Problems with Managed Care
Conflicts of Interest ' 20
Limiting Access to Treatment 21
Gatekeepers 21
Benefit Plan Design 22
Limiting Treatment
Restricted levels of care 23
Session limits 23
Limiting treatment modalities 24
Quality of Care 25
Utilization Review
Background 27
Procedure 28

Chapter 2

Chapter 3

Problems with Utilization Review
Quality of Care
Lack of Cost Effectiveness
Conflict of Interest
Lack of Clear Criteria
Ethical Conflicts
Utilization Review and Psychologists
Career Satisfaction
Theoretical Foundation
HMOs and Career Satisfaction
HMOs and Burnout
Managed Care and Career Satisfaction
Managed Care and Burnout
Summary

Methodology

Hypotheses
Subjects
Instrumentation
Career Satisfaction
Predictor Variables
Operationalizing Key Concepts
Procedure
Data Analysis

Results

Description of the Sample
Representative Characteristics of the Sample
Demographic Information
Third Party Payors and Managed Care
Interactions with Third Party Payors
and Managed Care
Communications
Personnel
Influence over Clinical Decisions
Ethics
Overall Impact of Managed Care
Satisfaction with Managed Care
Career Satisfaction
Hypothesis Testing
Research Hypothesis #1
Research Hypothesis #2
Research Hypothesis #3

vi

28
29
31
32
33

35
41
42
43
44
44

46
46

47
49
52
53
54

56
56
57
62

64
66
68
71
75
75
77

82
83

Research Hypothesis #4
Testing of Theoretical Constructs

Chapter 4 Discussion
Conclusions
Career Satisfaction
Gender and Career Satisfaction
Theory of Work Adjustment
Limitations
Implications
Directions for Future Research
Potential Avenues of Change
Legislative Initiatives
Judicial Initiatives
Proactive Participation
Ethics
Education

Appendices

Appendix A
Glossary

Appendix B
Sample of Study on the Practice of Psychology
Questionnaire

Appendix C
Item Key: Sample of Study on the Practice of
Psychology Questionnaire

Appendix D
Sample Letter to Study Subjects

Appendix E
Accounted for Variance in MSQ General
Satisfaction after Controlling for Demographic
Variables

List of References

vii

85
93

94

100
102
104

109
110
111
112
112

113
114

116

118

131

132

133

136

LIST OF TABLES

Table 1: Work Time and Activities

Table 2: Average Caseload

Table 3: Type of Clients in Caseload

Table 4: Practice Location

Table 5: Fee Structure

Table 6: Total Family Income

Table 7: Third Party Payors and Treatment

Table 8: Third Party Impact on Demand for Services

Table 9: Practitioner Reliance on Third Party Referrals

Table 10:
Table 11 :
Table 12:
Table 13:
Table 14:
Table 15:
Table 16:
Table 17:
Table 18:
Table 19:
Table 20:
Table 21:
Table 22:
Table 23:

Case Manager Availability

Time Required for Messages to be Returned

Time Required for Authorization of Treatment

Time Required for Emergency Authorization
Professionalism of Managed Care Personnel

Licensure Status of UR Personnel

Case Manager Collaboration with Practitioners
Experience with Reauthorization

Utilization Review Criteria

Perceived Practitioner Control Over Treatment Decisions
Managed Care Influence over Treatment

Average Sessions Requested and Authorized

Third Party Impact on Treatment Relationships and Quality

Incidence Rate of Ethical Dilemmas

viii

58
59
59
60
61
62
63
64
64
65
65
66
66
67
67
68
68
68
69
7O
70
71
72

Table 24:
Table 25:
Table 26:
Table 27:
Table 28:
Table 29:
Table 30:
Table 31:
Table 32:
Table 33:
Table 34:
Table 35:

Table 36:

Table 37:

Acceptance of Third Party Funds and Treatment Dilemmas
Reactions to the Occurrence of Ethical Dilemmas

Role of the Therapist

Peer Review and Confidentiality

Overall Impact of Managed Care

Overall Satisfaction with Managed Care

Satisfaction with Managed Care

Minnesota Satisfaction Questionnaire Scores

Managed Care Involvement and Career Satisfaction
t-test for Paired Samples

Demographic Variables Related to General Satisfaction
Third Party Payor and Managed Care Variables
Related to Career Satisfaction

Variance Accounted for by Third Party Payor and
Managed Care Variables

Theory of Work Adjustment

72
73
74
74

.75

76
77
79
81
82

9O

92
93

Figure 1: Work Settings

LIST OF FIGURES

6O

INTRODUCTION

Over the last five years, a new technology has transformed the practice of
psychology (Bloom, 1990; Kiesler & Morton, 1988; Zimet, 1989). The innovation that
revolutionized mental health care originated in the medical field in the early part of
the 1980’s. This new development did not emerge from any scientific or theoretical
framework, but rather from the world of finance. The new technology that changed
the delivery of psychological services was managed care.

Managed care is a global term, and refers to the regulation of health care
delivery by a third party, the payor, usually an insurance company or health
maintenance organization (HMO). At the heart of managed care are two core
technologies: utilization review and selective contracting (England & Vaccaro, 1991).
What makes these two practices so powerful is that they are prospective and
prescriptive in nature: they determine what types of treatment the patient will receive.

The net effect of these innovations cannot be underestimated, for they have
changed the hierarchy of the health care environment. In the traditional model, the
practitioner wielded considerable power, both in assessing the patient and in carrying
out the treatment. In the new managed care environment, the power has shifted away

from the practitioner, who provides the services, to the party that pays for those

2
services. This fundamental change, from a practitioner-oriented model to one

dominated by a third party, has sparked enormous debate over who should determine
treatment strategy: those who deliver services, or those who pay for them (Kiesler &
Morton, 1988).

The resolution of this debate will have enormous consequences for
psychologists, and for the practice of psychotherapy. The provision of psychological
services continues to be the primary professional activity of most psychologists
(American Psychological Association, 1996). Norcross, Prochaska, & Farber (1993)
reported that APA Division 29 members devote 72% of their professional time to
providing psychotherapy. Because psychologists spend most of their professional time
providing psychotherapy, any force that dictates how therapeutic services are
delivered will also have a profound impact on practitioners.

By any standard, managed care has changed the way psychologists conduct
their business. In 1983, 89% of the members of Division 29 were involved in fee-for-
service private practice (Norcross & Prochaska, 1983). Seven years later, the
percentage remained largely unchanged. In his survey of licensed psychologists in New
Jersey, Moldawsky (1990) found that more than 87% of the respondents were in solo
practice. These proportions changed drastically over the next six years, as managed
care plans became the predominant health care delivery system (Austad & Sherman,
1992). Because mental health benefits were included as part of a standard package of

health benefits, most individuals received therapy services in a managed care system

3
(Austad & Sherman, 1992). As the number of individuals covered by managed care

plans increased exponentially, HMOs began to recruit providers from outside of their
own mental health systems to deliver those services. By 1991, 75% of HMOs used
private practitioners to provide mental health services (DeLeon, VandenBos, &
Bulatao, 1991). The trend continued over the next two years: Norcross, Prochaska,
and Farber (1993) found that only 65% of the psychologists engaged in private
practice, down from 89% in 1983. Currently, fewer than 30% of psychologists licensed
less than three years are in private practice (APA, 1996a), which represents a 60%
decrease in only thirteen years.

As more psychologists worked for managed care companies, the portion of
their income that was derived from third parties also increased dramatically.
Moldawsky (1990) reported that 90% of the psychologists in New Jersey were not
associated with a Preferred Provider Organization (PPO), and 92% received no
referrals, or less than 5% of referrals, from HMOs. Less than two years later, Bowers
and Knapp (1993) found that 64% of the private practice psychologists in their study
accepted third party reimbursement, and the majority indicated that 80% or more of
their patients had third party coverage. Nick Cummings, a former president of the
American Psychological Association, estimated that 93% of the cases seen by licensed
psychologists involve third party payments (1992, in Sinnet and Holden, 1993).

As caseloads of managed care clients increase, psychologists have found that

new administrative responsibilities consume their professional time. Reviewing the

4

results of a nation-wide survey conducted by the American Psychological Association
of its members who are licensed psychologists, Newman and Taylor (1996) reported
that practitioners currently spend only 43% of their time providing therapy, and now
devote 13% of their time to taking care of administrative tasks, including utilization
review and reimbursement procedures. In business terms, psychologists spend less ‘
time delivering services that earn income, and considerably more time involved in the
procedures necessary for obtaining reimbursement for those services.

How have psychologists reacted to managed care? In an early study, DeLeon,
VandenBos, and Bulatao (1991) reported that psychologists had three primary
concerns related to managed care: 1) patient access to treatment in managed care
systems; 2) the quality of care that patients received; and 3) the lack of consumer
awareness regarding the shortcomings of managed care systems. Bowers and Knapp
(1993) followed with a report on the problems psychologists encountered when
working in managed care environments. The primary complaints concerned increased
paperwork, decreased fees, and difficulty in getting on panels of approved health care
providers. The psychologists in the study also reported problems in obtaining
hospitalization for patients and reauthorization for additional treatment.

The reaction of psychologists to managed care can also be gauged by a recent
American Psychological Association (APA) survey (Burnette, 1996). The Committee for
the Advancement of Professional Practice (CAPP) of the APA Practice Directorate sent
a questionnaire to all APA members who were licensed psychologists. As part of the

survey, the respondents were asked to list their concerns related to the practice of

5
psychology. Over 15,000 members returned their surveys, and the results were

persuasive.

The top six professional concerns were all directly related to managed care.
The concerns were: 1) managed care changing clinical practice; 2) excess pre-
certification and utilization review (UR); 3) decreasing income due to managed care;
4) ethical dilemmas created by managed care; 5) fewer clients due to managed care;
and 6) exclusion from managed care panels (PPO’s). The opinions about managed
care transcended professional domains: psychologists across all settings - medical,
academic, and private practice - shared the same concerns.

In addition, the CAPP study asked psychologists to evaluate the overall impact
of managed care. Again, the results were conclusive: 80% of those surveyed indicated
that managed care had a negative impact: 25% indicated that managed care had a
highly negative impact; 37% stated that the impact was moderately negative, and 16%
indicated that the impact was slightly negative. Again, those results represented the
opinions of psychologists across all professional settings. Among the respondents,
psychologists in independent practice had the strongest reaction to managed care:
89% of the independent practitioners felt that managed care had a negative impact.

The CAPP study provides evidence that managed care has had a direct impact
on psychologists, both in terms of lost income and increased interference in clinical
practice. While it is clear that most psychologists believe that managed care has

exerted a negative influence on the practice of psychology, what has been the

6

cumulative effect of managed care on the practitioners themselves? Has managed care
changed the way that psychologists feel about their work?

Historically, psychologists have had a high rate of career satisfaction. In a 1983
study, Norcross and Prochaska found that 90% of the psychologists in independent
practice in their survey were either very satisfied or quite satisfied with their career.
When asked if they would choose psychology as a career again, 70% of the sample
indicated they would make the same decision. Walfish, Polifka, & Stenmark (1985)
asked the same question, and found that 90% of their sample would choose
psychology again. In a 1991 follow-up study, Walfish, Moritz, & Stenmark, asked
participants from their 1985 study to rate their level of career satisfaction on a Likert
scale, from 1 to 6, with 1 representing high satisfaction, and 6 indicating very
dissatisfied. The average level of career satisfaction was 2, suggesting that most
psychologists appeared to be quite satisfied with their work.

Norcross, Prochaska, and Farber (1993) have provided the most recent data on
career satisfaction among psychologists. Once again, the authors found that a majority
of the respondents would choose psychology as a career if they had to make the
decision again. Replicating the methodology of their 1983 study, a single direct item
was used to assess career satisfaction among psychologists. Although the majority of
their sample reported satisfaction with their career - 47% were very satisfied, and 36%
were quite satisfied - those results represented a 10% decrease from the initial study

ten years earlier.

7
Summary

A review of the literature on career satisfaction among psychologists suggests
that they are satisfied with their chosen careers. Although the level of satisfaction has
historically been high, there has been a considerable decline over the last ten years.
Despite the efforts of previous researchers, the overall picture of psychologists’ career
satisfaction remains incomplete. Current levels of career satisfaction are unknown.
While several studies have investigated career satisfaction among psychologists,
researchers have not taken into account the recent changes in the delivery of
psychological services. In addition, research has thus far failed to examine career
satisfaction in depth. For example, it is unclear which factors contribute to the sense of
fulfillment that psychologists derive from their work, and which factors detract from
their overall satisfaction with their careers.

The lack of accurate data on career satisfaction among psychologists presents a
problem for individuals who may be considering psychology as a career. The scope of
this problem can be inferred from the number of individuals who are involved courses
of undergraduate study in psychology. According to Clay (1996), psychology is the
most popular major among college freshmen who have chosen a major course of
study. Similarly, Murray (1996) reported that psychology continues to be the second
most popular major overall among all undergraduates, with over 66,000 degrees
granted each year. Without current research on the satisfaction that psychologists

obtain from their chosen profession, those students will not have the information that

8
they need to make an informed decision about what they might expect from a career

in psychology.

The absence of accurate information on career satisfaction among psychologists
has a number of implications for both managed care companies and practitioners. As
the cost of providing health care has leveled out among HMOs and managed care
companies, patient satisfaction has replaced price differential as the critical factor for
corporate purchasers of health insurance (Mahar, 1996). In order to compete
effectively in the future, managed care companies and HMOs will need to become
increasingly sensitive to those aspects of their business that impinge upon patient
satisfaction.

According to Bloom (1990), patient satisfaction appears to be very responsive
to the experiences that patients have with their health care providers. If low career
satisfaction leads to high turnover among psychologists on a provider panel 0r staff
HMO, the ensuing lack of continuity of care may result in decreased patient
satisfaction. Without accurate information on which aspects of their business practices
have a positive or a negative impact on psychological service providers, managed care
companies and HMOs may not be able to avoid the potential negative repercussions
of low career satisfaction among practitioners.

Finally, psychologists fill a vital role in the provision of mental health care. If
practitioners begin to leave the field as a result of low levels of career satisfaction,

mental health care may no longer be available to large segments of the population,

9

and the quality of care that patients receive may suffer when there are fewer
practitioners to handle the burden. Without accurate information on current levels of
career satisfaction, and the factors linked to that satisfaction, the profession of
psychology will be ill-equipped to identify problem areas and to initiate solutions.
Statement of the Problem

While the literature on career satisfaction among psychologists established a
frame of reference, the research has a number of shortcomings. First, all the studies
assessed career satisfaction, a complex construct, using a two or three item
questionnaire. As a result, the research has only been able to render a global picture
of career satisfaction. The studies were not designed to discriminate between intrinsic
and external sources of career satisfaction - in this case, between the fulfillment that a
practitioner obtains from providing psychotherapeutic services, and the amount that
managed care contributes to or detracts from that sense of fulfillment. So while there is
a reasonable amount of historical data on career satisfaction among psychologists,
there is no current accurate and comprehensive information, nor has there been any
research on the relationship between managed care and career satisfaction.

This study will be concerned with the following two research questions: 1) what
is the level of career satisfaction among psychologists who are engaged in delivering
psychological services? and 2) what is the relationship between managed care and

career satisfaction among psychologists?

CHAPTER 1
LITERATURE REVIEW
Health Maintenance Organizations
Histori I round

The original purpose of health maintenance organizations was to provide ‘
health care to a greater portion of the population. The HMO movement began in the
Pacific Northwest in the early 1900’s, when individual physicians were hired by
lumber and mining companies on a salaried basis to take care of the health care needs
of their employees. The first HMOs were formed thirty years later, during the
Depression, when groups of physicians began to contract with municipalities and
corporations to provide complete medical care to employees for a fixed per capita
cost per month (Bennett, 1988).

In the early years, investment capital to cover start—up costs for new HMOs
often came from organized labor or private philanthropy, and these sources imbued
the movement with a sense of idealism and positive social purpose (Bennett, 1988).
The New Deal programs of the Thirties created an environment that stressed social
reform, and these social initiatives were later championed by organized labor in the
post-war era. As unions began to insist on health insurance for employees,
corporations started to look for an organizational structure that would provide health
care to large populations. HMOs fit the need, and provided an indispensable service

where none had existed.

10

1 1
The rapid growth of HMOs can be traced to several legislative initiatives in the

60's and 70's. Operating on the principle that health care is a basic human right,
Congress passed legislation that created Medicare and Medicaid in 1965 (Kiesler &
Morton, 1988). A large portion of the population that had previously not had any
health insurance immediately enjoyed full medical coverage. The dramatic increase in
the portion of the population that was covered by government medical insurance was
inevitably followed by a surge in the percentage of the gross national product spent on
health care.

In an initial attempt to contain health care costs, the federal government turned
to HMOs as a lower cost alternative to traditional fee-for-service indemnity plans. To
promote the growth of the HMO industry, the government provided federal funding to
assist with start—up costs. In order to qualify for these subsidies, HMOs had to offer
both physical and mental health services, including outpatient mental health care and
alcohol and drug abuse treatment (DeLeon, VandenBos, & Bulatao, 1991).

In the 1970’s, a second round of legislation led to rapid growth in the HMO
industry. The 1973 HMO Act allowed profit-making companies to receive federal
financing. It was followed in 1976 by additional legislation that required corporations
with more than twenty-five employees to offer a health maintenance organization as a
health care alternative (Flinn, McMahon, & Collins, 1987).

These federal initiatives were extremely effective. In 1970, there were only 33

HMOs in the United states; by 1988, the number had grown to 659, and 62% of the

12
new HMOs were for-profit enterprises (DeLeon, VandenBos, & Bulatao, 1991). The

rapid increase in the number of HMOs had its desired collateral effect: the percentage
of the U.S. population that was served by HMOs tripled in the ’70's, and tripled again
in the ’80’s. By 1988, 33 million Americans obtained their health care through HMOs.
The growth of HMOs continued at a phenomenal rate through the end of the decade,
when 65 million Americans had their health care delivered through HMO services
(DeLeon, VandenBos, & Bulatao, 1991).
Current HMO trends

HMOs and the profit motive

A number of authors (Dorwart, 1990; Zimet, 1989) have observed that the
most important trend in HMOs is a new emphasis on competition and profit. Bennett
(1988) observed an ”increasing domination of health care by those whose primary
business is the preservation and increase of capital" (p. 1546). As HMOs shift the focus
from their original social objectives and towards a new emphasis on business, health
care has become a commodity, and individual components, such as mental health
care, have now become ”profit centers”. The move towards profitability haslbeen
pervasive: Shadle and Christianson (1988) noted that 75% of all HMOs that were less
than three years old were for-profit enterprises.
HMOs and cost containment

The second major trend in HMOs is a byproduct of the new emphasis on

profits. As profits increase in importance, HMOs have been forced to find new ways of

13
containing costs. Originally, HMOs sought to control costs by providing preventive

health care. Over time, HMOs moved away from preventive care, because it was no
longer cost effective for the insurer. Preventive care requires a capital investment,
which may not be realized if the individual moves to another part of the country, or to
another health care system (Bloom, 1990). Currently, HMOs attempt to cut costs not
through preventive care, but by restricting access to hospitalization, and by reducing
the length of hospital stays (Flinn, McMahon, 8: Collins, 1987). In practice, these are
the two basic strategies of managed care.
Managed Care
Historical Background

According to Bloom (1990), managed care was virtually unheard of in 1975.
The rise of managed care over the last twenty years can be traced to a series of
financial pressures that faced the health care industry in the 1980's. Initially, the
federal government tried to contain health care costs by promoting HMOs as an
alternative health care system. In addition to subsidizing HMOs, the federal
government also developed a reimbursement system to limit the costs of providing
services. The system consisted of prospective fixed payments for diagnosis-related
groups of illnesses (DRG's). In effect, the DRG’s worked as a ceiling: treatment
procedures would only be reimbursed at a specified rate. DRG’s were very successful
at containing costs, and eventually became an industry standard, used by both insurers

and HMOs.

14

As a result of the use of DRG's, hospitals began to lose revenue. To make up
for that lost revenue, many hospitals opened inpatient psychiatric or substance abuse
treatment facilities. This solution appealed to many institutions, because alcohol, drug,
and mental health (ADM) charges were exempted from DRG regulations (Broskowski,
1991). The strategy worked in the short term, as ADM treatment brought in needed
income.

By the end of the 1980’s, the costs of providing mental health care had
climbed dramatically. In 1988 alone, utilization of inpatient psychiatric hospital
facilities rose 37%. Overall, between 1988 and 1991, mental health care expenditures
increased at a rate of 41% per year (Cummings, 1992). As mental health care
utilization costs skyrocketed, many HMOs and third party payors perceived that
providers were acting out of their own financial self-interest, and abusing patient
health care benefits through overutilization of unnecessary services (DeLeon,
VandenBos, & Bulatao, 1991). Insurers and HMOs were once again forced to develop
a new way of cutting costs.

Case management, or managed care as it came to be known, represented a
new approach. Traditional insurance plans attempted to save costs by limiting care,
primarily through altering the design of their health care benefit package. Under this
strategy, the cost of providing health care is limited to specific dollar amounts, either
through annual or lifetime caps, or through the use of DRG’s (Dworkin & Hirsch,

1994). While many managed mental health care organizations (MMHCOs) also rely

1 S
on benefit design to limit care and thereby reduce costs, managed care is based on a

different principle: the direct intervention of a representative of the payor in the
provision of health care services. Using protocols or their own judgment, case
managers make decisions about what types of care, if any, will be reimbursed, and at
what rate.

Managed care is currently the primary means used to control health care costs
(Lowman, 1991; Newman & Bricklin, 1990). By 1991, less than three years after it was
introduced, over 70% of inpatient psychiatric care was delivered in managed care
systems, and over 30% of all employers used special managed mental health care
networks (England & Vaccaro, 1991). Cummings (1992) reported that managed care
was growing at a rate of 25% per year, and that over 52 million Americans were
receiving their health care from managed care systems.

The benefits of managed care are not limited to its potential to cut costs. Many
professionals believe that managed care patients receive better health care than those
individuals who are involved with more traditional delivery systems. England and
Vaccaro (1991) outlined some of the advantages of managed care. They noted that
fee-for-service plans often resulted in overuse of hospitalization. As a result, many
health care purchasers came to believe that psychiatrists were operating in their own
self-interest. Managed care systems have sought to restore purchaser confidence by
reducing unnecessary hospitalization, and referring patients to less costly but equally

effective treatment alternatives. Instead of limiting benefits to inpatient hospitalization,

16

clinicians can choose the appropriate level of treatment from a wide variety of options,
including partial hospitalization, residential care, and day or evening treatment
programs.

England and Vaccaro also observed that insurers and third party payors often
purchased mental health care services without knowing what constituted effective .
clinical care. Without accurate information, purchasers could not be sure that their
clients were receiving quality care from competent mental health care professionals.
Managed care companies have attempted to improve patient care by developing
protocols that match specific patient problems with appropriate clinical interventions,
and by mandating specific minimum levels of credentials for approved providers
(England and Vaccaro, 1991).

Panzarino and Wetherbee (1990) argued that case management can result in a
more effective integration of services. Case managers are involved with a referral from
the time of the initial complaint. After making an referral to the appropriate level of
care, the case manager maintains contact with the provider, and monitors the patient’s
progress. After each phase of treatment, the case manager continues to coordinate
mental health services, making sure that the patient receives referrals for the

appropriate level of aftercare.

1 7
Managed Care Strategies

Reducing the Cost of Services

Managed care systems use two basic approaches to containing costs: reducing
the cost of services, and reducing utilization of those services. ‘Managed care
companies save money by negotiating fee-for-service contracts with a group of
preferred providers, who agree to discount their services in return for a steady source
of referrals (Broskowski, 1991). Under the prevailing industry standard, third party
payors reimburse providers for 50% of their fee - that is, if a psychologist charges $80
per hour, the third party pays $40 (Zimet, 1989). In addition, virtually all HMOs and
MMHCOs reduce the price of services by using prospective fixed payments for
diagnostic-related groups (DRG’s). Finally, managed care companies often lower the
price of services through the process of claims review, in which services that have
already been delivered are subject to re-examination (Broskowski, 1991).

HMOs also attempt to reduce the cost of services by providing a limited range
of benefits to a clearly defined set of covered individuals (Haas & Cummings, 1991).
Using this approach, HMOs and managed care systems offer coverage for less
expensive, but equally effective, treatment alternatives. For example, most third party
payors now refer substance abuse patients to a hospital for a 5 day inpatient
detoxification, followed by outpatient treatment, as opposed to a 28 day inpatient stay

(Broskowski, 1991).

1 8
Reducing the Utilization of Services

Managed care systems and HMOs have developed a variety of ways to save
costs by reducing the amount of services used by beneficiaries. These mechanisms
include pre-treatment authorization, benefit plan design, session limits, and utilization
review. According to Panzarino and Wetherbee (1990), ”taken separately, each step
can be an effective tool for decreasing utilization”.

Limiting access to treatment

Limiting access to treatment is the primary cost cutting strategy used by
managed care systems (Haas & Cummings, 1991; Hannigan-Farley, 1992). Most
MMHCOs and HMOs require patients to obtain pre-treatment authorization before
they receive services (Dworkin & Hirsch, 1994). Shadle and Christianson (1988)
reported that 75% of HMOs require a referral from a primary care physician, or
”gatekeeper", for mental health care. In particular, managed care systems rely on
prospective control systems to regulate patient access to inpatient treatment (Lowman,
1991; Panzarino & Wetherbee, 1990).

Many HMOs and MMHCOs also rely on benefit plan design to limit access to
treatment. Benefit plan strategies for limiting access include diagnostic exclusions,
copayments and deductibles, and the use of preferred providers.

Patients who have chronic mental illness consume 43% of the total cost of
direct mental health care. As a result, many managed care companies attempt to

reduce their financial exposure through the use of diagnostic exclusions, which

19

prevent those patients from entering the health care system (Haas & Cummings,
1991). In addition to diagnostic exclusions, HMOs and managed care systems rely on
deductibles and copayments to limit patient access to treatment. Finally, most HMOs
and MMHCOs attempt to limit access by providing financial incentives or constraints
to receive services from a specified set of preferred providers, who are selected on the
basis of their efficiency (Dworkin & Hirsch, 1994; Panzarino & Wetherbee, 1990;
Richardson & Austad, 1991).
Limiting treatment

Limiting the type or amount of treatment that a patient can receive is another
way of reducing utilization of services. Most HMOs and managed care systems rely on
concurrent utilization review to limit patient care (Dworkin & Hirsch, 1994; Panzarino
& Wetherbee, 1990). In concurrent utilization review, case managers monitor a
patient's progress through periodic reports by the provider. After a pre-determined
number of sessions, the provider applies to the managed care system for re-
authorization. The case manager will examine the report using a set of criteria, and
make a decision regarding the patient’s treatment. If the case manager concludes that
the patient is not benefiting from treatment, or that the provider is not using an
effective treatment plan, additional sessions will not be granted, thereby limiting
treatment.

Almost all HMOs and managed care systems use session limits as a means of

reducing the utilization of services. The HMO Act of 1973 required HMOs to provide

20

a minimum mental health benefit of 20 sessions per year of outpatient psychotherapy
(Newman & Bricklin, 1990). According to Richardson and Austad (1991), that
requirement has become the industry standard: 79% of all HMOs employ a 20 session
limit.
Problems with Managed Care

Conflicts of Interest

Many fundamental problems associated with managed care stem from the
nature of HMOs, and how they differ from indemnity insurance plans. In traditional
indemnity plans, the financial risk is spread among the insured. If expenditures exceed
premiums, rates can be raised to cover the shortfall. HMOs differ in that they have
contractual relationships with purchasers, and therefore take a direct financial risk:
they stand to lose substantial amounts of money, because their income is limited for
the duration of the contract. Because they take a financial risk, HMOs have a natural
incentive to contain costs (Flinn, McMahon, & Collins, 1987). As a result, the
profitability of HMOs often hinges on providing only those services which are
absolutely necessary (Bloom, 1990; DeLeon, VandenBos, & Bulatao, 1991).

This situation gives rise to the key issue in medicine today: who defines what is
necessary? Currently, that determination is made by third party payors and managed
care systems. This practice creates an unavoidable conflict of interest (Berman, 1992),

and raises questions about how third party payors can remain impartial when they

21
stand to profit through underserving the needs of their clients (Kiesler & Morton,

1988).

The evidence suggests that most HMOs find it difficult to maintain impartiality.
Levin (1988) compared service utilization in for-profit and not-for-profit HMOs. The
results of the study revealed a significant difference in two areas: non-profit HMOs
had higher mean annual hospital utilization rates, as well as longer patient stays.
Limiting Access to Treatment

Many HMOs and MMHCOs attempt to contain costs by limiting access to
treatment (Haas & Cummings, 1991; Hannigan-Farley, 1992). Miller (1992) studied
access to treatment in both HMO and fee-for-service arrangements. The results
showed that fee-for-service plans offered increased access to treatment, and that
HMOs were associated with a decrease in patient access to medical care.

Gatekeemrs

For most patients, restricting access poses the greatest threat to the quality of
care that they receive (Panzarino & Wetherbee, 1990). Often, the required pre-
treatment authorization by a gatekeeper results in the patient being denied adequate
care (DeLeon, VandenBos, & Bulatao, 1991). Wells led a team that examined the use
of primary care physicians as gatekeepers for mental health referrals (Wells, Hays,
Bumam, Rogers, Greenfield, 8: Ware, 1989). The authors tracked depressed patients
in both fee-for-service and pre-paid settings. In the fee-for-service plans, depressed

patients were interviewed by mental health professionals, while in the pre-paid plans,

22
patients went to primary care physicians, who acted as gatekeepers for further

referrals. After their office visits, patients in both groups filled out a depression
screening instrument. Patients who exceeded the cut-off score for the screening
measure were administered the depression section of the Diagnostic Interview
Schedule, which provided an independent assessment of the presence of depression. .
The authors found that the method of payment had a significant influence on the
ability of the provider to identify the presenting problem: 86% of the patients who
consulted a mental health provider had their depression detected, compared to only
51% of those who visited primary care physicians.
Benefit plan design

Benefit plan design is another strategy HMOs and managed care systems use to
control costs. According to Miller, (1992) lbenefit design often discriminates against
individuals who come from lower socio-economic classes, especially when the benefit
package requires enrollees to cover a deductible or to make a copayment. For those
who cannot afford them, deductibles and copays serve as effective barrier to treatment;
(Kisch & Austad, 1988).

In addition, most HMOs and MMHCOs ruse diagnostic exclusions to

discriminate against patients with specific diagnoses Evidently the practice is

'J
widespread: Lange, Chandler-Guy, Forti, Foster-Mooge, and Rohman (1988) found
that 46% of the HMOs in their study used exclusionary criteria. In particular, insurers

discriminate against patients who have histories of drug or alcohol abuse, as well as

23
borderline or multiple personality disorder (Dorwart, 1990). Insurers have also

developed a complement to diagnostic exclusions, called “skimming” (Haas and
Cummings, 1991), which involves the use of specific criteria to select enrollees who
will be less likely to use health care services.
Limiting Treatment

Restricted levels of care

According to Miller (1992), ananaged care restrictions on levels of care can
prevent patients from having access to appropriate treatmenfi Many HMOs attempt to
prevent hospitalization through use of crisis intervention services and alternative
holding environments (Austad, DeStafano, & Kisch, 1988). Shadle and Christianson
(1989) noted that inpatient days had dropped 82% in the twelve year period between
1975 and 1987. The authors reported that HMOs hospitalize patients at less than half
the rate of the community as a whole, and concluded from the evidence that HMOs
discourage the use of inpatient treatment. This trend is especially strong in group
HMOs, where the increased financial risk provides an extra incentive to avoid patient
hospitalization.(Austad & Sherman, 1992).

Session limits

Originally, HMOs were required to offer a minimum mental health benefit of
20 outpatient psychotherapy sessions as a prerequisite for receiving federal subsidies.
Richardson and Austad (1991) have observed that for most HMOs and third party

payorsfininimum coverages have become maximum benefits.) According to DeLeon,

24
VandenBos, and Bulatao (1991), (most benefit packages are not designed to provide

ongoing mental health care, which can create a dilemma for practitioners with patients
who have exhausted their benefits (Strom, 1992). Under the APA Code of Ethics,
psychologists cannot abandon their patients, yet as patients exhaust their benefits,
providers can be faced with a growing portion of their caseload that is served on a pro
bono basis. Many practitioners must now choose between abandoning their patients
or going bankrupyCummings, 1986).

Rather than make provisions for continuing care for patients who have
exhausted their benefits, many HMOs and MMHCOs refer their chronic mentally ill
patients to public mental health facilities (Berman, 1992; Haas & Cummings, 1991).
Shadle and Christianson reported that in one Midwest HMO, 66% of all child
psychiatric hospitalizations were eventually transferred to publicly funded facilities.
The problem of patient dumping has been exacerbated by cuts in federal mental
health care budgets, leading some practitioners to wonder where patients will be
transferred to when publicly funded facilities close (Levin, 1988).

Limiting treatment modalities

Some HMOs and MMHCOs cut costs by placing limits on the type of treatment
that a patient can receive (Steefel, 1992). In practice, this restriction is achieved by
only reimbursing a specific range of interventions, selected from a limited constellation
of theoretical orientations (Haas & Cummings, 1991). For example, most MMHCOs

favor the use of short-term behavioral, crisis, or problem solving therapy (Austad,

25
DeStafano, & Kisch, 1988). In addition, some insurers enforce limits on the type of

treatment by restricting modalities. Patients at Kaiser Permanente, a large HMO,
receive group therapy, regardless of the presenting problem (Wright, 1992).
Qualig of gre

For many patients, negotiating their way through gatekeepers and benefit
package restrictions makes gaining access to appropriate treatment a difficult process.
Once they have been authorized to receive services, many patients are faced with a
separate set of problems. According to Newman and Bricklin (1990), ”the greatest
focus of concern stimulated by managed care has been the potential adverse impact of
financial incentives on the quality of care provided."(p. 26).

To substantiate their claim, the authors noted that 86% of mental health care
professionals believe that the quality of patient care suffers when services are delivered
through managed care systems. Miller (1992) also found that psychologists associate
HMOs with a decrease in the quality of care. Finally, Lange et al. (1988) asked
providers to rate the quality of HMO mental health services. The results revealed that
a substantial portion of the respondents felt that HMOs offered substandard care.

Most HMOs and MMHCOs use preferred providers as a means of cutting costs.
Ostensibly, using preferred providers allows third party payors to reduce expenditures
by negotiating fees with highly skilled practitioners who are selected on the basis of
their effectiveness and efficiency. In practice, referring patients to preferred providers

often means that patients receive their care from staff who have fewer credentials

26
(Austad, DeStafano, & Kisch, 1988; Bloom, 1990; Cummings, 1986; Cummings,

1988; Flinn, McMahon, & Collins, 1987). In a survey of over 30 HMOs, Lange et al.
(1988) found that less than half of the mental health care providers had a doctoral
degree.

l'The erosion of professional standards represents an additional threat to the
quality of patient care (Chipman, 1994). The CAPP study (APA, 1996) revealed that
exclusion from panels remains one of the most pressing concerns among psychologists.
The difficulty that most practitioners face in getting on provider panels makes staying
on them even more important. Without the income generated by referrals from
managed care sources, practitioners who are dropped from provider panels may be
faced with financial disaster. As a result, managed care systems can exert enormous
financial pressure on practitioners to acquiesce to a case manager’s treatment
decisions. {P/sychologists who insist on appropriate mental health services for their
patients risk being removed from provider panels, because they are not “managed
care compatible". This difficult situation is exacerbated by clauses in managed care
contracts that allow payors to terminate psychologists from panels ”without causeLj
(APA Monitor, July 1996).

Wany practitioners avoid being removed from provider panels by adopting the
system standards in place of professional ones. This shift in the standard of care can
have a significant impact on the quality and amount of treatment that a patient

receives—.jAustad, DeStefano, and Kisch (1988) state, ”the HMO practitioner values

27
minimalist therapeutic intervention" (p. 450). The authors expand on this premise, and

provide a rationalization for minimal care in HMOs:
For some therapeutic tasks to be accomplished, the therapist does not even
have to meet with the patient to have an impact. Many patients claim that they
are helped just by knowing that, if at crucial times in their lives, they were to
call, there does exist someone who knows and understands their problems.
This information is often as much comfort as the patient needs, and ironically
enough, serves as a deterrent to actual contact (p. 454).
Utilization Review
Background
Utilization review (UR) is one of the core technologies of managed care
(England & Vaccaro, 1991). According to Tischler (1990), more than 60% of
Americans with group health insurance receive health care from managed care systems
that employ utilization review. @hen it was first developed, utilization review was a
retrospective procedure, analogous to quality assurance (Tischler, 1990). The goal of
utilization review was ensure that patients obtained the appropriate level, modality,
and type of treatment (Blackwell, Gutmann, & Gutmann, 1988; Lowman, 1991).
Over time, the nature of UR has changed, in response to profit-making
pressures. The primary emphasis is now on cost containment, and utilization review
has shifted from a retrospective process to a prospective procedure (Lowman, 1991;

Sharfstein, 1990). Currently, utilization review is defined as:

28
A set of techniques used by or on behalf of purchasers of health benefits to

manage health care costs by influencing patient care decision making through

case by case assessment of the appropriateness of care prior to its provision.

(Institute of Medicine, 1989, in Sharfstein, 1990, p. 965:1
121031113

In utilization review, case managers make decisions by comparing
documentation submitted by providers to a pre-established set of criteria (Tischler,
1990). Before they authorize treatment, managers consider patient diagnoses, as well
as provider treatment and aftercare plans. In addition to approving treatment, case
managers make a number of other decisions. Upon review, a manager may decide to
deny coverage for a mental illness, on the basis of an exclusionary diagnosis. Similarly,
a manager may disapprove a request for inpatient hospitalization, and recommend
that a patient be referred to a lower level alternative. Finally, a manager may decide to
terminate a patient’s treatment, on the grounds that it is no longer warranted by
medical necessity.
Problems with Utilization Review

Quality of Care

Hoyt (1992a) observed that there is a difference between quality assurance,
which is devoted to evaluating the care a patient receives, and utilization review,
which is concerned with containing costs. Sharfstein (1990) reported on the results of

an extensive study commissioned by the Institute of Medicine, which investigated the

29
impact of utilization review on the quality of patient care. The study found that there

was no evidence that supported the use of utilization review as a means of ensuring
that patients receive appropriate care. Tischler (1990) concurred, noting that research
has only addressed the effectiveness of utilization review in reducing the length of
inpatient hospitalization, and that there has been no documentation of the
appropriateness, adequacy, or effectiveness of utilization review treatment decisionsj

q-jlowever, part of the difficulty in assessing the impact of managed care and
utilization review on the quality of care comes from a lack of clear standards. The
absence of any clear definition of quality care has prevented researchers from
developing any objective measures of quality care. Without any objective criterion,
discussions of the impact of utilization review on the quality of care remain
speculatin
Lack of Cost Effectiveness

During the 1980's, hospitals turned to mental health care as a way of making
up revenue lost to DRG's. As more and more patients used inpatient psychiatric or
ADM services, mental health care costs rose from 4% to more than 11% of total
medical expenditures. Of particular concern to insurers was the large proportion of
total mental health expenditures that was devoted to treating the small percentage of
patients who used a disproportionate amount of services. According to Zook and
Moore (1980), half of all health care resources are consumed by high cost users, who

constitute only 13% of the population. Utilization review was designed to contain the

30

financial risk associated with providing services to those chronic or severely distressed
patients.

(The application of utilization review procedures in outpatient settings is based
on the premise that outpatient mental health care patients tend to overuse services.
Consequently, the profitability of utilization review lies in the difference between the
cost of performing utilization review and the savings that accrue from preventing the
overuse of servicesj

lUsing data gathered by the APA (1994), Michaelson (1993) came to the
conclusion that utilization review was not cost effective in outpatient settings].
According to the National Medical Care Utilization and Expenditure Study, mental
health patients comprise only 4.3 % of the total amount of medical care users in 1984
(Taube, Goldman, Burns, & Kessler, 1988). Contrary to the expectation that mental
health care patients tend to overuse services, the median number of therapy sessions
was two. Kisch (1992) also provided evidence that most patients use mental health
care conservatively, noting that only 38% of the patients in his study used more than
five therapy sessions, and that only 4.3% used more than 30 sessionslBecausc—i high
psychological service utilization is not widespread, even in the absence of case
management, utilization review has not proved to be cost effective1

Blackwell, Gutmann, and Gutmann (1988) also studied outpatient
psychological service utilization rates, comparing patients in a pre-paid plan that

employed utilization review with patients in a fee-for-service plan that offered

31
unlimited access to treatment. The authors reported that fee-for-service and pre—paid

patients did not differ in service utilization. In both groups, patients had an average of
six sessions, and 78% of the patients completed treatment within eight sessions. The
modal amount of sessions was one.

A substantial body of research suggests that utilization review is not cost
effective. Dorvvart (1990) reviewed the literature, and found that utilization review
resulted in a one-ti me savings at implementation, but that it was not cost effective on a
continuing basis. Rather than being an effective means of containing costs, utilization
review has created a downward spiral in service provision. In order to offset the
increased overhead associated with utilization review, many managed care systems are
having to scale back mental health care services even further (Sharfstein, 1990).

Conflict of Interest

Newman and Bricklin (1990) noted that in utilization review, as with managed
care in general, there is a tension between the profit motive and providing adequate
care. In utilization review, this tension is crystallized in a conflict of interest, between
evaluating the need for psychological services and making a profit by decreasing the
utilization of those services (Wright, 1992).(Tf a managed care system is to remain
profitable, administrators cannot afford to hire or maintain case managers who are not
cost effective (Berkman, Bassos, 8: Post, 1988). Because their job security often hinges
on cost cutting, case managers can experience a considerable amount of difficulty in

separating self-interest from the best interests of the patient (Patterson, 1990).

J

32
Lack of Clear Criteria

The absence of clear and consistent policies or criteria for making treatment
decisions frustrates many practitioners in their attempts to secure appropriate
treatment for their patients. England and Vaccaro noted that 45% of the psychiatric
hospitals surveyed complained that utilization review criteria were often ambiguous.

(Some managed care companies simply refuse to reveal the criteria that they use in
their decision-making (Tischler, 1990).)

[A second problem with utilization review criteria stems from the use of a
specific criterion 1- ”medical necessity" - which often acts as a barrier to treatment
(Berman, 1992; Sinnett 8: Holen, 1993). Even though the medical necessity for most
outpatient treatment has never been established, medical necessity remains the central
criterion used in utilization review decision-making related both to initial patient
access to services and the continuation of ongoing outpatient treatment/«Zimet, 1989).

Chipman (1994) noted that the medical necessity is increasingly defined in
functional terms. According to Berman (1992), functional necessity refers to
”biopsychosocial interventions that are necessary and sufficient to help an individual
cope more effectively with a difficult situation, or alleviate a state of acute distress" (p.
40). While this definition clarifies what constitutes functional necessity, it leaves open
the question of which party determines when the patient has been restored to a

suitable level of functionality.

33
Ethical Conflicts

Dealing with utilization review often means that practitioners must negotiate a
new set of ethical challenges, Especially in the areas of diagnosis and patient
confidentialityfiecause diagnostic exclusions do not cover certain conditions, many
providers misdiagnose patients deliberately in order to obtain reimbursement. In a
survey of clinical social workers, Strom (1994) found that 37% of the providers
reported giving a more severe diagnosis in order to obtain reimbursement, and that
57% had reported treatment falsely (e.g., indicating that individual treatment had been
delivered instead of family therapy). Kirk and Kutchins (1988) also reported epidemic
rates of misdiagnosis. In their study of social workers, 72% of those surveyed indicated
that they had used a more severe diagnosis to obtain reimbursement for a patient, and
56% had used an Axis I diagnosis of a major mental disorder.

Problems with utilization review and patient confidentiality have led to an
increasingly public debate about the privacy of medical records (Lewin, 1996; Scarf,
1996). A study of Kansas psychiatrists found that most practitioners believed that
Etilization review had a great potential for compromising patient confidentiality
(Sinnett 8: Holen, 1993). While some managed care companies respond that patient
confidentiality is no longer possible (Dworkin 8: Hirsch, 1994), almost half of the
HMOs surveyed by Shadle and Christianson (1988) saw a need for improvement in

their own procedures in handling patient records. For some patients, the lack of

34

confidentiality in managed care settings is a key factor in their decision to terminate
treatment (Patterson, 1990);j

Most psychologists have grave concerns about the role of managed care and
utilization review in changing clinical practice (APA, 1996). In particular, practitioners .
have expressed reservations about the potential for utilization review to infl uence the
clinical decision-making process (Barnett, 1993). Zuckerman (1989) noted that the
nature of utilization review has changed, from a retrospective process to a prospective
procedure, as managed care systems began to require pre-authorization for mental
health care. According to Zuckerman, when utilization review becomes prospective, it
exerts a direct control over treatment. Sharfstein (1990) concurred, calling utilization
review "the most explicit and direct effort to regulate and control physicians by
modifying their decisions" (p. 965). In fact, in a study commissioned by the American
Psychiatric Association, 60% of the psychiatrists surveyed indicate that they had been
discouraged by utilization reviewers from hospitalizing patients, or pressured to
shorten inpatient stays.

As utilization review is becoming a central force in clinical decision-making,
many providers are experiencing an increasing degree of discomfort. Michaelson
(1993) commented that utilization review entails "asking a person, sight unseen, to
make a life and death decision about a patient that you have a relationship with” (p.

23). Adding to this discomfort is a sense of frustration regarding the personnel who are

35

involved in utilization review. Most often, case managers and utilization reviewers are
social workers and registered nurses (Panzarino 8: Wetherbee, 1990; Tischler, 1990),
creating a situation where many psychiatrists view utilization review as ”social workers
are telling physicians what to do" (Shadle & Christianson, 1989, p. 1149). For many
practitioners, utilization review has reduced professional practitioners to the role of
technicians carrying out, the directives of managed care staff (Berkman, Bassos 8: Post,
1988; Strom, 1992b; Weimer, 1990).
Career Satisfaction
HMOs and Career Satisfaction

Theoretin Foundation

Managed care has brought a great deal of change to the practice of psychology.
How is this change related to career satisfaction among practitioners? Dawis, England,
8: Lofquist's Theory of Work Adjustment (1964, can provide a conceptual framework
for investigating the role of managed care in career satisfaction among psychologists.

Work Adjustment Theory is a person-environment interaction approach to
career satisfaction. The theory combines elements of learning theory - stimulus,
response, and reinforcement - with a traditional matching model derived from the
work of Frank Parsons, in which career satisfaction is considered to be the result of
matching individuals with environments that fit their interests, skills, or personalities.
According to Work Adjustment Theory, as workers’ personalities vary, so do their

respective needs. Similarly, work environments differ in the type and degree of

36

reinforcers present: each work environment is defined by a specific set of reinforcers.
Career satisfaction is the result of a correspondence - or ”match" - between the
worker's needs and the capacity of the work environment to meet those needs. Dawis,
Lofquist, and Weiss (1968) note that although work-related needs remain relatively
stable over the adult lifespan, career satisfaction can fluctuate with changes in the
work environment.

The Theory of Work Adjustment has received a considerable amount of
empirical support. Tziner (1983) examined the relationship between career satisfaction
and correspondence between worker needs and occupational reinforcers. The results
of the study showed that career satisfaction and correspondence between individual
needs and occupational reinforcers were strongly related: the higher the level of
correspondence, the greater the individual satisfaction.

Rounds (1990) evaluated need/reinforcer correspondence as a predictor of
career satisfaction, and compared the effectiveness of the Work Adjustment model
with Holland's theory of vocational interest congruency. Both Work Adjustment
Theory and Holland’s interest congruency are matching models, and both posit career
satisfaction is a function of the fit between worker characteristics and features of the
occupational environment. The theories differ in their description of the critical
predictor variable: Work Adjustment Theory focuses on the fit between worker needs
and occupational reinforcers, whereas Holland emphasizes the relationship between

individual interests and characteristics of the work environment.

37

Rounds found that work values or needs made a significant contribution to the
prediction of career satisfaction, after controlling for interest congruency. Worker
needs accounted for 29% of the variance in career satisfaction, compared to only 4%
contributed by interest congruence. In addition, the results gave strong support to the
hypothesis that interest congruency and needs correspondence are two separate and
unrelated constructs.

After initial research supported the validity of the needs/reinforcer model,
Rounds, Dawis, and Lofquist (1987) studied the relative contributions of occupational
reinforcer patterns (ORPs) and worker needs to career satisfaction. The researchers
used the Minnesota Importance Questionnaire to assess individual needs, and the
Minnesota Job Description Questionnaire to define occupational reinforcers. Once
again, the authors found that there was a moderate to strong relationship between
need/reinforcer correspondence and career satisfaction. Overall, occupational
reinforcers were more effective in predicting career satisfaction than individual needs.

Rounds and his colleagues examined the construct of occupational reinforcers
in depth, in an attempt to identify the critical aspects of reinforcement. Occupational
reinforcers patterns were assessed along three dimensions: reinforcer elevation, a
measure of the strength of a specific reinforcer; scatter; and profile shape, which
captured the presence, rather than the degree, of the reinforcer. Multiple regression
analysis revealed that profile shape proved to be the most effective predictor of career

satisfaction.

38

A number of studies have examined the underlying factor structure of worker
needs and occupational reinforcers. Lofquist and Dawis (1978) performed a factor
analysis on the Minnesota Importance Questionnaire, a measure of worker values or
needs. The authors derived six value dimensions. The first factor was termed
Achievement, and consisted of ability utilization and achievement. The Comfort value
dimension was comprised of compensation, working conditions, activity, security, and
variety. The third factor was defined as Status, and was composed of advancement,
recognition, authority, and social status. Altruism was the fourth factor, and contained
elements of moral values, social service, and values related to co-workers. The fifth
factor was termed Safety, and was composed of company policies and practices,
supervision in human relations, and technical supervision. Autonomy was the last
factor, and included both creativity and responsibility. The authors also divided
individual needs into three separate categories: preferences related to the external
environment; reinforcement from other people; and self-reinforcement, which
included the need for achievement and autonomy.

Macnab and Fitzsimmons (1987) used a multitrait-multimethod analysis to
investigate the relationship between needs, work values, and preferences.
Confirmatory factor analysis of the multitrait-multimethod matrix revealed an 8 factor
structure of work values or needs: authority, coworkers, creativity, independence,
security, altruism, work conditions, and prestige. Pryor (1987) also examined the

underlying structure of work values, using the Work Aspect Preference Scale. Analysis

39
of the data supported a three factor solution to describe work values. The first factor

was termed Non-work Orientation, and was composed of lifestyle, money, and
detachment. Pryor described this factor as the individual’s concern ”that work not
interfere with the rest of one’s life”. (p. 427). The second factor was termed Freedom,
and contained elements of creativity, self-development, and independence. Pryor
defined the Freedom factor as ”indicating a personal commitment to work in which
the person exercises prerogative and initiates rather than follows, innovates rather than
implements". (p. 428). The final factor was described as Human/Personal Concern,
and was composed of altruism, coworkers, and security. The results supported Lofquist
8: Dawis’ (1978) taxonomy, which separated needs into three distinct groups:
environmental reinforcers, reinforcement from other people, and self-reinforcers.
Finally, Doering, Rhodes, and Kaspin investigated the factor structure of both
individual needs and occupational reinforcers. The authors found a three factor
solution for both constructs. For worker needs, the first factor was composed of
autonomy and achievement; the second factor grouped compensation, recognition,
and social status, and the third factor contained the elements supervision/human
relations and company policies and practices. Occupational reinforcers were also
grouped into three underlying factors. The first factor was described as self-
reinforcement, and contained ability utilization, creativity, achievement, recognition.
The second factor was composed of reinforcers that were derived from the

organizational environment, and was comprised of supervision/human relations and

40

company policies and practices. The last factor was termed ”working alone” and was
composed of independence and autonomy. According to the authors, ”Given that
autonomy was reinforced, it follows that individuals would perceive that working
alone is important in achieving, using their abilities, and expressing creativity.” (p.
137).

Overall, research has supported Lofquist and Dawis’ original model 6f needs
and reinforcers. Lofquist and Dawis have continued their investigation into
occupational reinforcer patterns (Stewart, Greenstein, Holt, Henly, Engdahl, Dawis,
Lofquist, 8: Weiss, 1986). The team assembled a index of 187 occupational reinforcer
patterns, including profiles of both clinical and counseling psychology. The two
disciplines shared an identical pattern, with achievement, altruism, and autonomy
being the key reinforcers.

In the Lofquist and Dawis model, the achievement reinforcer is composed of
ability utilization, defined as the opportunity for individuals to use their abilities, and
achievement, or the ability to obtain a feeling of accomplishment. The altruism
reinforcer captures three areas: the degree to which an individual has coworkers who
are easy to make friends with; social service, or the opportunity to benefit other
people; and moral values, which is defined by an environment that allows workers to
perform their duties without feeling that they are morally wrong. The final reinforcer is
autonomy, which is composed of creativity, or the opportunity for workers to try out

their own ideas; responsibility, which is defined as the chance for workers to make

41

decisions on their own; and autonomy, or the workers' ability to plan their work
activities with little supervision.

Historically, achievement, altruism, and autonomy have been the key
reinforcers for psychologists. Recent changes brought about by managed care have
had an enormous impact on the reinforcement structure of the mental health care
professions. Practitioners no longer enjoy the same degree of independence and
influence over clinical decisions, and many professionals have complained that
working with managed care or utilization review entails unavoidable ethical conflicts.
According to Work Adjustment Theory, these changes in the reinforcement structure of
psychology would suggest that career satisfaction among psychologists has also
changed.

HMOs and Career Satisfaction

Baker and Cantor (1993) supplied evidence that supported a connection
between managed care and career satisfaction. They surveyed a group of HMO and
self-employed physicians, and found that HMO physicians were significantly less
satisfied with their practice than self-employed doctors. The HMO physicians were
also significantly less satisfied with their income. The authors also found that perceived
clinical freedom was associated with a number of satisfaction indices. HMO physicians
reported that managed care exerted its strongest negative influence on their autonomy
in the areas of patient selection and time management. Similarly, self-employed

physicians with managed care contracts were also less likely to feel able to spend an

42
appropriate amount of time with patients. Baker and Cantor found a negative

correlation between managed care and perceived autonomy: as involvement with
managed care rose, physicians were less likely to perceive that they were able to
control their time.

W

A team of researchers led by Snibbe investigated burnout among psychiatrists,
primary care physicians, and social workers in an HMO setting (Snibbe, Radcliffe,
Weisberger, Richards, 8: Kelly, 1989). The Maslach Burnout Inventory was used to
assess burnout along three dimensions: emotional exhaustion, depersonalization, and
sense of personal achievement. For the purposes of their study, the authors defined
depersonalization as ”an unfeeling and impersonal response towards recipients of
one’s care or service” (p. 776).

The results showed that that the psychiatry group suffered from a very high
level of burnout. In particular, HMO psychiatrists had significantly higher levels of
emotional exhaustion than the normative sample for the Maslach Burnout Inventory.
The authors drew a number of conclusions from the evidence. First, the authors found
that burnout was associated with job dissatisfaction. Secondly, the researchers felt that
assembly-line treatment was harmful to the providers: practitioners need to have a
sense of accomplishment. Finally, the authors observed that mental health care
providers work best when they feel some measure of control over their work

environment.

43

Austad, Morgan, and Holstein (1992) surveyed practitioners who were salaried
employees in 10 separate staff model HMOs in New England. The participants offered
a number of suggestions on avoiding burnout to psychologists who might be
considering accepting a position in a staff model HMO. The majority recommended
limiting the length of employment to two to three years as the best way of avoiding
burnout. DeStefano (1992) also observed that long term work in an HMO setting
inevitably leads to feelings of burnout. DeStefano followed with a list of the three
primary causes of burnout for psychologists in HMO settings: 1) on-call systems; 2) a
perceived lack of control over patients caseloads; and 3) managed care policies of not
hospitalizing patients unless they are in imminent danger of harming themselves or
others.

Managed Care and Career Satisfaction

McKelvey and Webb (1995) examined the links between managed care and
career satisfaction in a group of Houston-area psychiatrists. The majority of the
psychiatrists in the study listed managed care and changes in third party payments as
the leading threat to the quality of psychiatric care. The results also showed that
psychiatrists in private practice had the lowest level of career satisfaction, and were the
most pessimistic about the potential for positive change in their professional field.
McKelvey and Webb listed four factors that were associated with career satisfaction
among psychiatrists: 1) the quality of patient care; 2) the financial rewards of practice;

3) the type of patients in the caseload; and 4) the work environment. Overall, the

44

source and the amount of physician income had the strongest univariate correlations to
career satisfaction.
mugged Care and Burnout

Levant (1994) reported on a survey that had been conducted under the
auspices of the Oregon Psychological Association. The results of the study showed that
levels of practitioner burnout rose as a function of increased managed care market
penetration. Analysis of the data led to a list of five factors which are associated with
burnout among mental health service providers: 1) lack of control over treatment
decisions; 2) an increase in conflicts of interest; 3) an increase in practitioner
workload; 4) negative practitioner perceptions of workload; and 5) an increase in
work-related stress.

A number of other authors have commented on negative aspects of managed
care settings that have an impact on burnout and career satisfaction. Hoyt (1992b) and
Henault (1992) cited overwork as a primary correlate of burnout. Hoyt identified three
additional sources of burnout in managed care settings: limited treatment goals;
pressures to undertreat patients; and threats to patient confidentiality.

Summary

Though research in the allied mental health professions suggests that managed
care has a negative influence on career satisfaction, there is no information on the
impact of managed care on career satisfaction among psychologists. This study will be

concerned with the following two research questions: 1) what is the level of career

45

satisfaction among psychologists who are engaged in delivering psychological services?
and 2) what is the relationship between managed care and career satisfaction among

psychologists?

CHAPTER 2
METHODOLOGY

mm
This study will test the following set of four alternative hypotheses:
H1 #1: Psychologists’ career satisfaction will vary as a function of the percentage of -
practitioners’ caseload that is under managed care.
H, #2: Among licensed psychologists, intrinsic career satisfaction will be greater than
extrinsic career satisfaction.
H1 #3: Among licensed psychologists, career satisfaction will vary as a function of their
demographic characteristics.
H1 #4: Among licensed psychologists, career satisfaction will vary as a function of
variables that represent managed care business practices, managed care
communications, and practitioners’ experience of ethical dilemmas associated with
third party payors and managed care.

Midi
The participants in the study were licensed doctoral level psychologists who

spent at least twenty five hours per week providing direct psychological services. The
Research Office of the APA provided a random sample from its membership of over
62,000 psychologists, and generated a subject pool that matched the desired sample

size and target population of the study.

46

47
The planned data analysis required a minimum of 150 complete data sets. The

return rate of 30% in the APA CAPP study provided the guideline for the
determination of the sample size for this study, which used a pool of 700 practitioners
to generate a sufficient amount of participants for data analysis. Research subjects
were not remunerated or offered incentives to participate.

Instrumentation
Career Satisfaction

This study used the short form of the Minnesota Satisfaction Questionnaire
(MSQ; Weiss, Dawis, England, 8: Lofquist, 1967) to assess career satisfaction.
According to Weiss, Dawis, England, 8: Lofquist, the MSQ ”measures satisfaction with
several specific aspects of work and work environments” (p. vi), and provides a more
detailed representation of worker satisfaction than a global assessment of satisfaction
with a career as a whole. The short form of the MSQ is a self-report questionnaire
containing 20 items. Responses are based on a 5-point Likert scale. The manual for the
MSQ indicates that completing the short form should require no more than ten
minutes (Weiss et al., 1967).

The MSQ assesses career satisfaction along three dimensions, each
corresponding to a separate scale. General Satisfaction is defined by a scale that is
composed of all 20 items on the short form. Intrinsic Satisfaction is defined by
responses to items 1, 2, 3, 4, 7, 8, 9, 10, 11, 15, 16, 17, 18, and 20, and Extrinsic

Satisfaction by responses to items 5, 6, 12, 13, 14, and 19.

48

The General Satisfaction raw score was generated by summing the Likert scale
responses for all twenty items on the MSQ. For classification purposes, the raw scores
were then translated into percentile scores, using the norms for employed non-
disabled workers provided in the MSQ manual. Percentile scores above 75 indicated
high levels of career satisfaction, while scores below 24 represented low satisfaction.
The scores for the Intrinsic and Extrinsic subscales were generated by summing the
Li kert scale responses from the relevant questions.

The MSQ has been used extensively since its development thirty years ago.
Canonical correlation analysis of test-retest results for the long form of the MSQ
produced maximum reliability coefficients of .89 over a one year period. The
reliability coefficients for the short form were in a similarly high range. The median
Hoyt reliability coefficients for the General Satisfaction scale ranged from .92 to .87;
on the Intrinsic scale, the range was from .91 to .84; and for the Extrinsic satisfaction
scale, the values ranged from .82 to .77.

The construct validity of the MSQ has been supported by factor analysis, which
revealed two essential components, corresponding to internal and external sources of
career satisfaction (Weiss et al., 1967). The concurrent validity of the MSQ can be
inferred from analysis of variance data, which indicate that the MSQ can detect
differences in career satisfaction between different occupational groups (Weiss et al.,

1967).

49
Predictor V ri bles

Three sets of predictor variables corresponding to the above research
hypotheses were used in this study: 1) the proportion of a participant’s practice that
was under managed care; 2) the practitioner’s demographic characteristics; and 3)
variables that represented practice financial characteristics, managed care business
practices, managed care communications, and practitioners’ experience of ethical
dilemmas associated with managed care. The predictor variables were assessed by
responses to items on the self-report questionnaire, the Practice of Psychology Survey
(PPS).

The format and content of the researcher-developed PPS survey were derived
from a number of sources, including Strom (1992a, 1994) and Sinnet 8: Holen (1993).
The PPS contained 72 items, and was designed to assess pertinent practitioner
demographic characteristics, as well as relevant aspects of both clinical practice and
the role of managed care in the delivery of psychological services.

The survey contained three types of questions: items that required participants
to provide a numerical response or percentage estimate (e.g., A-1 or A-8); items that
involved selecting an answer from a limited range of responses (for example, A-2 or A-
7) ; and items that required a response that was based on a 5-point Likert scale (e.g. B-
29, C-37, or 044). Completion time for the survey was estimated to be between 45

minutes and one hour.

50

The survey was divided into four sections: Demographic Information; Practice
Information; Third Party Payors; and Managed Care. The survey also contained nine
questions that were related to the measurement of the criterion variable of career
satisfaction: items A-10, A-11, and items B-29 through B-35.

The first section, Demographic Information, was comprised of items A-1
through A-9, and required participants to answer questions related to their age,
ethnicity, gender, years in practice, and income. The second section, Practice
Information, was composed of items 8:12 through B-28, and asked participants to
provide responses to questions concerning the structure of their practice, the
composition of their caseload, and the nature of their work environment (staff or group
HMO, PPO, or private practice). The Third Party Payors section, which contained
items C-36 through 056, was concerned with the nature of the relationship that
psychologists have with third parties, such as insurance companies or HMOs, that
provide compensation for the provision of therapeutic services. The final section,
Managed Care, was composed of items D-57 through D71, and asked participants to
describe their interactions with managed care companies and utilization review
personnel.

The questions in the survey questionnaire cover six basic areas: practitioner
demographics; practice structure; practice finances; managed care; managed care
communications; and ethical dilemmas. Questions were included in the survey on the

basis of two primary criteria. The first criterion was evidence from previous research

51
that suggested a connection between the content area and career satisfaction. For

example, McKelvey and Webb (1995) found that among psychiatrists, career
satisfaction was related to the subjects’ age as well as the number of years that they
had been in practice. The second criterion was the list of practitioner concerns
contained in the APA’s CAPP study (1996). The CAPP study list provided the rationale
for including questions related to managed care, utilization review, practice income,
ethical dilemmas, managed care referrals, and membership on managed care panels.

The practitioner demographic questions captured the information related to the
service provider, including age, gender, type of degree, number of years in practice
and theoretical orientation. The demographic information questions were represented
by items A-1 through A-9 and B-26 through B-28.

The questions related to practice structure provided a picture of the
practitioner’s work setting, including caseload, client characteristics, and professional
environment (group HMO, staff HMO, PPO, etc.). The practice structure questions
were items B-12 through B-15 and B-17 through B-25.

The practice finance questions provided information on the number of
managed care referrals, relative ease or difficulty in obtaining reimbursement, and
increases or decreases in income related to managed care. The practice finances
questions were represented by items B-16, G36, 037, 0-69, and 0-70.

The questions related to managed care addressed the practical aspects of

service provision. They included items concerning the need for pre-authorization, the

52
number of sessions that are typically granted, and utilization review. The managed

care questions were items C-38 through C-42, D-61 through D66, D68, and 0-71.

The managed care communications questions were concerned with the
interactions between the service provider and the managed care entity, both in writing
and on the telephone. The communication items also addressed the relative ease or
difficulty of establishing and maintaining contact with the managed care entity. The
managed care communications questions were represented by items 0-58, D-59, D-
60, D-61, and D67.

Finally, the ethical dilemma questions addressed insurance reporting,
confidentiality, continuity of care, and the influence of reimbursement policies on
diagnosis and treatment approach. The ethical dilemma questions were comprised of
items C-43 through 056.

For the first research hypothesis, the predictor variable was the proportion of a
provider’s caseload that was reimbursed by third party payors, as measured by
questions B-23, B-25, and 0-70 of the PPS. The outcome variable was career
satisfaction, as measured by the General Satisfaction, Intrinsic Satisfaction, and
Extrinsic Satisfaction scale scores on the MSQ. For the second research hypothesis, the
criterion variables were defined by the Intrinsic and Extrinsic Satisfaction scores on the
MSQ. For the third research hypothesis, the independent variable was the provider

demographic data derived from the FPS, and the outcome variable was career

53
satisfaction, as measured by the General Satisfaction scores on the MSQ. Finally, the

predictor variables for the last research hypothesis were based on questions from the
PPS that corresponded to practice finances, managed care business practices,
managed care communications, and practitioners’ experience of ethical dilemmas
associated with third party payors and managed care. The outcome variables were the
General Satisfaction, Intrinsic Satisfaction, and Extrinsic Satisfaction scores on the
MSQ.

Procedure

The Research Office of the APA provided two identical sets of labels for the
subject pool of 700 participants. The first set of labels was used for mailing the
materials to the participants, and the second set of labels was used to address the
follow-up postcard that was sent six weeks after the initial mailing. The Minnesota
Satisfaction Questionnaire and the Practice of Psychology Survey were placed in an
envelope, along with a cover letter, a consent form, a set of instructions, and a
stamped pre-addressed return envelope.

The cover letter described the topic of the dissertation research, and invited the
subjects to participate. The subjects in the study were completely anonymous. The
survey forms were not coded in any way, nor was there be any personal identification
information on the surveys (except for age and number of years of practice). No copies
of the labels were made, and no records were made or kept of the identity of the

participants.

54

The subjects were be asked to fill out the consent form and two questionnaires.
Upon completion of the two instruments, the participants could return the materials
in the pre-addressed and stamped return envelope. Six weeks after the initial mailing,
a reminder postcard was sent to the entire subject pool. The card asked participants to
complete the materials and return them in the pre—paid return envelope.

Data Analysis

The data analysis fell into two main areas. The first analysis addressed the
MSQ, and employed descriptive statistics, including the mean, median, range, and
standard deviation of the scores, to provide a picture of career satisfaction among
psychologists who are active in providing psychological services. In addition,
descriptive statistics were also used to identify interesting data from the Practice of
Psychology Survey.

The second set of statistical analyses focused on the relationship between
managed care and career satisfaction. For the first alternative hypothesis, a
correlational analysis using Pearson’s r statistic was used to assess whether involvement
with managed care was related to career satisfaction. The second alternative
hypothesis was examined using a paired sample t-test to investigate the relationship
between intrinsic and extrinsic career satisfaction.

The final set of data analyses began with a principal components analysis on
the items related to managed care and third party payors, to reduce the data and

identify underlying factors. A regression analysis was performed on the factors to

55

inspect the relative contributions of each of the factors to the outcome variable of
career satisfaction. Factors that were significantly related to the outcome variable were
then examined using multiple regression to identify specific items that were associated

with variation in career satisfaction.

CHAPTER 3
RESULTS
Description of the Sample

A total of 194 surveys were filled out and returned, which represented 28% of
the subject pool. Thirty nine respondents did not meet the minimum criterion of 25
hours per week of direct service provision, and their protocols were removed from the
data analysis, leaving a total of 155, or 22% of the subject pool.

Representative Characteristics of the Sample

The demographic characteristics of the practitioners in the study sample
appeared to conform to the demographic data on the general membership of the APA
(APA, 1995). The gender balance of this study - 56% male and 44% female -
corresponded well with the APA statistics of 55% male and 45% female. The average
age of the psychologists in the sample was 48.7 years old, compared with 49.5 for the
APA as a whole. The psychologists in the survey had been in practice for an average of
13.5 years, which approximates the 16.8 years of the APA general membership.

The practice characteristics of the psychologists in the survey were also found
to be similar to data generated by the CAPP study (APA, 1996). Approximately 41 % of
the survey sample was involved in private practice, which matched the 40.7% of the
practitioners in the CAPP engaged in independent practice. Similarly, 11.6% of the
study sample worked in medical settings, and a further 7.7 % were employed in

government facilities, which corresponded with the 12% of the CAPP study

56

57
psychologists who worked in hospitals and the 7.1% who had positions in government

facilities.
Demographic Information

The profile of the participants in the study reflected the demographic changes
that have been taking place within the profession over the last ten years. While
minorities were underrepresented in terms of the population as a whole - the sample
was 92% Caucasian - it was more evenly balanced in terms of gender: 56% of the
respondents were male, and 44% were female. The average participant was 49 years
old, and had been in practice for 14 years.

Participants in the survey averaged 48 hours per week on the job, divided
between 31 hours of billable time and 17 hours of time for which they received no
reimbursement. Providing direct psychological services was the primary professional
activity for most of the practitioners in the study: over 73% of their time was spent
doing therapy. A substantial proportion of their time was devoted to non-reimbursable
activities, with 10% consumed by utilization review, and 5% spent on billing. The
balance of their professional time was spent on other activities, including teaching,

supervision, and consultation.

58
Table 1: Work Time and Activities

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Variable Mean Std. dev. Range Minimum Maximum
Number of Billable
Hours 31.3 11.6 94 6 100
Number of Non-
billable Hours 16.8 11.7 60 0 60
Percentage
Worktime: Therapy 73.5 18.1 100 o 100
Percentage
Worktime: Billing 5.3 6.7 35 0 35
Percentage
Worktime: UR 10.0 9.5 50 0 50
Percentage
Worktime: Other 11.7 16.0 100 O 100

 

The psychologists in the study were very active, with an average caseload of 39
clients per week, or approximately 8 patients per day. The majority of caseloads were
made up almost exclusively of adults, with women clients outnumbering men by a
ratio of 3 to 2. White-collar professionals represented 40% of all caseloads, followed
by blue-collar workers (27%), students (18%), and the unemployed (15%). Though
Caucasians represented 78% of all clients seen, psychologists in the study also
provided psychological services to minority clients, who constituted 22% of the
average caseload. Relatively small proportions of the practitioners in the study

specialized in the treatment of children and adolescents - 11% and 7% respectively.

59
Iable g: Average Caseload

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Variable Mean Std. dev. Range Minimum Maximum
Number of
cases 39.1 20.1 94 6 100
% Caseload:
Males 43.6 19.7 100 0 100
% Caseload:
Minority 21.4 22.2 100 0 100
% Caseload:
Caucasian 78.4 22.2 100 0 100
% Caseload:
White Collar 39.8 29.4 100 0 100
% Caseload:
Blue Collar 26.9 21.9 95 0 95
% Caseload:
Students 18.6 23.9 100 0 100
% Caseload:
Unemployed 15.1 25.0 100 0 100

 

Table 3: Tym of Clients in Caseload

 

Variable Adults Adolescents Children

 

Clients in Caseload
Primarily: 80.5 7.8 11.7

 

 

 

 

 

 

The majority of psychologists in the survey - over 85% - practiced in urban or
suburban communities. Most of the psychologists were independent practitioners, with
41 % in solo practice and 29% involved in a group independent practice. A substantial
proportion of the psychologists in the study worked in medical facilities (11%),

followed by those employed in government institutions (8%) and community mental

60
health centers (8%). A small segment of the practitioners worked in staff or group

HMO settings - less than 2%.

Table 4: Practice Lgtion

 

 

 

 

 

 

 

 

 

Variable Urban Suburban Rural
Percentage of
Practitioners 49% 37.9% 13.1%
Medical fachity
11.6%

 

 
 
   
    
 
 

Governmert facility

7.7%
Solo Independeri

Comm. Memal Health

Grp. Ind. Practice
29.0%

 

 

 

Figure 1: Practitioner Work Settings

The average caseload was divided evenly between private fee-for-service and

contractual fee-for-service clients (i.e. Medicare or preferred provider referral), with

61
each group representing about 44% of all patients. The balance of the caseload was

comprised of clients seen under capitated contractual agreements. The mean fee for
an hour of individual, couples, or family therapy was $99. Group therapy patients
were charged an average of $50, roughly half of the fee for individual patients, and
assessment sessions averaged approximately $110. More than half of the average
caseload were charged a reduced rate for services, and 4% of all patients were treated

on a pro bono basis.

Igble 5: Fee Structure

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Variable Mean Std. dev. Range Minimum Maximum
Percent of Income
from Practice 71.5% 23.7% 99% 1% 99%
Fees: Individual
Therapy 599 $21.30 $140 $25 $165
Fees: Couples
Therapy $100 $20.20 $110 $55 $165
Fees:
Family Therapy $100 $23.60 $175 $45 $220
Fees:
Group Therapy $50 $17.00 $75 $15 $90
Fees: Diagnostic
Evaluation $112 $29.80 $165 $35 $200

 

The median annual income for the psychologists in the survey was between
$80,000 to $100,000. Although the majority of the practitioners in the study indicated
that their household had two sources of income, the revenue generated by their

practices represented 70% of their family’s total income.

62
Table 6: Total Family Income

 

 

$25,000 - $40,000 - $60,000 - $80,000 - $100,000 - $120,000 - Over I
39,000 59,000 79,000 99,000 1 1 9,000 1 39,000 $140,000
3.9% 11.2% 17.1% 19.1% 19.7% 11.8% 17.1% I

 

 

 

 

 

 

 

Third Party Payors and Managed Care

Third party payors play an active role in the provision of psychotherapy. The
degree of third party or managed care involved can be assessed along two dimensions:
1) the percent of caseloads that receive services under contractual agreements with
third parties, and 2) the percentage of practitioners in the survey who treat clients
under those agreements.

There were also four direct measures of the degree of managed care
involvement with the practitioners’ caseloads: 1) the percentage of the practitioner’s
caseload that required prior approval of treatment plans; 2) the percentage of clients
who were treated under a contractual agreement for a reduced fee (e.g. HMOs and
PPOs); 3) the percentage of the caseload that was seen on a capitated basis; and 4)
the proportion of patients that used third party funds to pay for their treatment under a
contractual fee-for-service plan. The data were consistent: 43% of the practitioners in
the survey required prior approval of treatment plans; 43% of the clients were treated
under a contractual agreement for a reduced fee; 10% of the clients were seen as a
result of capitated contracts; and 53% of the total client caseload received funds for

their treatment from third party payors.

63

Ia‘ble 7: Th_ird Party Payors and Treatment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Variable Mean Std. dev. Range Minimum Maximum
% Cases:
Pay Full Rate 42.0 32.6 100 0 100
% Cases: .
PayReduced Rate 52.3 32.0 100 0 100
% Cases:
Free (pro bono) 4.0 5.5 25 0 25
% Cases:
Fee-for-Service 43.7 33.8 100 0 100
% Cases: Contract Fee-
for-Service 43.1 33.2 100 0 100
% Cases:
Capitated Contract 10.3 23.8 100 0 100
% Cases:
Prior Approval 43.2 34.6 100 0 100
% Cases: Third Party
Determined Tx 15.4 26.5 100 0 100

 

These same four items also served as indirect measures of the percentage of
practitioners who were involved with third party payors or managed care.
Approximately 70% of the psychologists in the study required prior approval of
treatment plans before receiving authorization for treatment. Similarly, 78% of the
practitioners delivered services under preferred provider agreements, and 90% treated
patients for reduced fees under contractual fee-for-service plans. Delivering services
under capitated contracts appeared to be the least popular alternative, and involved
only 10% of the psychologists in the survey.

The impact of third party payors on caseloads was less clear - 25% of the

practitioners reported a moderate or substantial increase in the demand for their

64
services, while 36% of the respondents stated that third party payors had a negative

impact on their referrals. Approximately 40% of the psychologists in the survey

indicated that they relied on third party payors for patient referrals.

Table 8: Third Party Impact on Demand for Services

 

Greatly Moderately No Impact Moderately Greatly
Variable Increased Increased Decreased Decreased
Caseload Caseload Caseload Caseload

 

Third Party Impact on
Demand for Services 7.1 % 18.4 % 38.1 % 32.0 % 4.1 %

 

 

 

 

 

 

 

 

Table 9: Practitioner Reliance on Third Par_ty Referrals

 

 

 

 

 

 

 

Variable Not at all Very little Moderately Greatly
Depend on Third Party
Referrals 26.2 % 29.0 % 24.8 % 17.9 %

 

Interactions with Third Pam Payors and Managed Care

Communications
The practitioners in the study reported a wide variety of response times in their
attempts to contact managed care personnel. Less than 15% percent of the
respondents indicated that case managers were readily available by phone. The
balance of the sample was divided between those who reported having to wait less

than ten minutes (25%), and those for whom waits of ten minutes or longer were

 

65
typical (60%). There was a similar disparity in terms of the time required for managers

to return messages: one third of the sample indicated that their messages were
returned promptly or within 24 hours, while half of the practitioners reported having to

wait 48 hours or longer.

Table 10: Case Manager Availability

 

 

 

Readily Occasional Frequent Usually Long Waits
Variable Available Waits over 10 Waits over 10 Longer than Typical
Minutes Minutes 10 Minutes
Availability of
Case Managers 13.2 % 25.6 % 15.5 % 17.1 % 28.7 %

 

 

 

 

 

 

 

T_al_)le 11: Time Required for Messages to be Returned

 

 

Frequently Usually Usually Usually
Variable Promptly within 24 within 24 within 48 over 48
Hours Hours Hours Hours
Time Required for
Messages to be Returned 4.6 % 28.5 % 18.5 % 29.2 % 19.2 %

 

 

 

 

 

 

 

 

Most of the survey psychologists received authorization to provide services
within one week of their request. However, a considerable portion of the psychologists
(48%) indicated that they had to wait two weeks or longer. Third party payors and
managed care companies also varied in terms of the amount of time required to
authorize medical consultations and emergency services. The majority of case
managers responded within 24 hours, but 30% of the practitioners indicated that

authorization for emergency services regularly required more than 48 hours.

Table 12: Time Required for Authorization of Treatment

66

 

 

 

 

 

 

 

 

 

 

 

Within 1 Usually Usually Occasionally Usually
Variable Week Within 1 Within 2 Longer Than 2 Longer than 2
Week Weeks Weels Weels
Wait Time for
Authorization 30.7 % 21.3 % 17. 3 % 14.2 % 16.5 %
Table 13: Time Reguired for Emergeng! Authorization
Promptly Usually Occasionally Usually Usually
Variable within 24 Longer than 24 Within 48 Over 48
Hours Hours Hours Hours
Wait Time for
Emergency 15.8 % 30.8 % 24.2 % 15.8 % 13.3 %
Authorization

 

 

 

 

 

 

 

almond

The psychologists in the study varied in their assessment of the professionalism

of managed care personnel. Most of the respondents rated the professionalism among

case managers as adequate or better, but 25% of the sample reported that managers

were unskilled or occasionally unprofessional. Though most of the practitioners had a

positive view of the professionalism among managed care employees, they had a

strong reaction to the fact that many utilization review personnel are not psychologists.

Only 3% of the sample indicated that the issue was not relevant, while over 57% said

that they were considerably or profoundly distressed.

 

 

67
Iable 14: Professionalism of Managed Care Personnel

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Highly Professional Adequate Occasionally Unprofessional
Variable Professional Unprofessional
Professionalism of
MC Personnel 5.4 % 24.0 % 45.0 % 19.4 % 6.2 %
Table 15: Licensgre Status of UR Personnel
No Concern Small Moderate Considerable Profound
Variable Concern Concern Distress Distress
Licensure Status of
UR Personnel 3.0 % 6.7 % 32.6 % 32.6 % 25.2 %

 

 

 

 

 

 

 

 

Respondents also varied in their ratings of the extent to which case managers
collaborated in the course of a case: 40% of the practitioners indicated that their
relationship was usually collegial and constructive, but 20% of the sample stated that
those interactions were adversarial and counter-productive. While the vast majority of
the practitioners stated that dialogue with case managers was reasonable and
appropriate, a significant proportion of the psychologists - 20% - had a negative
experience with reauthorization. These practitioners stated that they had difficulty in
obtaining additional sessions, and that case managers were often contentious and
rigid. This situation may have been exacerbated by the absence of clearly stated
criteria for reauthorization - only 22% of the sample indicated that utilization review

personnel used clear and concise written rules to assist in the decision making process.

68

Table 16: Case Manager Collaboration with Practitioners

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Constructive Usually Occasionally Occasionally Adversarial
Variable Constructive Constructive Adversarial
MC Collaboration 10.2 % 30.5 % 36.7% 16.4% 6.3 %
with Practitioners
Table 17: Experience with Reauthorization
Dialogue Justification Sessions Difficulty Managers
Variable Reasonable Required Granted/Denied Obtaining Contentious
Without Sessions and Rigid
Justification
Practitioners’
experience with 17.6 % 53.6 % 12.0 % 13.6 % 3.2 %
reauthorization
Table 18: Utilization Review Criteria
Written: Clear Unwritten: Clear Unwritten: No Stated
Variable and Concise and Consistent Unclear and Criteria
Inconsistent
UR Criteria 22.0 % 17.2 % 29.3 % 31.7 is

 

 

 

 

 

 

 

Influence over Clinical Decisions

Most psychologists in the survey felt that case managers played a central role in
clinical decisions regarding patient treatment: approximately 44% of all patients
required prior approval of treatment plans by a third party before treatment is

authorized. Only 14% of the practitioners stated that they retained a strong degree of

69
control over their treatment decisions. The balance of the respondents - 86% -

indicated that case managers exerted various degress of control over the clinical
decision-making process: 33% of the psychologists in the study reported that they
retained moderate control over treatment decisions; 35% stated that they had some
control; 12 % indicated that they had very little control, and 6% stated that they had

no control at all.

Table 19: Perceived Practitioner Control Over Treatment Decisions

 

 

 

 

 

 

 

 

Strong Moderate Some Hardly Any No
Variable Control Control Control Control Control
Perceived Practitioner
Control Over Tx Decisions 14.6 % 32.3 % 34.6 % 12.3 % 6.2 %

 

 

Third party payors were reported to influence treatment in a variety of ways. A
considerable portion of the psychologists in the survey (44%) felt that third party
guidelines for reimbursement were a moderate or strong consideration in formulating a
diagnosis. Third parties were also reported to exert an influence over treatment
decisions: 43% of the practitioners in the study indicated that they felt pressure to
adjust their treatment decisions in order to stay on provider panels. Once treatment is
approved, third party payors also set strong limits on its duration: psychologists in the
survey requested an average of eleven therapy sessions for their patients, but received

only seven.

70
Table 20: Managed Care Influence over Treatment

 

 

 

 

 

 

 

 

 

Variable No Impact Very Little Moderate Great
Third Party Influence on
Diagnosis 28.6 % 27.9 % 30.0 % 13.6 %
Third Party Influence over
Tx Decisions 28.1 % 28.9 % 27.4 % 15.6 %

 

Table 21: Average Sessions Requested and Authorized

 

 

 

 

 

 

 

 

 

 

Variable Mean Std. Dev. Range Minimum Maximum
Average Sessions
Requested 10.5 5.8 46 4 50
Average Sessions
Authorized 7.0 3.6 24 1 25

 

The degree of managed care control over treatment decisions was significantly
related to the survey psychologists’ assessment of impact that third parties had on the
development of treatment relationships (p< .0001), and was also linked to the
practitioners’ views of the effect that third parties had on the overall quality of
treatment. Only 8% of the participants in the survey felt that third parties had a
positive impact on the development of treatment relationships, and less than 6%
believed that third party payors had a positive influence on the quality of treatment.
Most of the respondents felt that third party payors and managed care had an overall

negative impact: 58% indicated that third parties had a moderately or highly negative

71
influence on treatment relationships, and 53% stated that third parties have a

moderately or highly negative impact on treatment quality.

Table 22: Third Par_t! Impact on Treatment Relationships and Quality

 

Highly Moderately None at all Moderately Highly
Variable Positive Positive Negative Negative

 

Third Party Impact on Tx

 

 

 

 

 

 

 

 

Relationships .7 % 7.5 % 33.3 % 48.3 % 10.2 %
Third party Impact on Tx
Quality .7 % 4.8 % 40.1 % 46.3 % 8.2 %

 

Ethics

 

Working with third party payors led to ethical conflicts for many of the
psychologists in the study: 39% of the respondents indicated that acceptance of third
party funds created treatment dilemmas. A substantial portion of the practitioners have
submitted deliberately inaccurate diagnoses in order to conform with reimbursement
guidelines: 35% of the respondents had given a less severe diagnosis than was
warranted, and 60% of the psychologists in the sample had given patients a more
severe diagnosis than was appropriate. Third party payors also played a central role in
determining how treatment is conducted: 58% of the respondents reported that third
parties had influenced their treatment approach (e.g., using behavioral versus insight
therapy), and 40% stated that they had selected the treatment modality (e.g., group
versus individual therapy) on the basis of reimbursement guidelines. Furthermore, 70%

of the practitioners indicated that they had reported conjoint or family therapy as

72
individual treatment in order to comply with reimbursement guidelines. Finally, 79%

of the psychologists in the survey indicated that patients had received less treatment

than was needed due to limitations in treatment benefits.

Table 23: Incidence Rate of Ethical Dilemmas

 

 

 

 

 

 

 

 

 

 

 

 

 

Variable Never Rarely Occasionally Frequently
Given Less Severe
Diagnosis 64.5% 20.3% 9.4% 5.8%
Given More Severe
Diagnosis 40.0% 26.5% 25.8% 7.6%
Reported Family/Couples
as Individual Tx 28.8% 24.2% 35.6% 11.4%
Third Party Influenced Tx
Modality 60.0% 20.8% 14.4% 4.8%
Third Party Influenced Tx
Approach 42.7% 14.5% 25.0% 17.7%
Given Less Tx than was
Necessary 20.8% 20.8% 31.5% 26.9%

 

Table 24: Acceptance of Third Pam Funds and Treatment Dilemmas

 

 

 

 

 

 

 

 

Variable No Impact Very Little Moderate Great
Third Parties Create Tx
Dilemmas 28.8% 28.9% 21.6% 17.3 %

 

The emotional responses to these ethical dilemmas varied in their intensity.
More practitioners were comfortable with giving patients less severe diagnoses (37%)
than with any of the other ethical incidents outlined in the survey. Conversely, only 9%

of the psychologists were comfortable with selecting a treatment approach to conform

73

with third party reimbursement guidelines. More practitioners were distressed by the

prospect of patients receiving insufficient treatment than by any other dilemma (58%).

Once again, giving patients a less severe diagnosis appeared to be the least disturbing

situation, with only 12% of the sample indicating moderate or severe distress.

The emotional responses to ethical dilemmas also varied in the strength of their

relationship to the precipitating incidents: an increase in the incidence rate of ethical

dilemmas was not necessarily associated with a rise in the intensity of a respondent’s

emotional reaction. Overall, the strongest relationship between the occurrence of

ethical conflicts and practitioners’ emotional reactions involved patients receiving

insufficient treatment (p< .0001 ).

Table 25: Reactionato the Occurrence of Ethical Dilemmas

 

 

 

 

 

 

 

 

 

 

 

 

 

Slight Moderate Moderately Greatly
Variable Comfortable discomfort discomfort Disturbed Disturbed
Given Less Severe
Diagnosis 41.7% 22.9% 22.9% 10.4% 2.1%
Given More Severe
Diagnosis 17.5% 40.0% 28.8% 8.8% 5.0%
Reported Family Tx as
Individual Tx 28.7% 38.3% 20.2% 10.6% 2.1%
Third Party Influenced
Tx Modality 22.0% 38.0% 14.0% 16.0% 10.0%
Third Party Influenced
Tx Approach 11.1% 25.0% 27.8% 18.1% 18.1%
Given Less Tx than was
Necessary 1.0% 16.8% 22.8% 30.7% 28.7%

 

Working within a managed care framework or with third party payors can

create divided loyalties. While 70% of the practitioners held that the therapist is the

 

74
agent of the client, 16% of those surveyed felt that they represent both the patient and

the party that pays for the treatment, and 12% subscribed to the view that they are the

agent of the patient, the party that purchased the coverage, and the party that pays for

 

 

 

the treatment.
Table 26: Role of the Therapist
The Patient Patient and Patient,
Variable Purchaser Payor Payor Payor, and
Purchaser
Therapist Role
69.7% 2.1% 1.4% 15.5% 11.3%

 

 

 

 

 

 

 

 

Finally, many psychologists are concerned about case management processes
used by insurance companies. None of the psychologists in the study endorsed the
idea that utilization review enhanced confidentiality, and 37% of the practitioners in
the sample indicated that those procedures represent a serious threat to the security of

patient records.

Table 27: Peer Review and Confidentiality

 

 

Enhances No Effect Potential for Occasionally Greatly
Variable Confidentiality Breaches Jeopardizes Jeopardizes
Confidentiality Confidentiality

 

 

Peer Review and
Confidentiality 0% 3.6 % 38.6 % 21.4 % 36.4 %

 

 

 

 

 

 

 

75
Overall Impact of Managed Care

There was a strong agreement among the psychologists in the study about the
overall impact of managed care on the practice of psychology. None of the
practitioners in the survey felt that managed care resulted in a marked improvement of
services, and only 4% indicated that it had a moderately beneficial impact. Most of the
psychologists (91%) believed that managed care was a negative influence: 39% felt
that managed care had a moderately negative impact, and 52% stated that it had a
marked adverse influence on services. These percentages correspond with the
outcome data from the CAPP study (APA, 1996), which found that 89% of the solo
and group independent practitioners believed that managed care had an overall

negative impact on the practice of psychology.

Table 28: Overall Imgct of Managed Care

 

 

 

 

 

 

 

 

 

 

Marked Moderate No Influence Moderate Marked
Variable Improvement Improvement on Services Adverse Adverse
Impact Impact

Impact of
Managed Care 0 % 4.9 % 4.2 % 39.2 % 51.7 %

Satisfaction with Managed Care

The study assessed satisfaction with managed care through a number of specific
items in the Study on the Practice of Psychology questionnaire. The items (B-29

through B-35) addressed relationships with managed care personnel, as well as the

76
impact that third parties had on the provision of psychological services. The

participants were asked to respond to the questions on a S-point Likert scale, with 1
representing ”very dissatisfied”, and 5 indicating ”very satisfied”. The scores on this
constellation of questions could range from a minimum of 7 to a maximum of 35.

The mean total score for these seven items was 18.5, with a low score of 7, and
a high of 31, and a standard deviation of 6. The average item response was 2.65, with
a standard deviation of .84, with a high of 4.42 and a low of 1. Using the Likert scale
keys, this mean score suggests that the psychologists in the survey were dissatisfied

with managed care and utilization review.

Table 29: Overall Satisfaction with Managed Care

 

 

Variable Mean Std. Dev. Range Minimum Maximum
Satisfaction with
Managed Care 18.5 6.0 24 7 31

 

 

 

 

 

 

 

 

Investigating the individual item averages provided a more accurate
representation of the participants’ satisfaction with managed care. The highest relative
degree of satisfaction, as measured by the SPP, concerned the practitioners’ ability to
use their own treatment approaches. The average response for this item was 3.25,
which corresponds to ”neither satisfied nor dissatisfied”, and it was the only item to
earn this designation by averaging over 3 on the Likert scale. The practitioners in the

study were least satisfied with the acknowledgment that they received from case

77
managers for doing a job well: the average score was 2.12, which falls into the

category of ”dissatisfied”. The balance of the items - the competence, professionalism,
and management skills of utilization review personnel, the ability to use their own
clinical judgment, and their working relationships with case managers - were all in the

”dissatisfied” range.

Table 30: Satisfaction with Managed Care

 

 

 

 

 

 

 

 

Very Very
Variable Satisfied Satisfied Neither Dissatisfied Dissatisfied
MC Personnel
Competence 0% 13.6% 26.5% 32.6% 27.3%
MC Personnel
Professionalism 0% 24.2% 26.5% 25.8% 23.5%
MC Management
Skills 0% 15.6% 25.0% 35.9% 23.4%
MC Working
Relationship 3.1% 31.8% 33.3% 23.3% 8.5%
Use own Clinical
Judgment 5.3% 37.6% 10.5% 27.8% 18.8%
Use own Treatment
Approaches 9.9% 48.9% 9.2% 20.6% 11.5%
Acknowledgment
forjob well done 1.0% 11.6% 26.8% 19.6% 41.1%

 

 

 

 

 

 

 

 

Career Satisfaction
This study used a number of career satisfaction measures, both global and specific. The
first global index of career satisfaction was the number of practitioners who would
choose psychology as a career if they were given a second opportunity. While 70% of
the psychologists in the study reported that they would choose psychology again, 30%

indicated that they would pursue a different career. The second global measure of

78

career satisfaction addressed the percentage of psychologists who were planning on
changing careers within the next five years. A substantial proportion of the
psychologists in the survey - 13% . stated that they intended to make a career shift in
the near future.

The Minnesota Satisfaction Questionnaire (MSQ) served as the criterion ‘
measure for this study. Overall, the distribution of scores had a negative skew. Factor
analysis confirmed the two factor structure corresponding to Intrinsic and Extrinsic
Satisfaction, as outlined by Weiss, Dawis, England, and Lofquist (1967).

Scores on the General Satisfaction scale of the MSQ can range from a
minimum of 20 to a maximum of 100. Weiss and his colleagues (1967) recommend
transforming the raw scores into percentile scores before interpreting individual MSQ
protocols. Scores above the 75th percentile are defined as high satisfaction, while
scores below the 25th percentile are regarded as indicators of low levels of career
satisfaction. In the manual for the MSQ, the authors provided a set of norms for
employed workers for comparative purposes.

The mean total score on the MSQ in this study was 75.9, with a standard
deviation of 11.27, a low score of 31 and a high score of 93. According to the norms,
a raw score of 75 would correspond to the 45th percentile: consequently, the mean
General Satisfaction score for psychologists in the survey would fall slightly below the

middle of the average range of satisfactio

79
The MSQ also renders scores on two subscales: Intrinsic Satisfaction and

Extrinsic Satisfaction. The potential scores on the Intrinsic Satisfaction lie between a
minimum of 14 and the maximum of 70. The mean Intrinsic Satisfaction scale score
was 57.7, with a standard deviation of 7.64, and a range from 20 to 70. Finally, scores
on the Extrinsic Satisfaction scale can range from a minimum of 6 to a maximum of 30.
The mean Extrinsic Satisfaction scale score was 19.3, with a standard deviation of

4.56, a low score of 6, and a high score of 30.

Laple 31: M_ianesota Satisfaction Qqestionnaire Scores

 

 

 

 

Variable Mean Std. Dev. Range Minimum Maximum
General

Satisfaction 75.9 1 1.2 62 31 93
Intrinsic

Satisfaction 57.7 7.64 50 20 70
Extrinsic

Satisfaction 1 9.3 4.56 24 6 30

 

 

 

 

 

 

 

 

80
Hypothesis Testing

Research Hymthesis #1

The first research hypothesis proposed that psychologists’ career satisfaction
would vary as a function of the percentage of the practitioners’ caseload that was
under managed care. The study used four separate measures of the percentage of
managed care involvement: 1) the proportion of cases requiring prior approval of
treatment plans by a third party; 2) the percentage of cases that were contractual fee-
for-service (e.g. Medicare or preferred provider agreements); 3) the proportion of
cases that received services under capitated contracts; and 4) the percentage of
practitioners’ income that was derived from third party payments. Multiple regression
was used to examine the relationship among the variables.

The results supported the research hypothesis: General Satisfaction was
significantly related to both the percentage of income that was derived from third party
payments (p<.01) and the percentage of cases that were contractual fee-for-service
(p< .05). The percentage of income derived from third party payments was negatively
correlated with General Satisfaction: increased income from third party sources was
associated with lower General Satisfaction scores. Overall, these two variables
accounted for 9% of the variance in General Satisfaction.

Intrinsic Satisfaction was also significantly related to both the percentage of
income derived from third party payments (p<.001) and the percentage of cases that

were contractual fee-for-service (p<.05). Third party income was had an inverse

relationship with Intrinsic Satisfaction: higher percentages of income derived from
third party sources was associated with lower Intrinsic Satisfaction. Overall, third party
income and contractual fee-for service caseload explained 8% of the variation in

Intrinsic Satisfaction scores. Extrinsic Satisfaction was not related to any of the four

81

measures of managed care involvement.

Table 32: Managed Care Involvement and Career Satisfaction

 

Variable

General Satisfaction

Intrinsic Satisfaction

 

 

 

 

 

Percentage of Income from p < .01 p < .001
Third Party Payments 2 - .18 r = - .20
Percentage of Cases: p < .05 p < .05

Contractual Fee-for-Service r = .02 r = .01

 

 

82
Research Hmthesis #2

The second research hypothesis proposed that the Intrinsic Satisfaction scores
on the MSQ would be greater than the Extrinsic Satisfaction scores. A simple
comparison between the total scores on the two scales would be misleading, due to
the disparity in the number of items on each scale: the Intrinsic Satisfaction scale
contains 14 items, whereas the Extrinsic Satisfaction scale has only 6. To facilitate an
accurate comparison between the two measures of satisfaction, the item responses
were summed, and then divided by the total number of items, rendering an average
Intrinsic Satisfaction item score and an average Extrinsic Satisfaction item score. These
scores were then compared using a paired sample t-test. The results supported the
research hypothesis: the Intrinsic Satisfaction scores were significantly higher than the

Extrinsic Satisfaction scores (p<.001).

Table 33: t-test for Paired Samples

 

 

 

Variable Meg SD SE of Meg
Average Intrinsic MSQ 4.16 1 .08 .092
Average Extrinsic MSQ 3.28 .77 .066
Paired Differences

Mean SD SE of Mean t-value df 2flil Sig
.877 1.102 .093 9.39 138 p< .001

95% Cl (.693, 1.062)

83
Research Hymthesis #3

The third research hypothesis suggested that career satisfaction would vary as a
function of practitioner demographic characteristics. The relationship among the
variables was assessed using the Pearson r correlation for the continuous variables, and
analysis of variance (ANOVA) for the categorical variables. Alpha level was set at .01 to
reduce the chance of Type 1 error.

General Satisfaction was significantly related to six variables. Overall, male
psychologists were significantly more satisfied with their career than females (p<.01).
Both family income and the percentage of clients who were white collar professionals
were positively correlated with General Satisfaction (p< .01): higher income and
increased proportion of white collar clients were both associated with higher levels of
satisfaction. Conversely, work time spent doing non-reimbursable tasks and work time
involved with utilization review were negatively correlated with General Satisfaction
(p<.01): increased time spent in non-billable tasks and utilization review were both
associated with lower career satisfaction. Work setting was also significantly related to
General Satisfaction (p<.01). Practitioners involved in solo independent or group
independent practice had the highest levels of General Satisfaction, while
psychologists employed in community mental health facilities and staff HMOs had the
lowest.

After the initial statistical analysis, the six variables - gender; family income;

percentage of clients that were white collar workers; worktime spent in non-billable

84

tasks; worktime involved in utilization review; and work setting - were entered in a
multiple regression equation to determine the amount of variance in General
Satisfaction that was accounted for by the demographic variables. Altogether, these six

variables accounted for 36% of the variance in General Satisfaction.

Table 34: Demographic Variables Related to General Satisfaction.

 

 

 

 

 

 

 

 

 

 

Demographic Variable Probability
Correlation Coefficient
Gender p < .01 r = - .260
Family Income p < .01 r = .262
Percentage of Caseload:
White Collar Clients p < .01 r = - .298
Worktime Spent on Non-billable Tasls p <. 01 r = - .241
Worktime Involved with Utilization Review p < .01 r = — .262
Work Setting p < .01 r = .265

 

85
Research Hyppthesis #4

The fourth research hypothesis proposed that career satisfaction would vary as
a function of predictors representing managed care business practices, managed care
communications, and practitioners’ experience of ethical dilemmasassociated with
third party payors and managed care. The Practice of Psychology Survey data related
to these predictor variables was reduced through principle components factor analysis,
using a Varimax rotation. Following the data reduction, the relationships among the
variables were examined using multiple regression.

The initial factor analysis revealed multiple collinearity among the variables. A
preliminary analysis suggested that the fourteen ethics questions might have been
responsible for the collinearity. The rationale for this perception was based on the
nature of the questions: answering the emotional response items (G44, G46, G48,
050, 052, and 054) was predicated on the occurrence of the precipitating ethical
dilemma (survey items C-43, G45, G47, G48, C-51, and 053).

The fourteen ethics questions were removed, and the analysis was rerun
successfully, resulting in a final three factor structure. The three factors had Eigenvalues
of 6.7, 2.7, and 1.6 respectively. Variables with a factor loading of less than .40 were
eliminated. Examination of the data revealed three discrete factors, with no variables
having multiple factor loadings, and with all variables except demand for services
included in one of the three factors. Analysis of the component variables allowed the

three factors to be defined as follows: 1) Managed Care Interactions, composed of

86
fourteen items; 2) Managed Care Influence over Treatment, comprised of five items;

and 3) Allotment of Treatment Sessions, containing two items. A multiple regression
analysis revealed that both General Satisfaction (p<.05) and Extrinsic Satisfaction
(p<.001) were significantly related to Managed Care Interactions. The data also
showed that Intrinsic Satisfaction was significantly correlated with factor 2, Managed
Care Influence over Treatment (p<.01).

Having ascertained that the first factor representing managed care or third party
variables was significantly related to both General Satisfaction and Extrinsic
Satisfaction, and that the second factor was significantly associated with Intrinsic
Satisfaction, the data analysis followed with an examination of the relationship
between the individual component variables of the two factors and the three outcome
measures. The purpose of this additional investigation was to identify the specific
variables that were associated with the three outcome measures - General Satisfaction,
Intrinsic Satisfaction, and Extrinsic Satisfaction. Identification of the individual variables
that contribute to career satisfaction may be useful in providing a point of departure in
future efforts to improve the current relationship between mental health practitioners
and third party payors.

Because of the large number of items contained in the first factor, Managed
Care Interactions, the component variables were divided into three subfactors for
purposes of data analysis. The purpose of this subdivision was to provide a more

accurate assessment of the relationship between the component variables and the

87

outcome measure: a regression analysis containing fourteen items may omit some
significant contributions. The first subfactor was defined as the Impact of Third Parties,
which included four items: 1) the overall impact of managed care on the practice of
psychology; 2) the effect of third party payors on the quality of care; 3) the impact of
third party payors on the development of treatment relationships; and 4) third party
payors’ influence over clinical decisions. The second subfactor was termed Timeliness,
and contained items related to the availability of case managers, the time required for
messages to be returned or treatment to be authorized, and the amount of time
required for services to be reimbursed. The third subfactor was termed Personnel, and
was comprised of items concerning collaboration with case managers, practitioners’
experiences with reauthorization, and the Iicensure status and professionalism of
managed care personnel.

Multiple regression analysis showed that General Satisfaction was significantly
related to four specific variables: the availability of case managers (p< .01); the impact
of third party payors on treatment relationships (p<.01); the Iicensure status of
managed care personnel (p<.01), and the influence of third party payors over
treatment decisions (p<.05). These four variables accounted for 15 % of the variance
in General Satisfaction.

Intrinsic Satisfaction was also significantly correlated with four variables: the
influence of third party payors over treatment decisions (p<.01); the impact of third

parties on treatment relationships (p<.01); the availability of case managers (p<.01);

88

and the professionalism of managed care personnel (p<.05). Overall, these four items
accounted for 12% of the variance in the Intrinsic Satisfaction scores.

Finally, Extrinsic Satisfaction was significantly related to four variables: the
overall impact of managed care on the practice of psychology (p<.01); the availability
of case managers (p<.001); the Iicensure status of utilization review personnel
(p<.001), and the impact of third party payors on the demand for practitioner services
(p<.05). These four variables were responsible for 16% of the variance in Extrinsic
Satisfaction.

A separate factor analysis was performed on the fourteen ethics questions,
which revealed a three factor structure with multiple collinearity. The first twelve
questions were then divided into odd and even numbered items, which corresponded
to the occurrence of ethical dilemmas and practitioners’ emotional reactions to those
situations. Separate factor analyses were completed on the two groups of items,
without any further indications of multicollinearity. The occurrence questions were
grouped into a one factor solution, while the reaction items resolved into two factors.
The Pearson correlation coefficient was used to examine the relationship between the
occurrence factor and the outcome measures, and multiple regression was used to
examine the relationship between the occurrence and emotional reaction factors and
the criterion variables. Review of the data indicated that none of the three outcome
measures were related to the occurrence of ethical dilemmas, but that all three were

significantly correlated with practitioners’ reactions to those ethical conflicts.

89

Multiple regression analysis revealed that General Satisfaction, Intrinsic
Satisfaction, and Extrinsic Satisfaction were all related to practitioners’ reactions to two
specific situations: 1) reporting family or couples treatment as individual therapy
(p<.01); and 2) selecting a treatment approach to conform with third party
reimbursement guidelines (p<.01). Overall, practitioners who had stronger negative
reactions to these two ethical dilemmas reported lower levels of career satisfaction
across all three domains: General Satisfaction, Intrinsic Satisfaction, and Extrinsic
Satisfaction. In addition, Extrinsic Satisfaction was also significantly related to
practitioners’ views on the impact of utilization review on confidentiality (p<.05):
psychologists who thought that peer review processes used by insurance companies
had a negative impact on patient confidentiality reported lower levels of Extrinsic

Satisfaction.

90
Table 35:

Third Pam Payor and Managed Care Variables Related to Career Satisfaction

 

 

General Satisfaction

Intrinsic Satisfaction

Extrinsic Satisfaction

 

 

Ethics: Reporting
Family/Couples Treatment as
Individual Therapy
p < .01
r = - .432

Availability of Case Managers
p < .01
r = - .261

Third Parties’ Impact on the
Treatment Relationship
p < .01
r = - .280

Ethics: Selecting a Treatment
Approach to Conform with
Reimbursement Guidelines

p < .01
r = - .416

Licensure Status of UR
Personnel
p < .01
r = - .213

Third Party Payors’ Influence
over Treatment Decisions
p < .05
r = - .226

 

Ethics: Reporting
Family/Couples Treatment as
Individual Therapy
p < .01

= - .444

Third Party Payors’ Influence
over Treatment Decisions
p < .01

= - .282

Ethics: Selecting a Treatment
Approach to Conform with
Reimbursement Guidelines

p < .01
r = - .323

Third Parties’ Impact on the
Treatment Relationship
p< .01

= - .242

Availability of Case Managers
p < .01
r = - .188

Professionalism of Managed
Care Personnel
p < .05
= - .175

 

Availability of Case Managers
p < .001
r = - .272

Licensure Status of UR
Personnel
p < .001
= - .306

Overall Impact of Managed
Care on the Practice of ‘I’
p < .01

= - .240

Ethics: Reporting
Family/Couples Treatment as
Individual Therapy
p < .01
r = - .290

Ethics: Selecting a Treatment
Approach to Conform with
Reimbursement Guidelines

p < .01
r = - .389

Ethics: Peer Review Potential
for Jeopardizing Confidentiality
p < .05
r = - .239

Impact of Third Party Payors on
Demand for Services
p < .05
r = - .211

 

 

91

Adding ethics items to the multiple regression equations resulted in
considerable gains in the amount of explained variance in the criterion measures.
Including the two ethics items into the regression equation for General Satisfaction
increased the explained variance from 15% to 41 %. Adding the same two variables to
the Intrinsic Satisfaction regression equation raised the explained variance from 12% to
32%. Finally, including the three additional ethics items to the regression equation for
Extrinsic Satisfaction increased the explained variance from 16% to 36%.

Finally, a hierarchical regression was performed to examine the amount that
statistically significant managed care and third party variables contributed to the
variance in all three types of satisfaction scores, while controlling for the influence of
the demographic variables. A review of the data analysis showed that six managed
care and third party payor predictor variables were significantly related to General
Satisfaction: the availability of case managers; the impact of third party payors on
treatment relationships; the Iicensure status of managed care personnel; the influence
of third party payors over treatment decisions; reporting family or couples treatment as
individual therapy; and selecting a treatment approach to conform with third party
reimbursement guidelines. Altogether, these six variables accounted for 25.5% of the
variation in General Satisfaction scores, after controlling for the influence of the
significant demographic variables.

The same procedure was used to examine the relative contribution of the

relevant predictor variables to variation in Intrinsic and Extrinsic Satisfaction scores.

92

There were six predictor variables that were significantly associated with Intrinsic
Satisfaction: the availability of case managers; the impact of third party payors on
treatment relationships; the professionalism of managed care personnel; the influence
of third party payors over treatment decisions; reporting family or couples treatment as
individual therapy; and selecting a treatment approach to conform with third party
reimbursement guidelines. These six variables contributed 25.3% of the variance in
Intrinsic Satisfaction scores, after controlling for the contribution of the significant
demographic variables.

Finally, the seven variables related to Extrinsic Satisfaction were examined for
their unique contribution. The seven variables were: the availability of case managers;
the impact of third party payors on the demand for services; the Iicensure status of
managed care personnel, the overall impact of managed care on the practice of
psychology; reporting family or couples treatment as individual therapy; selecting a
treatment approach to conform with third party reimbursement guidelines; and the
impact of peer review processes on patient confidentiality. Taken together, these
seven predictor variables accounted for 26.1% of the variation in Extrinsic Satisfaction
scores, after controlling for the demographic variables.

Table 36:
Variance Accounted for by Third Pam Payor and Managed Care Variables

 

General Satisfaction Intrinsic Satisfaction Extrinsic Satisfaction

 

 

25.5% 25.3% 25.7%

 

 

 

 

93
Testing of Theoretical Constructs

The relationship between career satisfaction and career planning was examined
using independent samples t-tests. The decision to rechoose psychology as a career
was significantly related to all three outcome measures: General Satisfaction (p<.001);
Intrinsic Satisfaction (p<.01); and Extrinsic Satisfaction (p<.001). Similarly, there was
a significant relationship between three outcome measures - General Satisfaction,
Intrinsic Satisfaction, and Extrinsic Satisfaction - and changing careers within the next

five years (p<.01).

Table 37: TheoQL of Work Adjustment

 

 

 

 

Extrinsic Satisfaction
Variable General Satisfaction Intrinsic Satisfaction
Rechoose Psychology p < .001 p < .01 p < .001
= - .394 r = - .326 = - .353
Change Careers p < .01 p < .01 p < .01
Within Next 5 Years r = .428 r = .383 r = .278

 

 

 

 

 

CHAPTER 4
DISCUSSION
Conclusions
Career Satisfaction

One of the primary objectives of this research was to identify the constructs that
were associated with variation in career satisfaction among psychologists. This study
made a substantial contribution towards that goal. For this sample, 62% of the total
variance in General Satisfaction was explained by the demographic and managed care
predictor variables employed in this study.

This study investigated career satisfaction using both global and specific
measures. The first global measure - the choice of psychology as a career - has
remained fairly stable over the last ten years. In this study, 70% of the practitioners
indicated that they would make the same career choice a second time. This proportion
is similar to the findings of Norcross and Prochaska (1983) and Norcross, Prochaska, 8:
Farber (1993): Norcross and Prochaska (1983) found that 70% of their sample of
members of the APA’s Division 29 (Psychotherapy) would rechoose psychology as a
career, and Norcross, Prochaska, 8: Farber’s follow-up 1993 study showed that 68% of
the Division 29 psychologists in their sample would also select psychology as a career
if given the opportunity to rechoose.

The second global measure of career satisfaction was the proportion of

psychologists who were planning on changing careers within the next five years. The

94

95
results of this study suggest that a growing percentage of practitioners are dissatisfied

with their careers. In response to the current survey, 13% of the psychologists
indicated that they were planning on changing careers in the near future, compared
with only 7% in Norcross, Prochaska, and Farber’s 1993 study, a substantial increase in
only four years.

One of the secondary objectives of this study was to establish an accurate
baseline assessment of career satisfaction among psychologists, using a valid and
reliable instrument. Using the Minnesota Satisfaction Questionnaire as the criterion
measure, the results of this study reflect a substantial downward trend in career
satisfaction among psychologists.

Weiss, Dawis, Lofquist, and England (1967) recommend using percentile scores
in interpreting MSQ scores. In their Manual for the Minnesota Satisfaction
Questionnaire, high career satisfaction is defined by scores above the 75th percentile,
and low satisfaction is indicated by scores below the 25th percentile. Scores in the
middle range between the 25th and 75th percentile represent average career
satisfaction. The mean General Satisfaction raw score on the MSQ was 75.9, which
corresponds to the 45th percentile among employed non-disabled workers. For
interpretive purposes, this result places psychologists in the middle of the average
range of career satisfaction.

The results of this study can be compared with Norcross, Prochaska, and

Farber’s 1993 survey of career satisfaction. Although the two studies used slightly

96
different populations - this study used a random sample drawn from the all the

members of the APA, while Norcross and his colleagues surveyed members of APA
Division 29 (Psychotherapy) - the groups share sufficient similarities to allow an
investigation of broad trends in career satisfaction. Analysis of the percentile scores
generated by the current study show that 31% of the practitioners could be classified _
as highly satisfied with their careers, compared with 47% of the psychologists in the
Norcross et al. 1993 sample, which represents a substantial downward trend over a
four year period. Similarly, while only 10% of the Norcross et al. sample were
dissatisfied with their careers, over 22% of the psychologists in the current study were
classified as having low career satisfaction, suggesting a considerable increase in the
number of psychologists who are dissatisfied with their careers.

Although these two studies used different sample populations - APA members
who are licensed psychologists versus psychologists who are members of APA’s
Division 29 - the results suggest a very powerful trend, and may represent a substantial
change in career satisfaction over a very short period of time. This shift in career
satisfaction has coincided with the recent rise of managed care. Is the shift in career
satisfaction connected with the increased presence of third parties in the provision of
clinical services?

The results of this study provided strong evidence that career satisfaction is
linked with managed care. The data revealed that both General Satisfaction and

Intrinsic Satisfaction were significantly related to two measures of involvement with

97
managed care and third party payors: the percentage of income derived from third

party payments (p<.01 and p<.001 respectively), and the proportion of cases that
were served under contractual fee-for-services arrangements (p<.05 for both General
Satisfaction and Intrinsic Satisfaction). Both General Satisfaction and Intrinsic
Satisfaction were inversely related to involvement with managed care and third party
payors: higher involvement was associated with lower satisfaction.

The relative degree of Intrinsic and Extrinsic Satisfaction is another index of the
association between career satisfaction and managed care. If third party involvement is
related to career satisfaction, Intrinsic Satisfaction scores should be higher than
Extrinsic Satisfaction scores, because managed care is not an essential or inherent
aspect of the provision of psychological services. The results of the data analysis
provide support for this hypothesis: the difference between these two satisfaction
domains was significant at the .0001 level, providing additional support for association
between managed care and career satisfaction.

Given the apparent relationship between third party involvement and career
satisfaction, what specific aspects of managed care are associated with variations in the
respective outcome measures? A number of predictor variables were consistently
associated with career satisfaction across the outcome domains of General Satisfaction,
Intrinsic Satisfaction, and Extrinsic Satisfaction. Two of the most important predictors
concerned professional ethics: reporting family or couples therapy as individual

treatment, and selecting a treatment approach on the basis of reimbursement

98
guidelines. The relative availability of case managers was the third variable connected

with all three outcome measures: longer waits were associated with lower levels of
career satisfaction.

In addition to these common predictor variables, each of the outcome domains
was associated with specific independent variables. General Satisfaction was related to
three predictors: the impact of third party payors on the treatment relationship; the
influence of third party payors over treatment decisions; and the Iicensure status of
utilization review personnel. Intrinsic Satisfaction was also associated with the impact
of third party payors on the treatment relationship and the influence of third party
payors over treatment decisions, as well as the professionalism of managed care
personnel. Finally, Extrinsic Satisfaction was linked with the Iicensure status of
utilization review personnel, the overall impression of the impact of managed care on
the practice of psychology, the potential for peer review to compromise patient
confidentiality, and the impact of third party payors on the demand for the
practitioners’ services.

The most remarkable finding was the relative strength of the ethics items in
predicting satisfaction scores. Without question, the ethics items were the most
powerful predictors across all three domains of career satisfaction. Adding the two
ethics items to the General Satisfaction regression equation increased the explained
variance from 15% to 41 %. The same trend was evident in the other two outcome

domains: including the ethics items in the Intrinsic Satisfaction equation raised the

99
explained variance from 12% to 31%, and adding the three ethics variables to the

Extrinsic Satisfaction equation led to an increase in explained variance from 16% to
35%.

The ethics questions revealed a number of interesting trends. First, the
incidence of ethical dilemmas was not related to any of the outcome measures.
Instead, it was the practitioners’ reactions to the occurrence of ethical dilemmas that
predicted career satisfaction. As might be expected, psychologists felt most
comfortable in giving patients less severe diagnoses. On the other hand, practitioners
were most distressed with giving patients less treatment than they required.

The results of the study showed that providing psychological services in the
current business environment is frequently associated with ethical compromise. These
results are even more striking when one considers that endorsing the questionnaire
items implied that the respondent was violating the APA Code of Ethics, as well as
state laws concerning insurance fraud. The percentages are alarming: 60% of the
psychologists in the survey reported giving patients more severe diagnoses than were
warranted by the presenting symptomology, in order to comply with reimbursement
guidelines and obtain services for their clients. The impact of a severe psychological
diagnosis in a medical record should not be underestimated: in the event that a patient
decides to change insurance plans, or is required to make a shift due to a change in
jobs, diagnostic exclusions may prevent the patient from obtaining health care

coverage. In addition to deliberate misdiagnosis, 70% of the psychologists in the study

100
have reported family or couples therapy as individual treatment, and 79% of the

practitioners indicated that they had given less treatment than patients required, due
to reimbursement guidelines. The prevalence of ethical violations and the high
incidence rate of misrepresentation of treatment among practitioners provide strong
evidence that psychologists are being forced into untenable positions by systemic
forces. Ethical violations are inevitably detrimental to the profession: the question
remains whether psychology can survive a situation where practitioners routinely
violate their own ethical code.
Gander and Qreer gtisfaction

There was a significant difference in General Satisfaction between the male and
female psychologists in the study (p< .01): the results indicated that male practitioners
are more satisfied than their female counterparts. Further investigation using analysis of
variance indicated that gender was significantly associated both with the scores on the
Extrinsic Satisfaction scale (p<.001), and with the responses to the seven item
constellation of questions concerning satisfaction with managed care (p<.01). Once
again, male practitioners were more satisfied than female practitioners. Overall, there
was no apparent difference between male and female participants in terms of Intrinsic
Satisfaction scores.

Several different hypotheses may be advanced to explain these differences.
One explanation may be that women have a more negative reaction to managed care.

This proposition was supported by fact that the female psychologists in the study had a

101
significantly more negative evaluation of the impact of managed care on the practice

of psychology (p<.01). In addition, the women in the sample had a stronger reaction
to the Iicensure status of utilization review personnel (p<.01) and the potential
negative impact of peer review on patient confidentiality (p<.01). Finally, the female
respondents did not experience the same degree of collaboration with case managers
(p<.05): they indicated that it took longer for them to have their messages returned
(p< .05) and receive authorization for services (p< .05).

An alternative explanation of the difference in career satisfaction between male
and female psychologists can be found in the demographic variables. In particular, the
female psychologists in the study had been in the profession for a significantly shorter
period of time compared with male practitioners (p<.01). Although there was no
direct measure of individual income generated by their practices, the female
practitioners in the survey reported that they relied more heavily on the income
generated by their practice (p<.001), even though their earnings contributed a smaller
percentage towards the total family income (p<.01). Similarly, the female
psychologists indicated that they spent less time performing reimbursable tasks,
compared with the males in the sample (p<.001). Though the discrepancy in income
may be an artifact of the disparity in the amount of time that the respondents have
been involved in delivering psychological services, the differences between the two
groups suggest that the female respondents felt that they were under more pressure

than the males to produce income. The strain of greater perceived responsibility for

 

102
financial security, coupled with their relatively reduced earning power, may have led

to lower levels of career satisfaction among female practitioners.
Theogy of Work Adjustment

The study provided considerable evidence supporting the Theory of Work
Adjustment. Rounds, Dawis, and Lofquist (1987) examined the relative contributions .
of occupational reinforcer patterns and worker needs to career satisfaction. The results
showed that occupational reinforcers were more important than individual needs in
predicting career satisfaction. After establishing the relative strength of reinforcers,
patterns of specific occupational reinforcers were assessed along three dimensions:
reinforcer elevation, a measure of the strength of a specific reinforcer; scatter; and
profile shape, which captured the presence, rather than the degree, of the reinforcer.
After examining the three different dimension of occupational reinforcers using
multiple regression analysis, the authors concluded that profile shape was the most
effective predictor of career satisfaction.

The salient profile shape of reinforcers for counseling psychologists and clinical
psychologists included the following elements: 1) altruism (the opportunity to benefit
other people through their work, as well as the chance to perform their work-related
duties without feeling that they are morally wrong); 2) autonomy (the freedom to try
out their own ideas, make decisions on their own, and carry out their work without a
great deal of supervision; and 3) achievement (the opportunity to make use of their

individual abilities and gain a sense of accomplishment).

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The results of the study are consistent with predictions based on the theory.

The data showed that General Satisfaction was significantly related to variables that
corresponded with the three key occupational profile reinforcers: altruism, autonomy,
and achievement. Work Adjustment Theory and subsequent research suggested that
altruism, or doing work without feeling that it was morally wrong, was important for
psychologists. This study provided evidence that ethics variables were the single most
important predictor of career satisfaction. Similarly, the research literature indicated
that autonomy, which included making their own decisions and trying out their own
approaches, were important reinforcers for psychologists. These predictions were also
confirmed by the data this from study, which showed that General Satisfaction was
significantly related both to third party payors’ influence over treatment decisions
(p<.05), and to selecting treatment approaches to conform with third party
reimbursement guidelines (p<.01).

Finally, the Practice of Psychology Survey generated data on practitioners’
satisfaction with specific aspects of managed care (items B-29 through B-35 on the
questionnaire). The last item, B-35, concerned psychologists' satisfaction with the
acknowledgment that they received from case managers and utilization review
personnel, and served as an index of the final occupational reinforcer: achievement.
The average scores for this item revealed that practitioners were dissatisfied with the

acknowledgment that they received from case managers, and subsequent data analysis

104
showed that this achievement reinforcer was also significantly related to General

Satisfaction (p< .05; r= .25).

Finally, this study also generated support for one of the propositions associated
with Work Adjustment Theory. Proposition VII (Weiss, Dawis, England, 8: Lofquist,
1967) predicts that the probability of changing work environments is inversely
proportional to the workers’ degree of satisfaction. Inspection of the data using analysis
of variance showed that General Satisfaction was strongly related to planned career
change (p< .0001).

Limitations

While limitations in any research endeavor are unavoidable, this study took
steps to minimize the threats to validity through the use of random sampling and an
adequately sized sample. While the survey sample corresponded well with the general
demographic characteristics of the membership of the APA, caution should be used in
generalizing the results.

Although this study was designed to be comprehensive, it must be
acknowledged that career satisfaction is a complex construct. The process of research
is one of incremental improvements: all models, and all conclusions, will always be
incomplete. Consequently, the correlational nature of this research must be
emphasized: although the study found that third party payor and managed care
variables were associated with career satisfaction, it did not establish that those

predictors were responsible for causing the variation in career satisfaction scores.

1 05
It should be recognized that there are alternative explanations for the results of

this study. Practitioner dissatisfaction may in fact stem from personal characteristics,
and not from outside institutional forces. For example, psychologists have traditionally
been independent operators, and have become accustomed to developing their own
standards of practice. The new marketplace has changed the nature, and the source,
of professional standards of practice. Membership on managed care panels may result
in practitioners being held to expectations that reflect the priorities of a corporate
culture. Psychologists who were not accustomed to the imposition of standards by
outside forces must now accept that they are accountable to third parties, in addition
to their clients and their peers. The low levels of career satisfaction reported by many
practitioners in this study may be a reflection of their unwillingness to change in the
face of these new demands and new environments.

Despite the attempts to avoid limitations, a number of methodological
shortcomings remain. Although the total return rate of 28% was comparable to the
33% response rate of the APA CAPP study, it falls short of complete participation by all
the subjects in the sample pool. Consequently, self-selection may have played a role in
the determination of the results. Similarly, both of the instruments in the study were
self-report measures, and may have suffered from the effects of deliberate or
accidental errors by the respondents. In addition, although the inclusion of questions

in the Study on the Practice of Psychology survey was based on previous

106
questionnaires and relevant research, the reliability and validity of the instrument

remain uncertain.

Because this study attempted to gain a thorough understanding of the factors
that influenced career satisfaction among psychologists, the survey incorporated a large
number of variables. Assessing the relationships among these variables entailed a large
number of tests. Although the amount of testing was kept to a minimum through the
use of multiple regression and ANOVAs, Type I error remains a possibility.

The Minnesota Satisfaction Questionnaire contained a number of limitations.
The construction of the instrument reflected its original purpose, which was to assist
career counselors in assessing current career satisfaction. The design team identified
twenty items that contributed to career satisfaction. The twenty items of the General
Satisfaction scale were entered into a factor analysis, and then partitioned into two
subscales: Intrinsic Satisfaction, with 14 items, and Extrinsic Satisfaction, which had 6
items. This arrangement appeared to meet the career counselor’s need for an omnibus
satisfaction assessment tool.

Unfortunately, the distribution of the items into uneven subscales resulted in an
arbitrary weighting, which favored the Intrinsic Satisfaction scales. Due to the 2:1
disparity in the number of subscale items, reinforcer items that correspond with the
inherent aspects of a career exert a disproportionate leverage on the General
Satisfaction scale. Conversely, the limited number of items in the Extrinsic Satisfaction

scale make it difficult to detect changes in General Satisfaction due to external factors.

107
The unequal distribution of items into their respective scales may have created

an instrumentation artifact that affected the outcome of the study. Managed care and
third party interactions are external - they are not an inherent aspect of providing
psychological services. As such, they would naturally fall into the realm of Extrinsic
Satisfaction. However, the limited number of items in that scale made it difficult for
managed care and third party variables to exert an influence over General Satisfaction
scores.

This limitation was especially relevant to this study, because 41% of the
respondents identified themselves as solo independent practitioners. Because they are
self employed, these practitioners could not answer items 5 and 6 on the MSQ, which
concern the respondents’ relationships with their ’boss” or supervisor. Leaving out
responses on these two items reduces the Extrinsic Satisfaction scale to four questions,
creating a considerable barrier to the assessment of the role of managed care and third
party payors on General Satisfaction.

The potential impact of the unequal scales on the results of this study can be
estimated by modifying the Extrinsic Satisfaction scale to reflect the nature of the
research population. The modification began by investigating average scores on the
MSQ Extrinsic Satisfaction scale and the seven items on the Study on the Practice of
Psychology (SPP) that corresponded to satisfaction with managed care. A paired
sample t-test showed that the average scores on the two sets of questions were

significantly different at the .0001 level.

108
The MSQ Extrinsic Satisfaction scale was expanded by including four questions

specifically relating to managed care: B-29, which concerned practitioner satisfaction
with the competence of case managers and UR personnel; B-30, which addressed the
professionalism of case managers and UR personnel; B-31, which assessed the
management skills of case managers and UR personnel; and B-35, which gauged the ‘
practitioners satisfaction with the amount of acknowledgment that they received from
case managers and UR personnel for doing their job well.

Factor analysis revealed a three factor solution. The first two factors
corresponded exactly to the content items of Extrinsic Satisfaction scale, and contained
two items related to supervisors (MSQ questions 5 and 6) and four items concerning
pay, company policies, chances for advancement, and praise for doing a job well
(MSQ questions 12, 13, 14, and 19). The third factor corresponded precisely to the
additional four items from the Study on the Practice of Psychology (SPP). None of the
SPP items loaded above .25 on the MSQ factors, and none of the MSQ items loaded
above .25 on the SPP factor.

A regression analysis was performed on the managed care variables, with two
new outcome variables: 1) the modified extrinsic satisfaction scale, which included the
four additional questions related to satisfaction with managed care; and 2) a new
general satisfaction scale, which reflected the changes in the modified extrinsic

satisfaction scale. The analysis found three additional managed care variables that

1 09
were significantly related to general satisfaction, and five more managed care predictor

variables that were significantly linked to extrinsic satisfaction.

Finally, the construction of the MSQ does not lend itself to the resolution of a
vital question: which is more important in determining overall career satisfaction -
Intrinsic Satisfaction or Extrinsic Satisfaction? In addition, the MSQ does not address
the relationship between demographic factors (e.g. age or income) and career
satisfaction. These shortcomings suggest that the MSQ may benefit from a revision.
Future researchers may also want to consider modifying the MSQ to reflect the specific
characteristics of their sample pool.

Implications
Directions for Future Research

While this study answered a number of questions related to career satisfaction
among psychologists, several important issues remain. This study clarified the
relationship between managed care and career satisfaction, but it did not address the
relative importance of intrinsic versus extrinsic satisfaction in determining the overall
career satisfaction among psychologists. In addition, the results of this study showed
that several aspects of managed care involvement were related to Intrinsic Satisfaction,
suggesting that the dividing line between Intrinsic and Extrinsic satisfaction may not be
a function of the apparent inherent or external nature of the source of the satisfaction.

Further research may help to clarify these definitions.

110
The relationship between Intrinsic Satisfaction and managed care variables

suggests that third party involvement may have an impact on the satisfaction that
practitioners derive from the provision of psychological services. This hypothesis is
counter-intuitive: by definition, Intrinsic Satisfaction should be limited to those aspects
of a job that are inherently involved in its performance.

Certainly, the prospect of outside systemic forces gradually eroding the
satisfaction that psychologists obtain from providing therapy has significant implications
for the future of the profession. For example, negative experiences associated with
specific managed care organizations or third party payors may result in psychological
service providers treating patients enrolled in those programs differently. Frustrations
with required documentation or delays in reimbursement may start to intrude on the
client-practitioner relationship, and have a negative impact on the outcome of therapy.
A future study examining the relationship between practitioners’ satisfaction with
managed care or third party payors and therapeutic outcomes would help to clarify the
impact of third party payors on patient care.

Potential Avenqes of Chm

It is important to acknowledge that the introduction of managed care
techniques represented an opportunity for the mental health care field. The changes
brought about by managed care had the potential to be either positive or negative. In
theory, there were a number of different ways that managed care could have

transformed the delivery of psychological services, and those changes could easily

111
have been beneficial. (It is also important to acknowledge that managed care is a new

P~——-

technology, one that is its formative stages, and still subject to growth and modification
as a natural part of the developmental process. The challenge facing the health care
industry, and the practice of psychology in particular, is to participate in shaping future
developments in managed care so that they reflect the best interests of the patientj'

Fhe problems posed by third party payors will not disappear - the proportion
of psychological services under managed care continues to grow. According to
Adelson (1997), 65 million Americans receive their health care from HMOs. Working
with managed care has become an inescapable reality for many practitioners. If
psychologists wish to change the environment in which they practice, and thereby
improve their level of career satisfaction, they will have to begin to attend to the
political, social, and economic forces that have an impact on their practice (Austad,
1992L
Legislative Initiatives

In the 1980’s, the conventional wisdom held that market forces, and not

government regulation, should determine the shape of the health care system
(Cummings, 1986). Changes in health care delivery and the standard of care over the
last decade have led to a call for legislation to control managed care (Bowers 8: Knapp,
1993; Seppa, 1997). Prior to 1990, there were no laws governing the practice of

psychology in managed care settings (Newman & Bricklin, 1990). The situation has

begun to change: Sleek (1996a) reported that five states, including California and

112
Virginia, now have laws governing the utilization review process. Psychologists are

beginning to coordinate their activities with other health-care advocacy groups, in an
attempt to change the way health care is delivered. The APA has joined with a number
of other groups to form the Coalition for Fairness in Mental Illness Coverage (Sleek,
1996b). The purpose of the coalition is to continue lobbying for patient rights in
Congress. The group has achieved some notable success already: Congress recently
decided to ban annual and lifetime dollar caps on mental health care insurance
benefits.
ludicial Initiatives

In addition to promoting change in managed care practice through legislative
initiatives, psychologists are also beginning to use the judicial system to remedy some
of the problems that are associated with working in managed care systems. Sleek
(1997) reported that a group of seven New Jersey psychologists have filed a landmark
class action suit against a managed mental health care company, in an attempt to
regain some measure of power over clinical decision-making. While progress is being
made, sweeping change is not likely in the near future. Instead, psychologists will have
to accept incremental shifts in the way that services are provided (Sleek, 1996a).
Proactive Participation

Psychologists can begin to take a number of actions in addition to legislative
and judicial initiatives. Berkman, Bassos, and Post observed that, ’Mental health

professions can best be served if mental health professionals do not abdicate their

113
responsibility and leadership to those people who are primarily experienced and

trained in the business aspects of health care.” (1988, p. 436). Flinn, McMahon, and
Collins (1987) reported that only 45% of all HMOs have a mental health director, and
only 60% of the those mental health directors were psychologists or physiciansfFor
current managed care practices to change, psychologists need to participate in the
process, and take a more active role in designing benefits packages and delivery
systems for managed mental health care organization‘sJIZimet, 1989).
Etflas
The results of this study indicate that practitioners are routinely experiencing
ethical dilemmas in the course of providing psychological services within managed
care contexts. Unfortunately, the APA Code of Ethics (1990) and the General
Guidelines for Providers of Psychological Services (1987) do not make any specific
references to managed care, and therefore cannot provide any clear direction for
practitionersINewman and Bricklin (1991) observed that the current APA guidelines
for providers may require psychologists to take responsibility for situations over which
they have no control} For example, the Ethics Code prevents psychologists from
abandoning patients. However, what are the psychologists’ responsibilities when a
third party payor prematurely terminates therapy as a result of financial considerations?
:Seventy percent of the psychologists who participated in this study reported that they

had given less treatment than a patient required due to third party reimbursement

guidelinesijFor most psychologists, the alternative to abandonment is an increasing

\_

1 14
percentage of clients who are seen on a pro bono basis. Unfortunately, that solution is

limited: extrapolated over months or years, it can result in an entire caseload of pro
bono patients, a situation which is financially untenablej"

Psychology as a profession must begin to grapple with the question of how to
respond to a situation that forces its members to contravene its own ethical code. The .
question is difficult, for it implies a fundamental decision: should psychologists attempt
to change the circumstances and forces that lead to ethical dilemmas, or should they
adapt their ethics to meet the realities of the marketplace? Historically, the APA has
taken a leadership position in establishing a model code of ethics that serve as an
example for all professions. If psychologists are to determine their own professional
code of appropriate behavior, the APA must move quickly to revise its Ethical Code to
reflect the challenges presented by managed care.

Education
fihe involvement of third party payors in the clinical decision-making process
has had an enormous impact on the provision of psychological services. The climate
and the environment have changed profoundly. Unfortunately, many psychologists are
not equipped to face the realities of these shifts in the delivery of mental health care.
Some of the lack of preparation may be traced to the current system of training
psychologists. Many authors agree that graduate schools do not prepare psychologists

for the realities of working in a managed care environment (Austad, 1992 ; Hoyt, 1992 LJ

115
Nahmias, 1992; Walfish, Moritz, 8: Stenmark, 1991) or in pre—paid capitated systems

(Bennen,1988L

Much of the current focus on changing the curriculum of graduate school
training is centered on the relationship between clinical and counseling psychology,
and on improving the technical skills of student psychologists. lrhe results of this study
suggest that future practitioners must also be trained in the pragmatic aspects of
delivering psychological services in managed care contexts. Future students will benefit
from more extensive coursework in the identification and resolution of ethical
dilemmas related to third party payors and managed carffifudents will also need to
develop a sound theoretical knowledge of the fundamentals of brief therapy, and be
able to demonstrate their proficiency with these models in practicum settings.

In order to be successful in the current marketplace, practitioners must be able
to substantiate the efficacy of their interventions. This mandate is consistent with the
traditional scientist-practitioner model of psychology, in which theory and practice are
informed by research. The skills of the scientist-practitioner model are indispensable,
and adequate training in the future should include a balanced curriculum, one that

continues to emphasize both research and practical application J

APPENDICES

APPENDIX A

HMO:

116
APPENDIX A

GLOSSARY

"An HMO is a health care system that proVides comprehensive outpatient and
hospital services (including mental health services) for enrolled members for a
fixed, pre-paid annual fee through a single payment mechanism.” (Bloom,
1990: p. 1 10)

Staff HMO:

”In a staff model HMO, providers are salaried employees who work regular
hours (usually in specified location) and are not involved in financial risk
sharing.” (Austad & Sherman, 1992: p. 3)

Group HMO:
”A group of physicians, usually a partnership or separate corporation, contracts
to provide necessary services on a capitated basis” (Bennett, 1988: p. 1546)

Managed mental health care organization (MMHCO):

Payor:

"A managed mental health care organization provides comprehensive
outpatient and inpatient mental health services usually including treatment
services for alcohol and drug abuse using a variety of reimbursement models.
The MMHCO usually contracts with employers, insurers, or even HMOs to
provide a specified set of services to their covered employees or subscribers
through a fixed prepaid fee, or through a network of fee-for-service mental
health professionals whose efforts at cost containment may include a variety of
UR procedures." (Bloom, 1990, p. 111)

The party, usually insurers, that reimburses providers for services.

Preferred provider organization (PPO):

"In Preferred Provider Organizations (PPO) payers purchase health care
services from selected providers, at a discount. The provider receives an
increased volume of patients in exchange for discounted fees. Providers keep
their fee-for-service billing but with a fee discount to attract new business and
are not at risk.” (Austad 8: Sherman, 1992, p. 4)

Providers:

Professional medical or mental health practitioners

Purchaser:

117

The individual or corporation that buys a package of health care benefits from
an HMO or insurer.

APPENDIX B

118
APPENDIX B

SAMPLE: STUDY ON THE PRACTICE OF PSYCHOLOGY

Please answer all questions as thoroughly and accurately as you can. The information that you provide
will contribute to a more comprehensive understanding of the current nature of the practice of
psychology. All replies to this questionnaire will remain anonymous. If you have any questions, or
would like any further information, please contact Brooke Stevens, Kirby Hill, Jericho, New York
11753; (516) 921-4818.

 

7 Directions: Please answer questions by marking the space to the left of the appropriate response.
*Ifyou work Ill more than one environment, your responses should reflect your primary practice,
or the setting where you spend the majority of your professional time. ' 1

Do you spend at least twenty hours per week providing psychological services? (Psychological services
are defined as direct client or patient contact, providing individual, conjoint, family, or group
psychotherapy, counseling, or assessments)

Yes
No

If your answer is Y_es_, go to question A-1. If your answer is Np, you do not need to proceed further.
Please return this questionnaire in the envelope provided. Thank you!

I - RAPHI INFORMATION
A-1. In what year were you born?

19

A-2. What is your gender?
Male
Female

A-3. What is your racial/ethnic background?
Black/African American Caucasian

Alaska Native/American Indian Hispanic American
Asian/Pacific Islander

Other:

 

A-4. In what year did you receive your Doctorate?

19

A-S. Since receiving your Doctorate, how many years have you worked at least twenty
hours per week (or its equivalent) providing psychological services?

119

 

A-10.

A-11.

S

B-12.

How many wage earners contribute to your family’s income? (Count yourself as
one.)

What was your family’s total annual income for 1995? (Include income from all
sources, e.g. rental income, investments, child support, alimony, etc.)

Less than $25,000 $80,000 - $99,000
$25,000 - $39,000 $100,000 - $119,000
$40,000 - $59,000 $120,000 - $139,000
$60,000 - $79,000 Over $139,000

What percent of your family’s total annual income for 1995 was derived from
your professional practice?

%

To what extent does your household depend on your income from your professional
practice?

Essential

Important, but not essential
Helpful, but not important
Negligible contribution

If you had to choose a career over again, would you choose psychology?

Yes
No

Are you planning on changing careers and leaving the field of psychology within the next
five years?

Yes
No

- C IN TION

In what type of community do you practice?

Urban
Suburban
Rural

120

 

B-13. What is your primary work setting?

Solo independent practice

Group independent practice

Staff HMO

Group HMO

Community Mental Health facility
Government facility

Medical facility

B-14. What percentage of your work time is devoted to the following tasks:

% Psychotherapy or direct service provision
% Billing

% Utilization Review/Documentation

% Other

 

B-15. What is the average amount of time that you work each week? (both billable
and non-billable time)

Billable hours
Non-billable hours

B-16. If you have a solo independent practice, or are part of a group independent practice, what
are your customary fees for each of the following? (If not applicable, enter zero.)

Individual psychotherapy (50 minutes)
Couples therapy (50 minutes)

Family therapy (50 minutes)

Group therapy (1 1/2 hours)
Diagnostic evaluation (50 minutes)

%WMMW

 

This section (B- 17 through 828) relates to your current caseload; please answer all questions. If it
would be helpful, please feel free to refer to your appointment book or files. .

B-17. How many cases make up your current caseload? (Count each member of a
group as one case. Count couples and families, if the members are primarily
seen together, as one case.)

B-18. Is you caseload primarily (check one only):

children
adolescents
adults

121

 

B-19. Please estimate the percentage your current caseload that is:

% Male
% Female

8-20. Please estimate the percentages of your current caseload that are in the following groups:

% Black/African American % Caucasian
% Alaska Native/American Indian % Hispanic American
% Asian/Pacific Islander % Other:

 

821. Please estimate the percentages of your current active caseload that are:

% White collar (accountants, attorneys, managers, physicians,
administrators, computer specialists, teachers, personnel specialists)

% Blue collar (mail carriers, skilled laborers, stock handlers, warehouse
workers)

% Students, or those not currently in labor force by choice (women who
are currently staying at home, retirees)

% Unemployed (not fitting category 3)

B-22. Please estimate the percentage of your cases that pay at the following rates:

% Full rate
% Reduced rate (including PPO discounts and sliding scale fees)
% Free

B-23. Please estimate the proportion of your cases that require prior approval of treatment plans by
a third party before payment for services is approved:

%

B-24. Please estimate the proportion of your cases in which a third party payer determines the
specific treatment modality (e.g. individual, family, group) before services are provided:

%

8-25. Please estimate the proportion of your cases that use the following types of funding sources
to pay for services that you provide: (Please choose only one funding source for each client in your
caseload. If a family or couple is treated, include all the individuals in the unit under the appropriate
funding source. Choose the most appropriate source, even if co—payments are made by the client.)

% Fee-for-service
% Contractual fee-for-service (i.e., Medicare or Medicaid, PPO)
% Capitated

122

 

B-26. Which of the following approaches do you currently utilize? (check all that apply)

 

 

D Behavioral D Humanistic
D Client-centered D Psychodynamic/Psychoanalytic
D Cognitive/behavioral Cl Systemic
D Ego psychology D Other (please specify)
D Gestalt
B-27. Which of the following approaches were emphasized in your original training? (check all
that apply)
D Behavioral D Humanistic
Cl Client-centered Cl Psychodynamic/Psychoanalytic
Cl Cognitive/behavioral Cl Systemic
D Ego psychology C] Other (please specify)
D Gestalt

B-28. Have you had to change your theoretical orientation in order to stay on provider panels?

Yes
No

The following section (B-29 through 8-35) refers to interactions with third party payors or managed
care. Please use the scale below to indicate your level of satisfaction:

 

 

 

 

 

 

 

Highly :atisfied Satiified Neither3satisfied Dissafisfied Viry Neot
nor dissatisfied Dissatisfied Applicable

B-29. __ The competence of utilization review personnel or case managers:

B-30. __ The professionalism of utilization review personnel or case managers:

B-31. __ The management skills of utilization review personnel or case managers:

B-32. __ Your working relationship with utilization review personnel or case managers:

B-33. __ Your ability to use your own judgment in clinical matters:

B-34. __ The opportunity to use your own treatment approaches:

B-35. __ The acknowledgment you receive from utilization review personnel or case

managers for doing your job well:

123

 

SEQIION C - THIRD ram 1 PAYORS

 

Please check the space to the left of the appropriate answer. Note: "Ihird party payors” refers to
insurance companies, HMO’s, PPO’s, or managed care firms, who pay you for all or part of your
services to clients.

036. To what extent do you depend on referrals from third party payors to maintain your
caseload?

Not at all

Very little
Moderately
Greatly

Not applicable

C-37. What impact has working with third party payors had on the demand for your services?

Greatly increased your caseload
Moderately increased your caseload
No impact on your caseload
Moderately decreased your caseload
Greatly decreased your caseload

C-38. What type of impact have third party payors had on the development of treatment
relationships?

Highly positive
Moderately positive
None at all
Moderately negative
Highly negative

C-39. What effect does the involvement of third parties have on the overall quality of treatment
that you provide?

Highly positive
Moderately positive
None at all

Moderately negative
Highly negative

124

 

040. Are guidelines for third party reimbursement a consideration in your choice of
diagnosis?

Not at all

Very little
Moderately
Greatly

Not applicable

C-41. Do you feel any pressure to adjust your treatment decisions in order to stay on provider
panels with PPO or HMO contracts?

Not at all

Very little
Moderate
Great

Not applicable

C-42. Does the acceptance of third party funds create dilemmas for you when making case
decisions?

Not at all

Very little
Moderately
Greatly

Not applicable

 

This section (C-43 through C-56) relates to your current caseload as reported in question B 51 5. '
If it-would be helpful, (please feel free to refer to your appointmentbOOk' or files. '

C-43. How often were cases given a less severe diagnosis in order to conform with third party
reimbursement guidelines?

Never
Rarely
Occasionally

Frequently
Not Applicable

125

 

C-44. If you have used a less severe diagnosis in order to conform with third party reimbursement
guidelines, were you:

Comfortable with the decision
A little uncomfortable
Moderately uncomfortable
Considerably disturbed
Greatly disturbed

Not Applicable

C-45. How often were cases given a more severe diagnosis in order to conform with third party
reimbursement guidelines?

Never

Rarely
Occasionally
Frequently
Not Applicable

C-46. If you have used a more severe diagnosis in order to conform with third party
reimbursement guidelines, were you:

Comfortable with the decision
A little uncomfortable
Moderately uncomfortable
Considerably disturbed
Greatly disturbed

Not Applicable

C-47. How often were cases reported as individual treatment in order to conform with third
party reimbursement guidelines, when other treatment (such as conjoint or family) was
provided?

Never
Rarely
Occasionally

Frequently
Not Applicable

C-48. If you have reported a case as individual treatment in order to conform with third party
reimbursement guidelines, when other treatment was provided, were you:

Comfortable with the decision
A little uncomfortable
Moderately uncomfortable
Considerably disturbed
Greatly disturbed

Not Applicable

llllll

126

 

C—49.

C-SO.

C-51.

C-52.

How often was the modality of treatment selected in order to conform with third party
reimbursement guidelines, when another treatment modality was warranted (for example,
providing group therapy, when individual treatment might have been more appropriate)?

Never

Rarely
Occasionally
Frequently
Not Applicable

If you have selected a treatment modality in order to conform with third party
reimbursement guidelines, were you?

Comfortable with the decision
A little uncomfortable
Moderately uncomfortable
Considerably disturbed
Greatly disturbed

Not Applicable

How often was a treatment approach selected in order to conform with third party
reimbursement guidelines, when another treatment approach would have been more
appropriate (for example, providing brief or task-oriented treatment, when your
knowledge or experience suggested another choice)?

Never
Rarely
Occasionally

Frequently
Not Applicable

If you have selected a treatment approach in order to conform with third party
reimbursement guidelines, when you considered another treatment approach more
appropriate, were you:

Comfortable with the decision

A little uncomfortable

Moderately uncomfortable

Considerably disturbed

Greatly disturbed

Not Applicable

 

127

 

C—53. How often was a client given less treatment than the client needed in order to conform
to third party reimbursement guidelines?

Never

Rarely
Occasionally
Frequently
Not Applicable

C-54. If you have given less treatment than the client needed in order to conform to third party
reimbursement guidelines, were you:

Comfortable with the decision
A little uncomfortable
Moderately uncomfortable
Considerably disturbed
Greatly disturbed

Not Applicable

055. The peer review processes which are used by insurance companies:

Enhance confidentiality

Have no effect on confidentiality

Have the potential for breaches in confidentiality
Occasionally jeopardize confidentiality

Greatly jeopardize confidentiality

C-56. Do you feel that you, as the therapist, are the agent of:

The patient

The purchaser of the health care, including employers
The payor, if different from the patient or purchaser
Both the patient and the payor

The patient, the purchaser, and the payor

SE I ION Q - MACE]; CARE

 

This section refers to your interactions with managed care organizations. If you have business contacts
with more than one managed care company, please choose the response that best represents the
majority of your interactions.

D—57. Please rate your ease in contacting managers:

Readily available, with minimal wait time

Occasional (20% or less) waits over 10 minutes - usually less
Waits over 10 minutes between 20% to 50% of the time
Waits over 10 minutes over 50% of the time

Long waits typical

128

 

D-58.

D-59.

D-60.

D-61.

D-62.

D-63.

Please indicate the time it takes for managers to return messages (voice mail etc):

Promptly, within a few hours

Nearly always within 24 hours

Usually within 24 hours, occasionally longer

Over 24 hours 20% to 50% of the time

Over 24 hours 50% of the time, or not returned at all

Please indicate the timeliness that you experience in obtaining authorization for
emergency services, medical consults, and ancillary services:

Promptly, within a few hours

Nearly always within 24 hours

Usually within 24 hours, occasionally longer
Usually within 48 hours

Usually over 48 hours

Please indicate the amount of time that it takes for you to receive authorization
for treatment (from the time you mail or call in your request until you receive a
written or verbal authorization):

Within 1 week

Usually within one week, occasionally longer
Nearly always within 2 weeks

Occasionally longer than 2 weeks

Usually longer than 2 weeks

In general, what is the average number of sessions that you request from
managed care companies:

After how many sessions do you usually have to apply for reauthorization?

Please indicate your experience with managers when you request reauthorization:

Dialogue reasonable and appropriate
Justification required but accepted

Sessions granted or denied without justification
Difficulty obtaining more sessions

Managers contentious and rigid

129

 

D-64. Please indicate the extent to which the manager collaborates with you throughout
the course of a case:

Collegial and constmctive

Usually collegial and constructive
Occasionally collegial and constructive
Occasionally adversarial and non-constructive
Adversarial and nonconstructive

D-65. Please rate the professionalism of the managers of the companies that you work with most
ofien:

Highly professional

Professional

Adequate

Occasionally unprofessional
Unprofessional, lacking knowledge or skill.

D-66. Does it concern you that utilization review personnel employed by insurance or
managed care companies are often non-psychologists?

No concem

Small amount of concern
Moderate amount of concern
Considerable distress
Profound distress

D-67. Utilization review personnel or case managers use criteria that are:

Written, in clear and concise terms.

Unwritten - but policy is clear and consistent.
Unwritten - but policy is unclear and inconsistent.
There are no stated criteria, either verbally or in writing.

D-68. When working in a managed care context, how much control do you feel you exert over
clinical decisions?

Strong control

Moderate amount of control
Some control

Hardly any control

No control at all.

130

 

D-69. Please indicate the average promptness of payment after billing:

Within 30 days

Between 30 and 60 days

Usually between 30 and 60 days, occasionally longer
Usually between 60 and 90 days, occasionally longer
Usually longer than 90 days

D-70. What proportion of your total annual income from professional practice depends on third
party payments?

Less than 20%
Between 20% and 40%
Between 41% and 60%
Between 61% and 80%
Over 80%

D71. Overall, what is your opinion of the impact of managed care on the practice of
psychology?

Marked improvement in services
Moderate improvement in services

No influence on services

Moderately adverse influence on services
Marked adverse influence on services

Thank you very much for your participation!
Please place the completed forms in the stamped and addressed envelope and return them to:
Brooke L. Stevens, M.S.

Kirby Hill
Jericho, NY 11753

APPENDIX C

131
APPENDIX C

ITEM KEY: STUDY ON THE PRACTICE OF PSYCHOLOGY QUESTIONNAIRE

DIE—M SIB MLC EJ_ Q9121. F_|_
A-1 B-12 C-38 c-43 D-58 B-16
A-2 B-13 c-39 c-44 D-59 C-36
A-3 B-14 c-4o c-45 D-60 c-37
A-4 B-15 c-41 C-46 D-61 D-64
A-5 B-1 7 c-42 c-47 D-67 D-69
A-6 B-18 D-61 C-48 D-70
A-7 B-19 D-62 c-49
A-8 B-20 D-63 c-so
A-9 B-21 D-64 c-51
B-26 B-22 D-65 c-52
B-27 B-23 D-66 c-53
B-28 B-24 D-68 C-54

B-25 0-71 c-ss

C-56

APPENDIX D

132
APPENDIX D

SAMPLE: COVER LETTER

Brooke L. Stevens, M.S.
Kirby Hill
Jericho, NY 11753

November 15, 1996

Dear prospective participant,

The practice of psychology has undergone a number of changes in the past ten years. My
dissertation will look at the current structure of the practice of psychology, as well as the
satisfaction that psychologists obtain from their careers. I would like to invite you to assist me
in the investigation of these professional issues.

You have been selected as part of a random national sample of practicing psychologists. If you
would like to participate in this study, you will be asked to sign a consent form, and then fill
out two questionnaires. The participants in this study are completely anonymous, and there is
no record of any type identifying any participants. To insure that security is being maintained,
there is also no coding of any type to identify the response forms. All responses will be
completely confidential.

Often, people who participate in studies like to find out about the results. If you are interested
in the findings of this study, please centact me, and I will be happy to brief you on the
outcome of the study, or send you a copy of the results.

Thank you very much for your time and your participation. If you have any questions that you

would like to have answered, please do not hesitate to call me: I can be reached at (516) 921 -
481 8.

Sincerely,

Brooke Stevens, M.S.

APPENDIX E

133
APPENDIX E

ACCOUNTED FOR VARIANCE IN MSQ GENERAL SATISFACTION

AFTER CONTROLLING FOR DEMOGRAPHIC VARIABLES

* * M U L T I P L E R E G R E S S I

ON **

Equation Number 1 Dependent Variable.. TOTLSATl

Block Number 1. Method: Enter
GENDER FAMINCOM PCTCASE3 WORKTIMZ PCTWRK3

Variable(s) Entered on Step Number

WORKSET

.36570
2.97884
.0205

Mean Square

226.391
75.999

12
85

1. WORKSET Primary Work Setting
2.. GENDER Gender
3.. PCTWRK3 Percent Work Time: UR/Documentationn
4.. EAMINCOM Total Family Income
5.. PCTCASE3 Percent Caseload: White Collar
6.. WORKTIMZ Average Work Time: Non-billable hours
Multiple R .60473 R Square Change
R Square .36570 F Change
Adjusted R Square .24294 Signif F Change
Standard Error 8.71779
Analysis of Variance
DF Sum of Squares
Regression 6 1358.34669
Residual 31 2355.99541
F = 2.97884 Signif F = .0205

............. Variables in the Equation

Variable B SE B Beta
GENDER -2.631 3.226 -.128
FAMINCOM 1.684 .861 .310
PCTCASE3 .063 .067 .165
WORKTIMZ -.017 .136 -.022
PCTWRK3 -.313 .174 -.298
WORKSET -.582 .899 -.115

(Constant) 76.064 7.351 10.347

-.816
1.956
.938
-.127
-.794
.648
.000

134
* * M U L T I P L E R E G R E S S I O N * *

Equation Number 1 Dependent Variable.. TOTLSATl

------------- Variables not in the Equation -----—------—

Variable Beta In Partial Min Toler T Sig T
ETHICSG -.390 -.445 .635 -2.725 .010
ETHICSlO -.282 -.317 .608 -1.835 .076
TPTXREL -.435 -.479 .639 -2.993 .005
MCI -.316 -.325 .587 -l.886 .068
MCURPLIC -.249 -.285 .614 -1.629 .113
TPINFLTX -.468 -.505 .601 -3.205 .003

End Block Number 1 All requested variables entered.

*************************

Block Number 2. Method: Enter
ETHICS6 ETHICSlO TPTXREL MCl MCURPLIC TPINFLTX

Variable(s) Entered on Step Number

7.. MCURPLIC MC UR Personnel non-licensed
8.. ETHICS6 Ethics: TX Report as Individual React
9.. TPTXREL TP Impact on Tx Relationship
10.. ETHICSlO Ethics: TP Influence Tx Approach React
11.. TPINFLTX TP Influence on Tx Decisions
12.. MCl Ease in Contacting Managers
Multiple R .78832 R Square Change .25575
R Square .62145 F Change 2.81501
Adjusted R Square .43975 Signif F Change .0312
Standard Error 7.49949
Analysis of Variance
DF Sum of Squares Mean Square
Regression 12 2308.28393 192.35699
Residual 25 1406.05818 56.24233

F = 3.42015 Signif F.= .0046

135

Equation Number 1 Dependent Variable.. TOTLSATl

------------- Variables in the Equation —------------

Variable B SE B Beta T Sig T
GENDER 2.354 3.107 .114 .758 .455
FAMINCOM 1.241 .836 .228 1.485 .150
PCTCASE3 .095 .067 .249 1.404 .172
WORKTIM2 -.006 .125 -.008 -.050 .960
PCTWRK3 -.242 .163 —.230 -1.482 .150
WORKSET .069 .850 .013 .082 .935
ETHICS6 -1.376 1.701 -.148 -.809 .426
ETHICSlO -.232 1.529 -.026 -.152 .880
TPTXREL -3.065 1.644 -.306 -1.865 .074
MCl -1.452 1.570 -.182 -.925 .363
MCURPLIC .390 1.934 .037 .202 .841
TPINFLTX -2.025 1.950 -.197 -1.038 .309
(Constant) 89.711 9.180 9.772 .0000

End Block Number 2 All requested variables entered.

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