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MANAGED CARE: VIEWS, PRACTICES, AND BURNOUT
0F PSYCHOLOGISTS

presented by

Tracy Lynn Thompson

has been accepted towards fulﬁllment
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MANAGED CARE: VIEWS, PRACTICES, AND BURNOUT
OF PSYCHOLOGISTS

BY

Tracy Lynn Thompson

A DISSERTATION

Submitted to
Michigan State University
in partial fulﬁllment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY

Department of Counseling, Educational Psychology,
and Special Education

1 998

ABSTRACT
MANAGED CARE: VIEWS. PRACTICES. AND BURNOUT
OF PSYCHOLOGISTS
BY

Tracy Lynn Thompson

The major purposes of this study were to explore the views and practices of
psychologists in their work with managed care organizations and to assess the
relationships between factors of managed care and burnout.

The sample for this study comprised 179 psychologists of the American
Psychological Association. The instruments used in this study were the Maslach
Burnout Inventory-Human Services Survey (Maslach & Jackson, 1986) and the
Practice of Psychology Survey (Stevens. 1997).

Correlations. t-tests, and multiple regression analysis were used to analyze
the data collected in the study. The results suggested that:

1. There was a relationship between percentage of managed care clients
and emotional exhaustion.

2. There were relationships between lack of control and increased

workload, and all three aspects of burnout.

3. Burnout can be predicted from managed care variables when
controlling for age.

The results of this study support the need to develop educational paradigms
that prepare psychologists, and provide recommendations for working more

effectively within the managed care milieu.

Dedicated to Virginia Maxine Moore DeGree.
whom I was blessed to have as my mother,
and who always believed in me and supported me through all of my endeavors.

This is for you . . . I Love You!

ACKNOWLEDGMENTS

Above all. I praise and glorify God, Jehovah Elohim (the powerful one who
created me). Jehovah Jireh (the God who provides). Jehovah El Shaddai (the God
who pours out blessings), the God who opened doors when all were shut, who made
miracles happen. and gave me mustard-seed faith to reach my goals.

Dr. Gloria Smith, my role model and inspiration, the angel whom God put in
my life. who went beyond the call of duty and was committed to helping me get
through. I was blessed by God that she was always there for me.

To my academic supporters and mentors, Drs. Lee June, Thomas Gunnings,
Vence Bonham, Jr., J.D., Steve Raudenbush, Ira Washington, and Craig Adams,
who all provided continual support, guidance. and inspiration.

To my family, Grandpa (Arthur Moore), Aunt Lolly, Aunt Jane, Uncle Gaines,
Aunt Vicky, Nana (Wade Nobles), and Dear (Aretha Thompson), who supported me
early on in my academic endeavors, served as my personal role models. and
encouraged me to reach my highest. To my sister (Tonya), my brother (Michael),
and my nieces (Talia, Tiffanie, and Jasmine). who I pray will achieve greater heights
unknown.

Finally, to my special friends, Joan Hinton, Dr. Earl Jones Ill. Jennifer Moore.

and my Palma Ceia church family, who provided spiritual, professional, and ﬁnancial

support and gave their precious time during my early efforts in applying to graduate
school.

I am deeply indebted to each of you. and I am grateful to God for putting you
in my life, each for a unique purpose. You are all the reasons for this achievement.

"I am because we are. and because we are, therefore, I am.”

vi

TABLE OF CONTENTS

LIST OF TABLES ................................................ x
LIST OF FIGURES ............................................... xi
Chapter
I. INTRODUCTION ...................................... 1
Background .......................................... 1
Statement of the Problem ............................... 5
Purpose and Importance of the Study ...................... 7
Research Questions ................................... 8
Hypotheses .......................................... 9
Definition of Terms ................................... 10
Overview ........................................... 11
ll. LITERATURE REVIEW ................................ 13
Introduction ......................................... 13
Managed Care ...................................... 13
Overview ......................................... 13
Definitions of Managed Care .......................... 15
Objectives of Managed Care .......................... 16
Types of Managed Care Organizations .................. 16
History of Managed Care ............................. 17
Managed Mental Health Care ........................... 20
Rising Costs and Cost-Containment Strategies ............. 21
Limiting Utilization and the Cost of Treatment ............. 22
Practitioner Concerns Under Managed Care ............... 26
Loss of Autonomy and Control ......................... 26
Financial Security ................................... 27
Ethical Issues ...................................... 27
Impact on the Client and the Therapist-Client
Relationship ..................................... 29
Burnout ............................................ 31

vii

Deﬁnition of Burnout ................................. 31

Components of Burnout .............................. 32
Causes of Burnout .................................. 33
Effects of Burnout ................................... 34
Related Constructs .................................. 34
Sources of Burnout ................................. 35
Managed Care and Burnout ............................ 38
Increased Workload ................................. 39
Percentage of Clients Under Managed Care .............. 39
Lack of Control Over Treatment Decisions ............... 40
Summary ........................................... 41
RESEARCH DESIGN AND METHODOLOGY .............. 43
Introduction ......................................... 43
Hypotheses ......................................... 43
Population and Sample ................................ 44
Instrumentation ...................................... 44
The Practice of Psychology Survey (PPS) ................ 45
The Maslach Burnout Inventory-Human Services
Survey (MBI-HSS) ................................. 47
Dependent and Independent Variables .................... 49
Dependent Variables .................................. 49
Independent Variables ............................... 49
Data-Collection Procedures ............................ 50
Data-Analysis Techniques .............................. 51
Summary ........................................... 52
RESULTS .......................................... 53 '
Introduction ......................................... 53
Demographic Characteristics of Respondents .............. 53
Age and Gender .................................... 54
Race ............................................. 54
Practice Community and Setting ....................... 54
Total Annual Income ................................ 56
Practice Information .................................. 56
Fees ............................................. 56
Orientation ........................................ 56
Weekly Professional Tasks ........................... 56
Third-Party Payments ............................... 57
Caseload ......................................... 57
Average Number of Therapy Sessions .................. 58
Percentage of Clients Under Managed Care .............. 58

viii

Respondents’ Levels of Burnout, Perceptions of Managed
Care, and the Impact of Managed Care on Their Practices . . . 58

Level of Burnout .................................... 59
Impact of Managed Care on the Providers and Their

Practices ........................................ 61
Workload ......................................... 62

Impact of Managed Care on the Treatment Relationship
and Quality of Treatment ............................ 65
Ethical Dilemmas Experienced ......................... 75
Comfort Level With Ethical Dilemmas ................... 77
Results of Hypothesis Testing ........................... 81
Summary ........................................... 86

V. SUMMARY, CONCLUSIONS, IMPLICATIONS, AND
RECOMMENDATIONS ................................ 87
Introduction ......................................... 87
Summary ........................................... 87
Conclusions ......................................... 88
Limitations .......................................... 93
Implications for Practice ............................... 93
Recommendations for Further Research .................. 95
APPENDICES

A. The Practice of Psychology Survey ....................... 98
8. Cover Letter ....................................... 111
REFERENCES . . .' ............................ ' ................. 113

LIST OF TABLES

Psychologists’ Responses to Lack of Control Items ............... 75

Psychologists’ Responses to Items Concerning Ethical Dilemmas .
Experienced .............................................. 76

Psychologists’ Responses to Items Concerning Comfort Level
With Ethical Dilemmas ...................................... 78

Psychologists’ Responses to Items Concerning Satisfaction
With Managed Care Plans ................................... 81

Results of t—Tests Investigating Differences in Levels of
Burnout Between Males and Females .......................... 83

Correlation Coefﬁcients for Percentage of Managed Care
Clients and Aspects of Burnout ............................... 83

Correlation Coefficients for Lack of Control and Aspects of
Burnout ................................................. 84

Correlation Coefﬁcients for Increased Workload and Aspects
of Burnout ............................................... 85

10.

11.

12.

13.

14.

LIST OF FIGURES

Distribution of Respondents by Gender ......................... 54
Distribution of Respondents by Community Setting ............... 55
Distribution of Respondents by Practice Setting .................. 55
Distribution of Respondents by Orientation ...................... 57
Percentage of Managed Care Clients .......................... 59
Levels of Three Aspects of Burnout for the Entire Sample .......... 60

Responses to Item B15: Have You Ever Been Excluded From 3
Provider Panel on Which You Requested to Participate? ........... 61

Responses to Item 817: Have You Had to Change Your Theoretical
Orientation in Order to Stay on Provider Panels? ................. 62

Responses to Item D15: Do You Feel That Participation in
Managed Care Programs Has Increased Your Professional
Liability Exposure? ......................................... 63

Responses to Item C2: What Impact Has Working With Third-
Party Payers Had on the Demand for Your Services? .............. 63

Responses to Item 021: What Impact Has Obtaining Phone
Authorization Had on Your Workload? .......................... 64

Responses to Item 022: What Impact Has Report Writing Had on
Your Workload? ........................................... 64

Responses to Item C3: What Type of Impact Have Third-Party
Payers Had on the Development of Treatment Relationships? ....... 65

Responses to Item C4: What Effect Does the Involvement of

Third Parties Have on the Overall Quality of Treatment That
You Provide? ............................................. 66

xi

15.

16.

17.

18.

19.

20.

21.

22.

Responses to Item CS: Are Guidelines for Third-Party

Reimbursement a Consideration In Your Choice of Diagnosis? ...... 67

Responses to Item C6: Do You Feel Any Pressure to Adjust
Your Treatment Decisions in Order to Stay on Provider

Panels With PPO or HMO Contracts? .......................... 68

Responses to Item D4: Please Indicate the Amount of Time It

Takes for You to Receive Authorization for Treatment ............. 70

Responses to Item D7: Please Indicate Your Experience With

Managers When You Request Reauthorization ................... 71

Responses to Item D8: Please Indicate the Extent to Which
the Manager Collaborates With You Throughout the Course of

a Case .................................................. 72

Responses to Item D10: Please Rate the Professionalism of the

Managers of the Companies Which You Work With Most Often ...... 72

Responses to Item D11: Utilization Review Personnel or Case

Managers Use Criteria That Are —-— ........................... 73

Responses to Item D13: Please Indicate the Average Promptness

of Payment After Billing ..................................... 74

xii

CHAPTER I

INTRODUCTION

Baskgmund

Managed care has become a major stmcture within the United States health
care system, and recently there has been widespread growth In managed care
organizations and their enrollment. The changing structure of health care through
the expansion of managed care has greatly inﬂuenced the practice of psychology
(Alperin 8 Phillips, 1977; Broskowski, 1991; Feldman, 1992). This effect on the
practice of psychology has engendered a number of concerns among mental health
providers, as well as a proliferation of research and articles addressing those
concerns. The Committee for the Advancement of Professional Practice (CAPP) of
the American Psychological Association conducted a study of more than 16.000
practitioners (Burnette, 1996). The aim of the study was to identify practitioners’
concerns and needs regarding their practice patterns with the present health care
environment. The primary concerns reported were that ”clinical practice is changing,
practitioners’ income and their number of clients are decreasing, managed care
creates ethical dilemmas for practitioners, [and] the precertiﬁcation process is
excessive” (Burnette, 1996. p. 2). In another study, conducted by Sleek (1997),

practitioners alleged that a managed care company

circumvented the psychologists’ judgment by determining which professional

services were appropriate; improperly concluded that each of the

psychologists provided too many sessions to patients; improperly terminated
them from the . . . provider panel; and restricted the providers’ ability to
exercise their clinical judgment or standards of care. thus violating the terms

of the contract. (p. 1)

In fact, many psychologists believe that managed care organizations function
beyond the role of a third-party payer, and that these organizations manage and
provide health care services in a fashion similar to hospitals (Sleek, 1997). In
Sleek’s study, psychologists also argued that it had become essential for them to
depend more on provider networks to sustain their practices. Hence.

for psychologists to practice effectively within such an environment.

psychologists need to understand the forces promoting the growth of

managed care and the ways they stand to be affected by and potentially
beneﬁt from this major shift in the way mental health and substance abuse

treatment services will be delivered in the future. (Broskowski, 1993, p. 1)
Therefore, because managed care will remain, In order to survive the changing
structure of managed care, psychologists must prepare themselves for the next
decade, as well as the next century (K. Phillips, 1997).

These concerns emphasize that attention needs to be focused on preparing
psychologists to meet the challenges of working with a managed care environment.
Unfortunately, many graduate training programs do not provide educational training
on managed care. Thus, many psychologists lack preparation to work effectively
within a managed care system. Increased attention needs to be aimed at preventive

strategies that psychologists can implement to address problems in their work with

managed care plans.

One primary effort toward this goal Is to ascertain the experiences of
psychologists and those factors that pose difﬁculties In one’s work. and to develop
recommendations to work effectively with managed care plans. It is equally
important to identify those factors of managed care that are most likely associated
with burnout of psychologists.

Given the changing work environment brought about by managed care, and
the effect of managed care on the practice of mental health workers, burnout is an
important area of study. Considerable attention has been given to burnout among
mental health providers. It has been reported that Individuals who work In
environments in which services are provided to people are particularly susceptible
to burnout (Maslach 8 Jackson, 1981; Schaufeli, Maslach, 8 Marek, 1993). In fact.
Snibbe, Radcliffe, Weishberger, Richards, and Kelly (1 989) found that mental health
professionals reported higher levels of burnout than did primary care physicians.
When burnout is experienced, the quality of care provided to one’s patients can
deteriorate (Maslach. Jackson. 8 Leiter, 1996).

Other researchers have Investigated burnout in an attempt to identify the
variables related to burnout. Burnout was found to be related to such demographic
variables as age and gender (Cordes 8 Daugherty. 1993; Maslach, 1982, 1993;
Maslach 8 Jackson. 1981; Pines 8 Maslach, 1980). Younger workers were more
likely to experience burnout than were their older counterparts. Relationships were
found between gender and burnout when examining individual aspects of burnout.
- Males experienced higher levels of depersonalization and personal accomplishment,

whereas females experienced higher levels of emotional exhaustion. Dupree and

3

Day (1995) found that males experienced higher levels of depersonalization and
reduced personal accomplishment, but they did not ﬁnd associations between
gender and aspects of burnout for females. However, when Raquepaw and Miller
(1989) examined burnout-among mental health providers, they found that burnout
was not related to demographic characteristics of the provider.

It has also been found that the environment of the job may be a major factor
contributing to workers’ burnout. Raquepaw and Miller (1989) examined burnout
across work settings. They found that workers in private practice reported less
burnout than did those who worked in organizational settings; those who worked in
organizational settings experienced more emotional exhaustion and fewer instances
of personal accomplishment than did those in private practice. Dupree and Day
(1995) found that workers in private practice experienced lower levels of the
depersonalization aspect of burnout than did those in organizational settings.
However. the signiﬁcance in both studies was small and indicated that neither type
of worker was more prone to burnout.

Burnout also has been found to be related to the size of one’s caseload
(Maslach 8 Jackson, 1981; Pines 8 Maslach, 1980). However. Raquepaw and
Miller (1989) found no such relationship. Dupree and Day (1995) also investigated
factors related to burnout in an effort to identify the effects of managed mental health
care on burnout of mental health workers. They found that the percentage of
managed care clients was signiﬁcantly correlated to burnout (speciﬁcally,
depersonalization and reduced personal accomplishment). However, because the

signiﬁcance was so small, the researchers concluded that they had little support for

4

the hypothesis that mental health workers with fewer managed care clients would
experience less burnout than those with more such clients.

Snibbe et al. (1989) investigated burnout among various health care workers
within a managed health care setting and compared their data with normative data
from Maslach and Jackson (1986). They found that subjects who had not worked
as many years In the ﬁeld experienced high levels of depersonalization, and that
psychologists experienced high levels of emotional exhaustion and depersonaliza-
tion. Interestingly, they also discovered that subjects experienced high levels of
personal accomplishment. However, although their ﬁndings conﬁrmed the existence
of burnout among mental health care workers, only 13 psychologists were included
In their study. Furthermore, an important limitation was apparent In that they did not
use a random sample; also. the psychologists In their study worked only In an HMO
setting.

Levant (1994) also investigated managed care variables related to burnout.
The factors found to be related to burnout Included (a) a lack of control over
treatment decisions, (b) an Increase in conﬂicts of interest, (c) an Increase in
practitioner workload, (d) negative practitioner perceptions of workload. and (e) an

increase in work-related stress.

Statemenmubei’mblem
Several researchers have examined burnout among mental health
professionals by administering the Maslach Burnout Inventory (Cordes 8 Daugherty,

1993; Dupree 8 Day, 1995; Maslach, 1982, 1993; Maslach 8 Jackson. 1981;

Maslach, 1982; Pines 8 Maslach, 1980; Raquepaw 8 Miller, 1989). Some of these
researchers found that burnout varied according to the professionals’ age, gender,
and/or work setting, whereas others found no such relationships. Because of the
mixed results from previous studies, research is needed to clarify further the
relationship of age and gender to burnout.

In addition, there Is a need to Integrate the ﬁndings regarding managed care
and burnout of mental health professionals, particularly psychologists, and to
Investigate the effects of managed care on one’s professional practice. It has been
reported that professionals who work in organizational settings experience more
burnout because of increased paperwork and less personal control (Raquepaw 8
Miller, 1989). With growing participation in managed care plans there is increased
paperwork, and some professionals perceive that they have less personal control
over treatment decisions (Giles, 1993; Saakvitine 8 Abrahamson. 1994; Zimet,
1989). Also, the size of one’s caseload has been found to be related to burnout
(Maslach 8 Jackson, 1981; Pines 8 Maslach, 1980). These elements (increased
paperwork, lack of control over treatment decisions, and size of caseload) are
prevalent factors when participating in managed care plans as well, yet they have
not been widely examined within the framework of managed care. Exceptions are
the investigations of Dupree and Day (1995). Snibbe et al. (1989), and Levant
(1994). Dupree and Day examined burnout and job satisfaction of mental health
workers who maintained a caseload of managed care clients. However, their
sample size was small (N = 86), which, as they agreed, resulted in inconclusive

results regarding the effect of managed care on burnout. Further, their study

6

Included only 24 psychologists. Also, Snibbe et al. examined burnout among
primary care physicians and mental health workers who worked In an HMO setting.
but only 13 psychologists participated In their study.

Only a few studies have been undertaken on the experiences of
psychologists who work with managed care plans. Also, much of the literature
addressing practitioners’ concerns with managed care has not been supported
empirically. In addition, there has not been as much research on burnout with
psychologists who work in private practice as there has been with those who work
In organizational settings (Raquepaw 8 Miller, 1989). As such, the focus In this

study Is on the private practitioner who works with managed care plans.

EumcseandJmpcdancecleeSludx

The researcher’s purpose in this study was to explore the views and practice
experiences of psychologists working in private practice settings In their work with
managed care plans. A secondary purpose was to explore job burnout of these
psychologists. The researcher also sought to clarify the relationship between the
demographic variables of age and gender, and the three aspects of burnout. The
study will provide empirical information about psychologists’ experiences with the
effects of managed care on their practice of psychology. The researcher drew from
previous research and combined, In a single study, many of the factors believed to
be related to burnout among psychologists working with managed care plans.

The study Is important for several reasons. First, It will provide data on a

sizable sample of psychologists throughout the United States who work with

managed care plans. Also, the researcher focused speciﬁcally on burnout of
psychologists who work in private practice settings, a combination of a sample and
issue that have been minimally addressed by previous researchers.

The research also will help in understanding the problems that psychologists
face In their practice with managed care organizations by providing information
about the ethical dilemmas these professionals face In their work with managed care
plans, as well as their satisfaction with various aspects of managed care. Further,
the study will enhance the knowledge base about how providers view managed care
and their Interactions with managed care agents. Finally, based on the ﬁndings from
this study, recommendations will be made for psychologists on how to better prepare

themselves for work with managed care.

Reseatchﬂuesticns

The present research was undertaken to address a number of questions
regarding the above-mentioned issues pertaining to burnout of psychologists in
private practice settings and their experience with managed care. The basis for
these questions is rooted in research by Dupree and Day (1995), Snibbe et al.
(1989), Levant (1994), and Sleek (1997), In which some of the speciﬁc burnout and
managed care concerns were reviewed, as well as the CAPP study by the American
Psychological Association (Burnette, 1 996). The questions that were posed to guide
the collection of data in this study are as follows:

1. Do psychologists experience burnout?

2. Is the work of psychologists Impacted by managed care?

3. How do psychologists view managed care and their interactions with

managed care agents?

4. In working with managed care, do psychologists have less control in

making treatment decisions?

5. Do psychologists encounter ethical dilemmas in their work with

managed care?

study:

6. Are psychologists satisﬁed in their work with managed care?

Hypotheses

The following hypotheses were formulated to test the data collected in this

Hypothesiﬂ: There will be a signiﬁcant relationship between age and
burnout.

BMW: There will be signiﬁcant differences In the levels of burnout
when categorized by gender.

Hypothesisa: There will be a signiﬁcant relationship between the percentage
of clients under managed care and burnout.

~ HypothesisA: There will be a signiﬁcant relationship between lack of control

and burnout.

Hypothesiiﬁ: There will be a signiﬁcant relationship between Increased
workload and burnout.

Hypothesisj: Burnout can be predicted from the managed care variables
(percentage of managed care clients, lack of control, and increased workload)
when controlling for the effects of age.

D [i 'l' [I

The following terms are deﬁned in the context In which they are used In this
dissertation:

Capitation: A method for payment to providers, common or targeted In most
managed care arenas. Unlike the older fee-for-service arrangement, in which the
provider Is paid per procedure. capitation Involves a prepaid amount per month to
the provider per covered member. The provider Is then responsible for providing all
contracted services required by members of that group during that month for the
ﬁxed fee, regardless of the amount of charges incurred.

Control: the freedom to choose, and the power to carry out one’s own
choices, rather than being told what to do (Maslach, 1982).

WWW: Payment systems that reimburse health
care providers a ﬁxed amount for all care in connection with a standard diagnostic
category.

W A traditional means of billing by health providers for each
service performed, with payment in speciﬁc amounts for speciﬁc services rendered.

Gatekeepec An individual who controls the access to health care services
for members of a speciﬁc group.

WWW: an organized health care system
that is responsible for both the ﬁnancing and delivery of a broad range of
comprehensive health services to an enrolled population (Wagner, 1993). An HMO

also has been deﬁned as ”a health plan that places at least some of the providers

10

at risk for medical expenses, and a health plan that utilizes primary care physicians
as gatekeepers” (Kongstvedt, 1993, p. 504).

Bayer: The agent, typically the insurer, that reimburses providers for services
(Stevens, 1997).

WWW: an organization In which “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“ (Sherman, 1992, p. 4).

WEE): one who supervises, coordinates, and provides
medical care to members of a plan. The PCP may Initiate all referrals for specialty
care.

Emitters: Mental health practitioners or medical professionals (Stevens,
1997).

Utilizatinn: The extent to which a given group uses speciﬁed services in a

speciﬁed period.

QJLenLiew
Chapter I was an introduction to the study. The problem was stated, followed
by the purpose and importance of the study. The research questions and
hypotheses were presented, as were deﬁnitions of key terms. Chapter II contains
a review of literature relevant to the study. Major topics considered are managed

care, managed mental health care, cost-containment strategies, practitioner

11

concerns under managed care, burnout, and sources of burnout within managed
care. The population, study participants, instrumentation, data-gathering
procedures, and data-analysis techniques are discussed In Chapter III. Chapter IV
contains a discussion of ﬁndings and the results of hypothesis testing. Chapter V
serves as a conclusion to the study. The results are discussed, and

recommendations are made. Implications for future research also are addressed.

12

CHAPTER II

LITERATURE REVIEW

lntmduslinn

In this chapter, literature related to the following areas of managed care and
burnout is reviewed: (a) managed care, (b) managed mental health care, (0) cost-
containment strategies, (d) practitioner concerns under managed care, (e) burnout,
and (f) sources of burnout within managed care. The ﬁrst section Includes
deﬁnitions, objectives, types, history, and strategies of managed care and managed
care organizations. The second section focuses on the development of managed
mental health care. The third section is a discussion of strategies used by managed
care organizations to contain health care costs. The fourth section focused on the
concerns of psychologists under managed care. The ﬁfth section is an overview of
burnout in the mental health ﬁeld, and the sixth section contains a discussion of the
factors within managed care that contribute to burnout. These factors were of

primary interest in the present study.

Managedrzate
013mm
Managed care Is not a new phenomenon In the United States. In fact, it can
be traced back to the early 1920s, when efforts were made to develop health care

plans so that affordable, accessible, and comprehensive care would be provided to

13

enrollees of such plans. As health care costs began to escalate, payers (6.9.,
patients, government, employers, and insurers) became concerned about how much
they were spending on health care, and they began to require justiﬁcation for the
type of treatment and charges for treatment (Goldsmith, 1984). As a result, many
strategies have been developed to control health care costs. lglehart (1996) stated,
”The core techniques include authorizing only approved providers under contract
with the managed-care company to treat enrolled clients, reviewing their decisions
as they provide services, and monitoring high-cost cases closely” (p. 131).

Currently, there are hundreds of managed care companies, which have
varying features in terms of access to care, cost, quality control, beneﬁt design, and
ﬂexibility (Wagner, 1993). Now that mental health beneﬁts are a standard Inclusion
of managed health care, many people receive their psychotherapy within the
framework of managed health care systems (Austad 8 Sherman, 1992). In fact,
more than half of all Americans are enrolled in some form of a managed care plan
(Alperin 8 Phillips, 1997). Also, because psychotherapy Is a form of health care, the
factors that inﬂuence general health care aﬁect psychotherapy, as well (Austad,
1992). Therefore, just as health care in general is being operated under some
managed care systems, so is mental health care.

As managed care networks increasingly dominate the provision of health care
in the United States, ”all practitioners are being affected by the principles and
practices of these organizations” (Alperin 8 Phillips, 1997, p. 1). Mental health care
providers have responded differently to this situation. Some have welcomed
managed care, whereas others disprove of it. However, ”there is general agreement

that the practice of psychotherapy will be Irrevocably changed. since managed care

14

has drastically altered the delivery, deﬁnition, and outcome of the psychotherapy that
patients receive under Its aegis“ (Alperin 8 Phillips, 1997, p. 1). Although some
psychotherapists have realized the necessity of incorporating managed care
principles Into their practice, most have found this adjustment difﬁcult (Alperin 8

Phillips, 1997) and have expressed numerous concerns about it.

D [i 'I' [II I D
Numerous deﬁnitions have been offered of managed care, citing many
different plans and features (Alperin 8 Phillips, 1997; Goodman, Brown, 8 Deltz,
1992; Wagner, 1993). In general terms, managed care Is a form of health care
delivery in which health care services are managed by third-party payers (i.e.,
Insurance companies, employers, managed care companies), and services are not
determined exclusively by the provider (Goodman et al., 1992; Hoyt, 1992; Mash 8
Hunsley, 1993). K. Phillips (1997) stated that managed care 'Is a term used to
deﬁne ways of delivering, managing and evaluating clinical services“ (p. 20).
Further, with managed care, there is generally some form of cost-containment on
third-party payments for health care services (Wooley, 1993). Austad and Sherman
(1992) considered this feature in deﬁning managed care as:
a variety of techniques devised to manage medical costs and based on the
premise that providers will alter their use of services In response to ﬁnancial
Incentives. It includes utilization review, provider negotiations, alternate
delivery systems such as HMOs, restricting reimbursement for unnecessary

services . . . [and] Integrates the ﬁnancing and delivery of appropriate health
care services to covered Individuals. (p. 3)

15

DI . I' [II I C

An objective of the traditional models of managed care was to develop a
method of health care in which services were provided to a larger proportion of the
population. There are opposing views as to the objective of present-day managed
care. Some view it as a way to monitor the quality of patient care (MacLeod, 1993).
Proponents view managed care as a way to provide new and effective forms of
mental health treatment (Budman, cited In Mash 8 Hunsley, 1993). Others view
present-day managed care as a means of containing escalating health care costs
(Rosenberg 8 Wright, 1997).

In attempts to contain managed care costs, managed care companies were
formed In an attempt to organize and manage the clinical and ﬁnancial services
provided to particular groups of consumers. One core method of managing services
Is utilization review (UR), which is used to monitor and review treatment before it Is
rendered and after it has begun. UR Includes "preadmission screening and/or
precertiﬁcation of treatment; close monitoring of ongoing treatment and regular
review of its progress; and, when appropriate, discharge planning” (Alperin 8

Phillips, 1997, p. 6).

I [I I | C Q . l'

The managed care company can Include varied organizations. Two primary
forms of managed care companies are health maintenance organizations (HMO)
and preferred provider organizations (PPO) (Mirin 8 Sederer, 1994).

Wagner (1993) deﬁned HMOs as

organized health care systems that are responsible for both the ﬁnancing and

the delivery of a broad range of comprehensive health services to an enrolled

16

population. . . . An HMO can be viewed as a combination of a health Insurer
and a health care delivery system. . . . HMOs are responsible for providing
health care services to their covered members through afﬁliated providers
who are reimbursed under various methods. (p. 13)
Several types of HMOs include the staff model, group model, network model,
individual practice association model, and direct contract model (Wagner, 1993).
With PPOs, providers contract with organizations and agree to abide by
certain guidelines, such as offering reduced fees and submitting UR forms In place
of increased referrals. PPOs do not offer comprehensive health services, as do
HMOs. A principal characteristic of PPOs is the select provider panel on which
providers are chosen to participate. The basis for selection is providers’ cost
efﬁciency, community reputation, and scope of services provided. Also, PPOs
require participating providers to agree to negotiated payment rates, which typically
are discounts from charges, per diem rates, or payments determined by diagnosis.
PPO enrollees may be able to use nonparticipating providers, but they are given

Incentives to use the PPO provider. If a non-PPO provider Is used, the enrollee will

incur a cost, such as a copayment.

HIstmLManagedJlare

Forms of managed care can be traced to prepaid health care and group
practice, which were established In the early 1900s, and to the development of
HMOs (Bennett, 1988, 1992).

WWW. Prepaid health care was developed
to provide affordable, accessible, and comprehensive health care to employees of
the lumber, mining, and transportation industries In the Paciﬁc Northwest (Bennett,

1988, 1992; DeLeon, VandenBos, 8 Bulatao, 1991). Prepayment involved "the

17

provision of a package of services for a prearranged and periodically renegotiated
price” (Feldman, 1992, p. 62). These Industries hired salaried physicians to provide
medical care to their employees.

Group practice was developed in the late 1880s. In group practice, a number
of health care professionals who specialized In various areas were arranged to
provide health care within one organizational setting (Bittker, 1992). In 1920,
prepaid health care and group practice were combined. At that time, a group of
medical specialists developed comprehensive health care services to be delivered
at prepaid fees. At the same time, another group practice was developed, which
provided services to a rural community of farmers and their families (MacLeod,
1993). Each enrollee paid annual dues that covered the cost of medical care,
surgery, and house calls for a minimal fee. Also, two physicians In Los Angeles
established a comprehensive health service on a prepaid—contract basis for
approximately 2,000 employees of a water company (Kongstvedt, 1993). Between
1930 and 1960, several other group-practice prepaid medical service plans were
established. These prepaid group-practice plans later were known as the ”ﬁrst
generation” HMOs (Bennett, 1992, p. 62).

mmmtenmmmamzaﬁgmumm. Another forerunner of managed
care is the HMO. In fact, until 1980, managed care and HMOs were basically
analogous constructs (DeLeon et al., 1991 ). HMOs initially were formed to provide
or arrange for comprehensive inpatient and outpatient services and to serve a
voluntarily enrolled population with a ﬁxed per capita fee. HMOs ushered In a

different model of health care delivery in the United States and led to epidemic

18

expansion of managed care plans. MacLeod (1993) Indicated that, in 1991, nearly
35 million Americans were enrolled In some form of HMO.

In an effort to provide health care to a greater proportion of the American
population, Congress passed a law in 1965 that brought about health care for the
uninsured (Nelson, 1987). With the passage of that law, Medicare and Medicaid
were Introduced, and the government became a direct payer for health care. To
help contain the escalating health care costs It had Incurred by providing medical
coverage to the uninsured, the government promoted the expansion of HMOs by
subsidizing their creation and expansion. In fact, the HMO Act of 1973 was adopted
to provide HMOs with federal ﬁnancial support.

Govemment’s involvement in HMOs changed their nature, which resulted in
the beginnings of competition. Proﬁt-making corporations now became part of the
HMO movement. This change profoundly Inﬂuenced participating providers and
their practice in diverse ways (F eldman, 1992). A few years following the passage
of the HMO Act of 1973, the government required that enrollment In an HMO be
offered as a health care option to employees of corporations that had more than 25
workers (Flinn, McMahon, 8 Collins, 1987).

As a result of receiving federal ﬁnancial support, the number of HMOs and
their enrollees began to Increase rapidly (MacLeod, 1993). From 1982 to 1987, the
number of HMOs grew to 650, and the number of HMO enrollees grew concomi-
tantly. In that same 5-year period, the number of HMO enrollees increased 300%,
to more than 29 million. By 1991, more than 35 million people were enrolled In

HMOs, and more than 70,000 were enrolled in PPOs.

19

MmmMMentaLtlealtbﬁaLe

Until the late 1960s, most HMOs were cautious regarding mental health
coverage, and employee beneﬁt plans did not Include substantial mental health care
coverage as a basic beneﬁt (Anderson 8 Berlant, 1993; Bennett, 1988, 1992; De
Leon et al., 1991). “No patient care, no beneﬁts for chronic or recurrent conditions,
and no beneﬁts for chemical dependency were required” (Anderson 8 Berlant, 1993,
p. 130). At that time, only a few companies provided mental health coverage, and
services were limited and included only diagnosis and consultation, although some
provided fee—for-servlce care at a reduced fee. The prevailing concerns were
directed at mental health diagnosis and treatment, as well as costs that might
Inﬁnitely increase.

In the early 19609, to address concerns about mental health coverage,
research Indicated that limited mental health coverage was affordable (Avnet, 1962).
Soon companies began to include mental health beneﬁts In their beneﬁt packages.
Further, with the passage of the HMO Act of 1973, companies were required to
include mental health beneﬁts In order to receive ﬁnancial beneﬁts from the
government (Bennett, 1988, 1992). Initially, the required beneﬁts included only
”crisis Intervention and evaluative services (up to 20 visits)" (Bennett, 1988, p. 65).
Companies were not required to include In beneﬁt packages Inpatient care and
treatment of chronic/recurrent conditions or chemical dependency. Soon these
limited beneﬁt packages were found to be unfeasible, and some companies
developed broader packages that included Inpatient visits and other more

comprehensive treatment.

20

Before long, the cost of health care overall began to increase rapidly.
Because the share of health beneﬁt payments by corporations and small businesses
was Increasing well beyond the annual rate of Inﬂation, concerns mounted (Phillips,
1997). Soon, with a 163% increase In employer spending between 1970 and 1989.
the costs of health care beneﬁts became one of the highest spending categories
within beneﬁt plans.

The cost of health care has been rising faster than any other spending
category of the federal government. In fact, that cost has Increased at a rate two to
three times greater than inﬂation (Broskowski, 1991; Giles, 1993). Between 1965
and 1990, health care expenditures burgeoned from approximately 6% to 12% of the
gross national product (GNP) (Frank, 1993; Giles, 1993) and are expected to equal
the GNP by the year 2015 (Giles, 1993). Moreover, health care expenses In the
United States are higher than In any other country (Mirin 8 Sederer, 1994). These
esmlating health care costs have been attributed to overuse of health services and
overcharges by health care providers.

Mental health care, which is one segment of health care, is ”one of the fastest
growing cost components of health care” (Bennett, 1992, p. 68). In 1993, Giles
wrote that mental health expenditures had Increased 30% to 40% annually over the
previous 10-year period. He also noted that mental health care Is ”the third most
expensive category of disorders, accounting for more than $20 billion of annual
health care costs” (p. 19). Kessler et al. (1994) reported that almost one—half of all
Americans between the ages of 15 and 54 had been diagnosed with a psychiatric

disorder at least once in their lives, and that 30% had at least one psychiatric

21

disorder during the previous 1-year period (Kessler et al., 1994). Two of the factors
contributing the most to mental health care costs are Inpatient services and
treatment for chemical dependence (Mirln 8 Sederer, 1994).

With the cost of mental health care rising faster than that of any other health
care service, payers of health care became concerned. They feared that costs
would become uncontrollable as a result of overuse of mental health services. Also,
over time, the emphasis of HMOs began to shift to proﬁtability. In fact, 75% of newly
established HMOs were for-proﬁt organizations (Shadle 8 Christianson, 1988). With
the shift to emphasis on proﬁt, and In an effort to combat spiraling health care costs,
HMOs developed myriad approaches that became the primary strategies of
managed care. One of the initial strategies of HMOs to control health care costs
was to focus on preventive health care. However, because this approach was not
proﬁtable, HMOs sought other approaches that became the primary strategies of
managed care. Some of these approaches focused on utilization and unit price,
which meant limiting utilization of health care services and reducing the cost of

treatment (Lowman 8 Resnick, 1994).

II 'II ”IT I' III C III I |

In attempts to limit the use of mental health services, some cost-containment
strategies focused on limiting utilization have Included (a) pretreatment authorization
by gatekeepers, (b) utilization review, and (c) beneﬁt plan design. These strategies
are discussed In the following paragraphs.

W. The gatekeeper serves as a

point of access to mental health treatment; each can authorize treatment as

22

necessary, and serve as a channeling mechanism to provide an initial assessment.
Gatekeepers determine whether treatment Is necessary, authorize use of services,
and direct the individual to the appropriate type of treatment (Anderson 8 Berlant,
1993; Kongstvedt, 1993). In essence, gatekeepers control who gets access to what
treatment. These gatekeeper functions are distributed among different managed-
care participants. Among those who serve a gatekeeper role are the primary care
physician and the case manager.

MW. Another method by which third-party costs are contained
is utilization reviews. Third-party payers conduct utilization reviews to evaluate the
medical necessity and appropriateness of mental health services before
(prospective), during (concurrent), or after (retrospective) they are rendered
(Feldman, 1992; Stern, 1993). In prospective management, the necessity for
Inpatient or outpatient services is determined before the service Is rendered (e.g.,
precertiﬁcation and second-opinion programs). In concurrent review, treatment Is
monitored to ensure that services continue to be appropriate. In retrospective
review, services are evaluated to determine whether treatment that has been
provided was appropriate. Focus typically is directed at reduced hospital stays and
reduced spending for psychiatric and substance-abuse care.

Beneﬁtmnjesign. The beneﬁt plan is the foundation of any managed
mental health program. One Issue that Is addressed Is coverage limits (Anderson
8 Bertant, 1993). The design of any beneﬁt plan has served to create barriers to
access and limit treatment. For instance, diagnostic-related groups (DRGs) are
used to limit the types of mental health disorders that will be Included in the beneﬁt

plan. With DRGs, payment is based on a ﬁxed amount per type of disease or

23

disorder (Broskowski, 1994). The other Issue that is addressed in beneﬁt plans is
the provision of ﬁnancial incentives or constraints for receiving care from efficient
providers.

Coverage limits. Beneﬁt plans contain coverage limits that are placed on the
number of Inpatient hospitalization days, visits, or annual dollar amount spent on
outpatient mental health beneﬁts (Anderson 8 Berlant, 1993; D. Phillips, 1997; Stern,
1993). Also, DRGs are used to limit the types of disorders (e.g., acute psychiatric,
chronic, custodial, speciﬁc diagnoses) and particular diagnostic categories that are
not covered (e.g., learning disorders and autism). Further, certain types of treatment
(e.g., psychosurgery, psychoanalysis, nutritionally based therapy, biofeedback, and
electroconvulsive therapy) are not covered under particular beneﬁt plans. Also, only
certain types of providers are authorized to give treatment. Whereas some plans
authorize only MD. and Ph.D. professionals, others authorize other professionals
(e.g., social workers and marriage, family, and child counselors) (Anderson 8
Berlant, 1993). Also, third parties limit service use to that which Is considered to be
medically necessary (Giles, 1993). Being medically necessary relates to ”the
directing ofcare toward least restrictive therapeutic treatments deemed appropriate
by various measures of clinical care [and], where available, acceptable standards
of empirical support” (Giles, 1993, p. 29). Hence, depending on the severity of the
problem, appropriate action will be taken. Coverage limits also ensure that beneﬁt
plans will not pay above certain levels, even for medically necessary and cost-
effective treatment.

Incentives. The design of a beneﬁt plan provides ﬁnancial Incentives to

members in the form of deductibles and copayments. For example, a deductible and

24

higher copayment are required for those who seek treatment from providers outside
of those speciﬁed In the beneﬁt plan.

Briefmmejimjtemneraples. Another cost-containment strategy Is to limit the
length of therapy, which includes placing limits on the number of sessions (Stern,
1993). lglehart (1996) stated, "All forms of managed care represent attempts to limit
the use of services” (p. 131). As such, one signiﬁcant effect has been the
requirement for psychologists to use brief, time-limited interventions in
psychotherapy (Hass 8 Cummings, 1992; Richardson 8 Austad, 1991). Brief, time-
limited therapy typically ranges from a few weeks to about 15 weeks. The number
of sessions authorized is sometimes up to 20 (Rosenberg 8 Wright, 1997), whereas
some are required to limit treatment to only ﬁve or six sessions annually (Karon,
1992, 1995). If additional sessions are necessary, a documented rationale, along
with the managed care reviewer’s approval, often is required. These forms of mental
health treatment have been shown, by some, to be both economical and effective
In handling a wide range of mental health problems (Butcher 8 Koss, 1978;
Rosenberg 8 Zimet, 1995), whereas others have disagreed (Karon, 1992; Stern,
1993).

Because of utilization reviews and Imposition of session limits, and with third-
party payers approving fewer outpatient treatment sessions, many mental health
providers have found it difﬁcult to change their practice to ﬁt within the managed care

framework (Rosenberg 8 Wright, 1997).

25

WWW
With the changing structure of health care, speciﬁcally, the entrance of
managed care, many concerns have been expressed. One contention is with the
loss of control and autonomy (Feldman, 1992). Other concerns mounted relate to
ﬁnancial security of the providers, the creation of ethical dilemmas believed to be
brought about by managed care, and the negative Impact on the client and

therapeutic relationship.

W

Issues that often are discussed regarding managed care pertain to the cost
and quality of health care, whereas other concerns relate to the mental health
provider’s control and autonomy (Feldman, 1992). With managed care, there have
been inherent changes in the balance of power. For example, control over the
payment and provision of mental health services has been taken away from
providers (Giles, 1993), who no longer maintain complete control over treatment
decisions or the terms and content of their work. Rather, the balance of power has
shifted to employers, third-party payers, unions, and even consumers (Zimet, 1989).
Third-party payers (I.e., owners and administrators of health care) maintain the
control that Individual providers once held. As a result, private-practice
psychologists are concerned that they will lose their Independence (Zimet, 1989).

In addition, managed care inﬂuences the cost of treatment and how much the
provider gets paid. Instead of the provider setting the fees for treatment, the third
party determines the fee structure (lglehart, 1996; Saakvitine 8 Abrahamson, 1994;

Zuckerrnan, 1989). Needing preauthorization by reviewers, which is required for

26

treatment, can also cause providers to lose their sense of autonomy (Saakvitine 8
Abrahamson, 1994). Also, to receive reimbursement for services rendered,
providers must justify, in writing, their treatment rationale and furnish a
comprehensive treatment plan, which a utilization reviewer then examines. Hence,
the autonomy that providers once held Is decreased because they must now obtaln

authorization to provide services.

E' 'IS 'I

When therapists participate in managed care plans, their perceptions of
ﬁnancial security are affected in several ways. For one, they may be uncertain about
receiving authorization for continued insurance reimbursement. In fact, Wooley
(1993) stated that there will be times when therapists will render treatment for which
they will never be reimbursed. Also, these professionals’ ﬁnancial security Is
affected because of the reduced market for therapists who work In private practice
(Cummings 8 Duhl, 1987; Foos et al., 1991; Ramsey, 1989) and Increased
competition for clients. Further, there Is a growing need for therapists who work in
a private practice to have business expertise, and those who do not have the

necessary business skills may struggle to survive ﬁnancially.

EthicaLlssues
As Indicated above, DRGs are used to lImItthe types of disorders reimbursed

by third-party payers to the health care provider. Therefore, If a particular diagnosis
Is not covered by a managed care plan, treatment rendered by the provider for that
diagnosis will not be reimbursed. To obtain reimbursement for treatment, then,

providers sometimes will purposely misdiagnose patients. Misdiagnosis can take

27

many forms, such as reporting a more severe diagnosis than what Is actually the
case, or reporting Individual therapy when, In fact, family therapy has been
conducted. To Investigate this matter, Kutchins (1988) conducted a study on ethical
Issues encountered, and found that an ovenNhelming majority (72%) of the subjects
had reported a more severe diagnosis In order to obtain reimbursement for their
services. Strom (1994) conducted a similar study, In which he found that a large
number of social workers (37%) also made false reports In order to obtain
reimbursement for their services. Further, the majority of these respondents
reported that they had falsely reported information regarding other facets of their
treatment.

W. Providers who work with managed care programs can
experience role conﬂict (Kassirer, 1995) when they participate in activities that are
counterproductive to carrying out their primary purpose—providing quality mental
health services to clients. For example, the managed care reviewer might require
a provider to discontinue treatment, even when the provider believes it to be In the
client’s best interest to have more sessions; this places the provider In a position of
conﬂict (Burcke, 1984). Role conﬂict under managed care programs also arises
when providers believe they are unable to advocate on behalf of the patient; hence,
they may be reluctant to challenge rules governing the appropriateness of particular
services. Further, role conﬂict can result because providers are required to take on
new and varied responsibilities in their work with managed care plans.

Limnedjreatmem. With managed care programs, limits are imposed on the
dollar amounts allowed fortreatment. Once these dollar caps are reached, providers

sometimes have no way to ensure continuation of treatment. Also, the requirement

28

to use brief models is one way to limit the length of treatment. Thus, limiting the
number of sessions can result In premature discontinuation of treatment before
positive change occurs, thereby creating an ethical dilemma for providers of whether
to discontinue treatment because allotted sessions or dollar amounts are depleted.
Although brief models oftherapy have been proven successful for some people, they
are not necessarily the most eﬂective treatment choice for everyone (Stern, 1993)
and can stir up legal Issues regarding some populations. As a result, many
therapists will be put in the position of having to offer a treatment that they do not
believe Is the most effective one or In the best interests of the patient (K. Phillips,
1997). Lynch (1994) posed the following question, which has remained unanswered
from both a legal and an ethical perspective: ”As professionals we see the patient
In need of a certain course of therapy. How do we fulﬁll our professional duties and
obligations to the patient and at the same time comply with insurance regulations?"
(p. 151).

Another way of limiting access to health care Is to require patient copayments.
Through the use of a copayment structure, patients are discouraged from accessing
treatment.

Cl' I B I l' l .
Ihotnerapoutio relationship. Saakvitine and Abrahamson (1994) maintained

that managed care directly affects the therapeutic relationship between the client
and the therapist. Many aspects of treatment under managed care programs are
predetermined without considering the needs of the particular client; this does not

occur with fee-for-service clients. For instance, the assurance of conﬁdentiality is

29

essential to enhance tmst in and develop the therapeutic relationship.
Conﬁdentiality provides the safety patients need In order to engage freely In the
process of self-disclosure. However, many argue that with managed care systems,
conﬁdentiality Is jeopardized (Munson, 1995; Patterson, 1990) because, among
other things, patients often are required to sign a blanket authorization for release
of detailed clinical information for the insurance company. In fact, because
conﬁdentiality is limited, many patients elect to terminate treatment themselves
(Patterson, 1990).

The adverse effects of managed care on the therapist can, in turn, be
aversive forthe patient, particularly when the provider’s ﬁnancial dependence on the
payer supersedes the needs of the patient and the therapeutic relationship. Also,
when the provider ls preoccupied with insurance-reimbursement concerns, this might
divert his or her attention from the patient, which can serve to disrupt treatment
(Wooley, 1993).

WWW. Concern also has been expressed
about the quality and appropriateness of treatment (Lowman 8 Resnick, 1994). The
gatekeepers, who determine the necessity and appropriateness of treatment, often
are not trained in the ﬁeld of mental health (Lowman 8 Resnick, 1994). This
situation leads to concerns about quality of treatment and questions about the
competence of gatekeepers in making vital treatment decisions on behalf of the
patient. An additional concern Is that consumers are not thoroughly Informed about
the procedures and ﬁnancial arrangements of the managed care plan; they are not
informed about unfavorable components of the plan that affect their access to

treatment and the quality of care they receive (Lowman 8 Resnick, 1994). For

30

example, consumers are not always informed, before they purchase particular plans,
that a lengthy process Is involved In applying for mental health services.

This change In the structure of health care has had a profound inﬂuence on
the nature of mental health practice, as well as on the role of providers. Mental
health care providers ”are experiencing the many stresses and strains that typically
accompany change” (Austad 8 Sherman, 1992, p. 3), and their aforementioned
concerns regarding managed care all can serve as a basis for the conﬂict and
burnout experienced by these professionals. Such burnout is examined in the

following section.

Deﬁnitionotﬁumout

Although burnout has been deﬁned In many ways, the various deﬁnitions
have common themes. One commonality Is that the symptoms of burnout are
related to one’s work. Burnout Initially became apparent within the human services
professions. Although the concept of burnout Is not limited to workers In the human
services ﬁeld, most initial studies on burnout were conducted on professionals In that
ﬁeld because it was believed that those in the human services profession might be
more at risk for burnout than other workers (Maslach, 1982; Maslach 8 Schaufeli,
1993).

Another commonality in the deﬁnitions of burnout is that the negative attitudes
and behaviors one maintains reduce one’s effectiveness and work performance
(Schaufeli et al., 1993). Maslach (1993) and Maslach and Jackson (1984) found that

burnout was a multifaceted concept Instead of a unitary one, as some believed It to

31

be. Maslach deﬁned burnout as a “psychological syndrome of emotional exhaustion,
depersonalization, and reduced personal accomplishment that can occur among
Individuals who work with other people in some capacity“ (p. 20). "It is a response
to the chronic emotional strain of dealing extensively with other human beings,
particularly when they are troubled or having problems“ (Maslach, 1982, p. 3).
'Bumout can lead to a deterioration in the quality of care or service provided”
(Maslach 8 Jackson, 1986, p. 2), and ”It appears to be a factor In job turnover,
absenteeism, and low morale” (Schaufeli et al., 1993, p. 14). These three
components of burnout—emotional exhaustion, depersonalization, and reduced
personal accomplishment—were subsequently developed into a three—component

model.

mmmnemuiBumout
EmotionaLexhaustion. Central to burnout are overload and emotional

exhaustion (Leiter, 1993; Maslach, 1982). Of the three components of burnout,
emotional exhaustion is the most responsive to environmental factors within the
organization. Emotional exhaustion "refers to feelings of being emotionally
overextended and depleted of one’s emotional resources" (Maslach, 1993, p. 21).
'A person gets overly involved emotionally, overextends him- or herself, and feels
overwhelmed by the emotional demands imposed by other people“ (Maslach, 1982,
p. 3). Once this happens, people no longer feel they are able to give of themselves
to others. They feel exhausted and have reduced energy. They decrease their
contact and involvement with others to just enough to perform their jobs. They

become psychologically detached, particularly toward those who are burdensome

32

(Maslach, 1982, 1993), and withdraw from getting to know others. They avoid
becoming Involved signiﬁcantly by maintaining emotional distance between
themselves and those who have overwhelming demands. This serves to protect the
provider from the emotional strain of working with these types of people.

Denetsmalizalinn. As detachment Increases, one can develop coldness or
feelings of Indifference toward the needs and feelings of patients; such action is
manifested In the subsequent aspect of burnout, depersonalization.
Depersonalization refers to "a negative, callous, or excessively detached response
to other people, who are usually the recipients of one’s service or care” (Maslach,
1993, p. 21). When the provider begins to have callous feelings about others, this
can result in Insulting others, behaving in a curt manner, and not providing the
appropriate care.

Beoooeooorsonalaooomoljsnmom. Ultimately, the negative feelings toward
others can be directed at oneself, which leads to a feeling of reduced personal
accomplishment or "a decline in one’s feelings of competence and successful
achievement in one’s work" (Maslach, 1993, p. 21). The provider begins to

experience an eroding sense of competence and feelings of failure (Maslach, 1982).

W

In the human services profession, the major cause of burnout Is the
”emotionally demanding Interpersonal relationships of professional caregivers with
their recipients” (Schaufeli et al., 1993, p. 17). Overtime, providers develop the
tolerance levels needed to manage the stress of working closely with people on a

daily basis. However, that tolerance level gradually diminishes.

33

EﬂectsoLBummn

The physiological symptoms of burnout often Include chronic fatigue, In which
the provider may feel tired and run-down, and have difﬁculty getting up In the
morning (Maslach, 1976, 1982; Maslach 8 Jackson, 1981 ). The provider also might
experience Insomnia, nightmares, and other sleep disturbances. The persistent
feeling of fatigue can lead to Illness, such as persistent colds, headaches, and
gastrointestinal problems. Psychosomatic symptoms also can result, as well as
ulcers and neck and back problems. To cope with these symptoms, one might turn
to tranquilizers, drugs, and/or alcohol. Psychological problems also can result from
burnout. The provider may have feelings of failure and decreased self-esteem, and
be easily Irritated or angered by others; all of this can lead to depression. These
symptoms can interfere with one’s work, including the quality of services one
provides.

Burnout can affect providers’ personal lives, as well. Providers suffering from
emotional exhaustion often feel tense, upset, and physically tired when they are
home; they tend to complain frequently to theirfamily members. When providers are

irritable and impatient, this affects their families.

W

Depression. Whereas some of the same symptoms of burnout also resemble
depression, burnout and depression are not equivalent constructs (Maslach et al.,
1996). One difference is that depression permeates all areas of one’s life, while

burnout relates only to a characteristic of the social work environment. Also,

depression Is a clinical diagnosis, whereas burnout relates to one’s Involvement with
his or her work, particularly the therapeutic relationship with recipients of care.
Stress. Another construct related to burnout ls stress. In fact, some believe
that the two conditions differ only with respect to time, and that “burnout can be
considered as prolonged job stress” (Maslach 8 Schaufeli, 1993, p. 9). Also, the
emotional exhaustion mentioned in the deﬁnition of burnout Is akin to a stress
variable (Maslach, 1993). In fact, many of the factors related to emotional
exhaustion have been found to be similar to the factors related to stress. However,
emotional exhaustion, Including overall burnout, and stress are different constructs,

with different meanings, and are measured by different Instruments.

SoumesoLBumcut

lnmlvemennuimmtlers. When providers experience burnout, their positive
and caring attitude toward others changes to a negative and uncaring one. Their
perceptions of the people they are attempting to help become cynical and
derogatory. When this happens, they might grow to dislike the people they help, be
unmotivated to help, and provide inadequate help. Further, if providers become
overly involved with clients on a personal level, higher stress levels can result.

Envirormmntljoluening. A number of situations In the environment or job
setting contribute to burnout among providers. These include overload, lack of
control, co-workers and supervisors, and policies and procedures.

Overload. When providers have too many people on their caseloads, with
too little time to serve their needs adequately, they often experience overload

(Maslach, 1982). Providers can perform their jobs well when their caseloads are

35

manageable; however, burnout can result when their caseloads rise to an
unmanageable number. When this happens, the quality of service or the contact
between the provider and the client is reduced. With larger caseloads, providers
may withdraw psychologically and have less involvement with each client.

Lack of control. Elevated levels of burnout are apparent when providers do
not feel a sense of control over the care they are providing (Maslach, 1982).
Feelings of lack of control can result when guidelines are Imposed on providers’
work and they no longer have the autonomy to do as they choose, and when they
have ”no direct Input on policy decisions that affect one’s job” (Maslach, 1982,
p. 40).

Co-workers and supervisors. Difficulties In dealing with co-workers,
supervisors, and administrators can be additional factors leading to burnout of
providers.

First of all, they are another source of emotional stress that adds to the

development of emotional exhaustion and negative feelings about people.

Second, they rob the individual of a very valuable resource for coping with

and preventing burnout. . . . If providers are put off by their peers, then they

lack people to whom they can turn for help, comfort, advice, praise, and just

a friendly pat on the back. They are alienated and alone In their battle

against burnout, and that does not bode well for a successful outcome.

(Maslach, 1982, p. 42)

Policies and procedures. The policies and procedures of the job setting
affect the relationship between providers and recipients, thus serving to either
promote or alleviate burnout. Institutional policies that promote burnout Include
requiring providers to engage in unpleasant tasks; Instituting policies that restrict

certain staff behavior, such as providing particular services to recipients; or placing

constraints on the time or length of services. For example, limitations might be

36

Imposed on the maximum number of therapy sessions. Also, providers often are
required to complete large amounts of paperwork, such as ”documenting
Information, ﬁlling out request forms, [and] writing reports“ (Maslach, 1982, p. 51).
Completing paperwork can be time consuming and can Interrupt providers’ direct
work with their clients, thereby contributing to burnout.

Wins. To determine “who Is more at risk for burnout,”
Maslach (1982) examined demographic characteristics of mental health
professionals. Some of the variables he examined in an attempt to identify
characteristics related to burnout were gender, age, and years worked.

Gender. The literature on differences In burnout between male and female
mental health professionals has shown mixed results. Several researchers have
documented differences between male and female psychologists’ levels of burnout
(Cordes 8 Daugherty, 1993; Etzion 8 Pines, 1986; Maslach, 1982, 1993; Maslach
8 Jackson, 1981; Pines 8 Maslach, 1980), whereas others have found no such
difference (Dupree 8 Day, 1995; Raquepaw 8 Miller, 1989).

Further, differences between the genders were apparent when individual
aspects of burnout were examined. Some researchers have found that males
evidenced higher levels of burnout on particular scales than did females (Cordes 8
Daugherty, 1993; Maslach, 1982). Males experienced higher levels of
depersonalization; they held negative, callous feelings; and they had excessively
detached responses to their health care recipients. Males also had higher scores
on decreased personal accomplishment (Cordes 8 Dougherty, 1993; Maslach,
1993). That Is, they had reduced feelings of competence in their work. In contrast,

women experienced higher levels of emotional exhaustion (Cordes 8 Dougherty,

37

1993; Maslach, 1982, 1993). That is, they felt more emotionally overextended and
depleted of their emotional resources. However, although differences in burnout
based on gender were found, they were very small differences, suggesting that
males and females have similar experiences of burnout (Maslach, 1982).

Age and years worked. Several researchers have found a positive
correlation between age and burnout (Cordes 8 Daugherty, 1993; Maslach, 1982,
1993; Maslach 8 Jackson, 1981). Younger workers were more inclined to
experience burnout than were older workers. This was the case for several reasons,
one being that maturity and stability come with age and tenure In a particular ﬁeld.
Maslach (1982) stated, "Older but wiser’ seems to be the case here-with Increased
age, people are more stable and mature, have a more balanced perspective of life,
and are less prone to the excesses of burnout” (p. 60). Other researchers, however,
have found no relationship between age and burnout (Raquepaw 8 Miller, 1989).
Snibbe et al. (1989) found that health care workers who had been with the agency
for shorter times (between 0 and 5 years) experienced higher levels of burnout than

workers with longer tenure.

Managedﬁamndﬁumout
Snibbe et al. (1989) found that psychologists who worked in managed care

settings, along with psychiatrists and social workers, experienced high levels of
emotional exhaustion and depersonalization. They also found that each group of
health care workers experienced high levels of personal accomplishment as well.
Several researchers have investigated the relationship between burnout and factors

related to providers’ involvement in managed care programs (Dupree 8 Day, 1995;

38

Snibbe et al., 1989). Speciﬁc managed care factors found to be related to burnout
included an increase in practitioner workload, percentage of clients under managed

care, and lack of control over treatment decisions.

WM

Researchers have speculated that agency workers experience
Increased burnout as a result of other variables, Including additional paperwork
required (T aylor-Brown, Johnson, Hunter, 8 Rockowitz, 1981). As providers
participate in managed care programs, they become Increasingly involved with
nonprofessional duties (e.g., Increased paperwork, increased report writing for
utilization review purposes, and increased time spent talking on the telephone with
managed care agents). Also, they are required to see aﬁxed number of patients per
hour (Karon, 1992, 1995). All of these additional factors, which participation In
managed care plans entails, can result In work overload; overload, In turn,

contributes to burnout.

WW

Dupree and Day (1995) investigated the effects of managed mental health
care on burnout of psychotherapists who worked In private practice, hospitals,
clinics, and managed mental health care settings. One aspect they examined was
the relationship between burnout and percentage of managed care clients. The
researchers found that subjects who reported having more managed care clients
also reported higher levels of burnout. However, the signiﬁcant ﬁndings were small
and considered as artifactual, and they did not support the researchers’ hypothesis

that the percentage of managed care clients would be related to burnout of

39

psychotherapists. They did conﬁrm that, for males, the higher the percentage of
managed care clients, the higher the levels of all three aspects of burnout that were

experienced.

WW

Burnout is associated with the experience of lack of control over or
involvement in decision making (Leiter, 1991; Maslach, 1982). Maslach stated,

The need to be independent and self-determining is a hallmark of personal

growth and maturity. We want the freedom to choose, and the power to carry

out our choices, rather than always being told what to do. People who feel
they have some say In their work and can exert control over it are happier

with their jobs and with themselves. (p. 66)

Taylor-Brown et al. (1981) hypothesized that burnout may be more prevalent
in agency workers because they have less personal control or a lack of role clarity.
Maintaining a sense of control has been said to be a vital deterrent to burnout
(Raquepaw 8 Miller, 1989). In fact, Ganster (1989) asserted that a lack of control
affects the mental health and well-being of people who work in organizations.
Hence, because psychotherapy under managed care involves arrangements that
regulate the utilization, site, and costs of services, and because the nature and
length of mental health treatment are determined partially by a third party, not the
clinician or the patient, decreased control is Inherent In participation In managed care
plans. Thus, under managed care, psychologists who work In private practice have
less control over their treatment decisions than they once held (Zimet, 1989).

Traditionally, decisions concerning the frequency of appointments, overall

length of treatment, and fees and payment arrangements were established between

the mental health provider and the patient. With increased participation in managed

40

care programs, providers’ decision making regarding treatment has been affected
(Zimet, 1989). With the advent of the managed care reviewer, decisions no longer
are made solely between the provider and the patient. Also, compensation for work
Is determined by a third party, whereas, in the past, the individual provider
determined the hours worked, the fees charged, and the use of additional services
(Feldman, 1992). As the number of enrollees In managed health care organizations
increases, it is the organization and managers, and not the providers, who will
determine the treatment standards, specifying what will be treated and how, who will
provide the treatment, and who will determine the reimbursement guidelines.
Hence, all of these factors might potentially contribute to practitioners’ burnout. In
fact, Levant (1994) found that lack of control over treatment decisions is related to

burnout of providers who work with managed care plans.

Summary
The ﬁndings of Dupree and Day (1995), Levant (1994), and Snibbe et al.

(1989) stimulated further Investigation of burnout among psychologists who work
with managed care clients. Dupree and Day found some relationships between
managed care and burnout. However, because of the small sample size used in
their study, those relationships were considered artifactual and did not support the
hypothesis that managed mental health care affects the practice of mental health
workers. Further, whereas Dupree and Day examined levels of reported burnout of
psychotherapists in private practice, they did not examine other factors related to
managed care, such as level of control or autonomy, or the effect of managed care

on practitioners’ workload. Also, Dupree and Day's focus was not speciﬁcally on

41

fully licensed, doctorate-level psychologists. Furthermore, whereas Snibbe et al.
(1989) did ﬁnd that workers in managed care settings experienced moderate to high
levels of burnout, they did not use a random sample.

The present research built on the investigations by Dupree and Day, Levant,
and Snibbe et al. by using a random sample of psychologists and testing speciﬁcally
for relationships between the managed care variables (percentage of clients under
managed care, control, and workload) to reported levels of burnout. Also, fully

licensed, doctorate-level psychologists were represented more In the present study.

42

CHAPTER III

RESEARCH DESIGN AND METHODOLOGY

lntmﬁuctinn

The researcher’s purpose in this study was to explore job burnout of
psychologists working In private practice settings. A secondary purpose was to
explore these psychologists’ perceptions of their work with managed care
organizations. The researcher also sought to clarify the relationship between
burnout and the demographic variables of age and gender.

In this chapter, the researcher describes the methods used In carrying out the
study. Included are a restatement of the hypotheses, a description of the population
and the method of sample selection, a discussion of the instruments used in the
study, the dependent and independent variables, and procedures used to obtain the

data. The techniques used in analyzing the data also are addressed.

Hypotheses

The following hypotheses were posed to guide the analysis of data collected
in this study.

HypothesisJ: There will be a signiﬁcant relationship between age and
burnout.

Whit-“23.23 There will be signiﬁcant differences in the levels of burnout
when categorized by gender.

43

ﬂyoojhosisﬁ: There will be a signiﬁcant relationship between the percentage
of clients under managed care and burnout.

HypothosjsA: There will be a signiﬁcant relationship between lack of control
and burnout.

tiypothosisﬁ: There will be a signiﬁcant relationship between increased
workload and burnout.

Hypothesisﬁ: Burnout can be predicted from the managed care variables

(percentage of managed care clients, lack of control, and increased workload)

when controlling for the effects of age.

Ecoulationandﬂmnle

The study population comprised the 8,396 licensed psychologists who were
members of the APA and listed in its 1997 membership directory. Of that number,
53% were males and 47% were females.

To select the study sample, the researcher obtained an Initial list of 1,000
randomly chosen psychologists from the APA’s Department of Division Membership,
which maintained records on current members for 1997. Questionnaires were sent

to the 1,000 licensed psychologists whose names were provided by the APA. These

individuals comprised the initial sample.
Insttumentation
The two Instruments used to gather data for the study were the Practice of

Psychology Survey (PPS) (Stevens, 1997) and the Maslach Burnout Inventory-

Human Services Survey (MBI-HSS) (Maslach 8 Jackson, 1986).

44

IbeEmcticacLEsyclmlccySunLeylEES)

The content of the PPS was abstracted from Stevens (1997), whose work
was based on that of Strom (1992, 1994) and Sinnet and Holen (1993). Stevens
developed the questionnaire to explore the experience of psychologists working with
managed care plans. At the time of this writing, his research ﬁndings had not yet
been published. The PPS contains Items concerning respondents’ professional
practice and their work with managed care programs. In its original form, the PPS
was a 72-item paper-and-pencil instrument. For the purposes of this research, the
PPS was modiﬁed to include questions focusing on psychologists’ work with
managed care programs. These additional items were included following an
extensive examination of the literature on managed care, in an effort to identify the
most prevalent managed care issues affecting psychologists today.

The PPS used in this study contained 77 Items divided into the following four
sections: (a) demographic information, (b) professional practice, (c) experience with
third-party payers, and (d) experience with managed care programs (see Appendix
A). The ﬁrst section of the PPS included 10 items (A1 through A10) designed to
elicit demographic Information such as age, gender, racial background, years
worked In the ﬁeld postdoctorate, and annual income.

The second section of the PPS included 23 Items (B1 through 823) designed
to elicit data about the participants’ professional practice and areas of work related
to providers’ work setting, workload, fees, caseload, pay rates, theoretical
orientation, and satisfaction with managed care programs. Percentage of clients

under managed care items (items B12, B13, B14b, and B14c) were also included.

45

An internal-consistency analysis was completed, using a sample of 179, with an
alpha coefficient of .70.

The third section of the PPS contained 21 items in two parts focusing on
providers’ experience with third—party payers. The ﬁrst part Included seven Items
(items C1 through C7) about the impact of third-party payers on participants’ practice
(e.g., caseload, demand for services, treatment relationship, quality of treatment,
diagnosis, treatment decisions, and dilemmas). In the second part, respondents
were asked to indicate whether they had experienced ethical dilemmas In their work
with managed care plans, such as having given a more or less severe diagnosis,
misreported a diagnosis, misreported the type of treatment rendered, or selected a
particular treatment modality in order to conform to third-party reimbursement
guidelines (items C8, C10, C12, CI4, C16, and 018). Participants were asked to
respond to each statement using the following Likert-type scale: never (1), rarely
(2), occasionally (3), frequently (4), and not applicable (5). They also were asked
to Indicate how they felt about the aforementioned decisions by selecting one of the
following choices: comfortable with the decision (1), a little uncomfortable (2),
moderately uncomfortable (3), considerably disturbed (4), and greatly disturbed (5)
(items cs, C11, C13, C15, C17, and C19).

The fourth section of the PPS contained 23 Items concerning participants’
interactions with and views of managed care programs and managers (items 01
through 011 and 013 through 015), lack of control (Items 012 and 016 through

020), and increased workload (items 021 and 022). An Internal-consistency

46

analysis was conducted using the sample of 179. Alpha coefﬁcients for lack of

control and Increased workload were .76 and .77, respectively.
W
W

Maslach and Jackson (1986) developed the MBl-HSS to assess the three
aspects of the burnout syndrome: emotional exhaustion, depersonalization, and
personal accomplishment (Maslach et al., 1996). The MBl-HSS is a self-report
questionnaire that contains a total of 22 Items based on a 7-point Likert scale. In
terms of the breakdown for each subscale, Emotional Exhaustion contains nine
Items, Depersonalization contains ﬁve items, and Personal Accomplishment contains
ﬁve items. Respondents were asked to indicate one of the following responses
expressing the frequency of experiencing feelings related to each item of the
subscales: Never, A few times a year or less, Once a month or less, A few times a
month, Once a week, A few times a week, and Everyday.

There Is no combined measure of burnout; rather, each aspect is measured
by a separate subscale. According to Maslach et al. (1996),

The Emotional Exhaustion (EE) subscale assesses feelings of being

emotionally overextended and exhausted by one’s work. The

Depersonalization (0p) subscale measures an unfeeling and impersonal

response toward recipients of one’s service, care, treatment, or Instruction.

The Personal Accomplishment (PA) subscale assesses feelings of

competence and successful achievement in one’s work with people. (p. 4)

Some example items from the Emotional Exhaustion subscale are: “Working
with people all day Is really a strain for me," 'I feel I’m working too hard on my job,"

and "Working with people directly puts too much stress on me” (Maslach et al., 1996,

p. 43). Example Items from the Depersonalization subscale Include: 'I feel Itreat

47

some recipients as if they were impersonal objects” and "I don’t really care what
happens to some recipients” (Maslach et al., 1996, p.43). Example items from the
Personal Accomplishment subscale are: "I deal very effectively with the problems
of my recipients“ and "I feel I’m positively Inﬂuencing other people’s lives through my
work” (Maslach et al., 1996, p.43).

On the MBl-HSS, burnout is conceptualized as a continuous variable, ranging
from low to average to high degrees of experienced feeling. It is not viewed as a
dichotomous variable that is either present or absent (Maslach et al., 1996). Scores
are regarded as high, average, or low according to cut-off points Indicated by
Maslach et al. Each respondent receives three scores, one on each subscale. High
levels of burnout experienced by the mental health worker are Indicated by higher
means on both the Emotional Exhaustion and Depersonalization subscales, and
lower means on the Personal Accomplishment subscale. Conversely, low levels of
burnout are indicated by lower means on both the Emotional Exhaustion and
Depersonalization subscales, and higher means on the Personal Accomplishment
subscale. Moderate levels of burnout are indicated by average means on each of
the three subscales. Speciﬁcally, for Emotional Exhaustion, scores ranging between
0 and 16 indicate low levels of burnout, scores between 17 and 26 Indicate moderate
levels, and scores over 26 Indicate high levels. For Depersonalization, scores
between 0 and 6 Indicate low levels, scores between 7 and 12 Indicate moderate
levels, and scores over 12 indicate high levels. For Personal Accomplishment,
scores ranging between 0 and 31 indicate high levels, scores between 32 and 38

indicate moderate levels, and scores over 38 indicate low levels.

48

Norms for each subscale of the MBI-HSS are available for mental health
workers, based on gender, race, age, marital status, and education. Psychometric
Investigations have supported the use of the Instrument as a valid and reliable
research tool. Reliabllities of the MBl-HSS subscales were .90 (Emotional
Exhaustion), .79 (Depersonalization), and .71 (Personal Accomplishment). Test-
retest reliability coefﬁcients were signiﬁcant beyond the .001 level over varying time
periods (Maslach et al., 1996). Convergent and discriminant validity have been

established (Maslach et al., 1996).

Dependmnandmdansndamyariablas
Qansndanlian'ahles
The three dependent variables In this study were emotional exhaustion,
depersonalization, and personal accomplishment. Each of these variables was

addressed in a separate section of the MBl-HSS.

lndapsndanﬂaﬂahlas
The four Independent variables in this study were age, percentage of clients
under managed care, lack of control, and increased workload. Data with which to
test the relationships of these variables to burnout were collected with the PPS.
W. The percentage of clients under
managed care was an average of responses to items 812, 813, B14b, and 8140,
which Indicated the percentage of providers’ caseloads that was managed care.
Laokojoomml. Lack of control was measured by items 012 and 016through

020. This variable ccncemed the extent to which providers working with managed

49

care programs had the freedom to choose, and the power to exercise their own
choices. Higher scores indicate less control by providers In making treatment
decisions.

Insteasadmrklcad. The increased-workload variable (measured by items
CZ, 021, and 022) ccncemed the Impact of managed care programs on one's
workload. Higher scores indicate a greater Impact of managed care In Increasing

one’s workload.

Wm

To achieve a statistically signiﬁcant power of .80, it was determined that 1 13
participants were necessary for this study. This number was determined based on
a priori analysis using Cohen’s (1977) medium effect size at alpha = .05, variance
.10. Heppener, Kivlinghan, and Wampold (1992) recommended Increasing the
sample size In order to obtain a 40% response rate when using mailed surveys to
compensate for respondents’ refusal to participate. Therefore, to obtain 113
respondents, the researcher determined that a sample of at least 283 participants
was necessary. Also, the researcher predicted a lower return rate due to the length
of the surveys, which totaled 13 pages. As such, the researcher set the sample size
at 1,000 as an added means of helping to obtain a return rate of 113 respondents.

The APA’s Department of Division Membership supplied a set of 1,000
address labels for psychologists who had been randomly selected for the sample.
A second set of Identical labels also was supplied for follow-up postcards. During

spring semester 1997, the researcher mailed a research packet consisting of a cover

50

letter, a research consent form, the PPS, and the MBl-HSS to the 1,000
psychologists for whom the APA had supplied mailing labels. In the cover letter, the
researcher described the purpose of the survey, assured conﬁdentiality of
responses, and asked potential respondents to complete the questionnaire (see
Appendix 8). A retum-addressed, stamped envelope was Included in the packet.
To improve the response rate, a follow-up postcard, encouraging potential
participants to return their packets, was mailed 4 weeks later.

A total of 375 survey packets were returned. Twenty-ﬁve were voided
because respondents returned only the PPS, not the MBl-HSS. Of the 375 returned
surveys, 171 were voided because they were Incomplete as the APA ofﬁce had
initially failed to send the correct labels. These 171 respondents were not
participants of managed care organizations and thus were unable to answer the
managed care section of the PPS. Of the 1,000 In the original mailing, there were
only 426 respondents who were appropriate for the study, thus representing a 42%
ﬁnal response rate. Hence, a total of 179 were complete and were used In the

statistical analyses.

D l -E I . I I .

Descriptive statistics (frequency, mean, and standard deviation), correlations,
multiple regression analysis, t-test, and analysis of variance (ANOVA) were used in
analyzing the data collected in this study. The Statistical Package for the Social

Sciences (SPSS) was employed In these analyses.

51

Descriptive statistics (frequencies, means, and standard deviations) were
used In analyzing the general perceptions of respondents in each section of the
PPS. These statistics were used in presenting the characteristics of the sample
(e.g., gender, race, age, and work setting).

Correlations were used to investigate whether a relationship existed between
each of the Independent variables and burnout.

Multiple regression analysis was run to investigate whether burnout can be
predicted from the managed care variables.

I-tests were used to compare group means of males and females on the

three aspects of burnout.

Summary

This chapter contained a discussion of the study population and sample and
the methodology used to investigate psychologists’ experiences and practices with
managed care. The instruments used in collecting the data were described, and the
data-collection procedures and data-analysis techniques were explained. Results

of the data analyses are presented in Chapter IV.

52

CHAPTER IV

RESULTS

Inttodummn

The researcher's purpose In this study was to explore job burnout of
psychologists working In private practice settings. A secondary purpose was to
explore these psychologists’ perceptions of their work with managed care
organizations. The researcher also sought to clarify the relationship between the
demographic variables of age and gender, and burnout. Five research questions
were posed and six hypotheses formulated. The ﬁndings are presented in this
chapter. The chapter is divided into four sections: (a) demographic characteristics
of respondents; (b) practice information; (c) respondents’ levels of burnout,
perceptions of managed care, and the impact of managed care on their practices;

and ((1) results of hypothesis testing.

0 I'Cl l'I' [E II

In the ﬁrst part of the PPS, demographic information was collected on all
participants. The 10 demographic Items were designed to elicit information
concerning respondents’ age, gender, race, years worked, practice community and
setting, and income, in order to provide an overview of the population participating

in the research project. The ﬁndings are discussed in the following paragraphs.

53

Agmndﬁsndst
The psychologists ranged In age from 36 to 80 years. The majority of

respondents (105 or 58.7%) were males; 74 (41.3%) of them were female (see

Figure 1).

females
41%

males
59%

 

Figure 1: Distribution of respondents by gender.

Base

Almost all of the psychologists in the study (171 or 95.5%) were Caucasian;
2 (1.1%) were African American, 2 (1.1%) were Hispanic/Latino, and 1 (0.6%) was
Asian/Paciﬁc Islander. The remaining 3 psychologists (1.7%) did not identify their

race.

E l' D 'l ISII'

Most of the psychologists (80 or 44.7%) worked in a suburban community.
Seventy-two psychologists (40.2%) worked In an urban community, and 22 (12.3%)

worked in a rural community (see Figure 2). The majority of respondents (125 or

54

69.8%) worked in a solo independent practice, whereas 54 (30.2%) worked in a

group independent practice (see Figure 3).

Rural
13%

    

Suburban
46%

Urban
41%

Figure 2: Distribution of respondents by community setting.

 

Solo
70%

Figure 3: Distribution of respondents by practice setting.

55

IotalAnnuaLInccma

The largest percentage of psychologists (27.9%) earned more than $139,000
annually. The median family income was between $80,000 and $99,000. Most
respondents (70%) reported that two wage earners contributed to their families’

Incomes.

E I. I II I'
The PPS also contained items designed to gather Information concerning the

respondents’ practices. These ﬁndings are reported In the following paragraphs.

Bees

The average fee psychologists charged for Individual psychotherapy was
$102, and the average fee for couples therapy was $105. The average fee for family
therapy was $104, the average fee for group therapy was $59, and the average fee

for diagnostic evaluations was $117.

0 . l I.
A majority of psychologists (83.1%) reported using a cognitive-behavioral
approach. This was followed by behavioral (60%), psychodynamic (51.7%), and

systemic (42.4%) approaches (see Figure 4).

W
Psychologists worked an average of 44.6 hours each week. The average

number of total billable hours was 31, and the average number of total nonbillable

hours was 13. On average, 80% of the practitioners’ time was spent providing

56

psychotherapy or direct service. Ten percent of their time was spent on utilization

review, whereas 5% was spent on billing.

 

90
80 4
70 .
60 ~
50 .
40 —
30 -
20 -

% Psychologists

 

 

Orientation

Figure 4: Distribution of respondents by orientation.

Wants

The proportion of cases paid by various funding sources also was
investigated. On average, 49% of the psychologists’ caseload paid on a fee-for-
service basis, 44% of the caseload used a contractual fee-for-service payment

method, and 5% paid on a capitated basis. On average, 60% of the caseload paid

at reduced rates, and 4% received services at no charge.

Qaseload

The average number of clients on psychologists’ caseloads was 46. The

primary caseload for the majority of psychologists comprised adults. In terms of

57

race, the majority of clients on psychologists’ caseloads were Caucasian (83%) and
female (60%). Fifty percent of the respondents’ caseloads were white-collar

workers.

Averageblumbemilberanvﬁessions
The average number of sessions psychologists requested from managed
care organizations was 11. On average, psychologists applied for reauthorization

after six sessions.

EementagutﬂﬂentiundeLManaoedﬁare

On average, 44.6% of psychologists’ cases required prior approval of
treatment plans by a third party before payment for services was approved (see
Figure 5). An average of 43.6% of the cases were contractual fee-for-service (I.e.,
Medicare, Medicaid, PPO), and 5.2% were capitated cases. Also, in 18% of the
cases, a third-party payer determined the speciﬁc treatment modality.

E I I’I I'IEE IE II [II I:
W

The PPS also contained questions concerning respondents’ levels of burnout,
along with their perceptions of managed care and the impact of managed care on
their practices. In the following pages, each research question and its corresponding

questionnaire Items are stated, and the ﬁndings are presented.

58

 

50
45 .
40~
35 ~
30 —
25 «
20 ~
15 ~
10 -

% Cases

 

 

     

Prior Approval Contractual Fee Capitated Third-party
Required for Service determines
treatment
modality

3rd Party Involvement

Figure 5: Percentage of managed care clients.

LmLQLBquuI

WW: Do psychologists experience burnout?

The levels of the three aspects of burnout for the entire sample are shown in
Figure 6. Most psychologists (46.9%) experienced low levels of emotional
exhaustion, 36.9% experienced moderate levels, and 16.2% experienced high
levels. In terms of depersonalization, most psychologists (76.2%) experienced low
levels, 17.1% experienced moderate levels, and 6.7% experienced high levels. For
personal accomplishment, 78.4% experienced low levels, 18.9% experienced

moderate levels, and 2.7% experienced high levels.

59

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60

WW: Is the work of psychologists impacted by
managed care?

ImpacLQLManaoedCaLeoaneEmvideLs
III 'E I'

ﬂemDJA: What proportion of your total annual income from professional
practice depends on third-party payments?

Most psychologists (31.3%) reported that between 61% and 80% of their
annual income from their professional practices depended on third-party payments.

nem_B_1_5: Have you ever been excluded from a provider panel on which you
requested to participate?

An overwhelming majority of psychologists (74.3%) who were surveyed
reported that they had been excluded from a provider panel on which they had

requested to participate (see Figure 7).

 

 

 

 

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Response

Figure 7: Responses to Item 815: Have you ever been excluded from a
provider panel on which you requested to participate?

61

Itemle: Have you had to change your theoretical orientation in order to
stay on provider panels?

A majority of psychologists (77.7%) indicated that they had not had to change

their theoretical orientations In order to stay on provider panels (see Figure 8).

 

go
so -
7o «
so I
so ~
40 -
30 ~

20-

% Psychologists in Agreement

10—

 

 

 

 

 

Yes

Response
Figure 8: Responses to Item B17: Have you had to change your theoretical
orientation In order to stay on provider panels?
Item_D_1_5: Do you feel that participation in managed care programs has
increased your professional liability exposure?
Most psychologists (40.2%) reported that they thought their participation in

managed care programs had moderately increased their exposure to professional

liability (see Figure 9).

workload
Responses to items CZ, D21, and 022 are presented in Figures 10 through

12. As shown in Figure 10, most psychologists (50.3%) Indicated a moderate

62

 

-* MN 00 0) -h
010010 01 O

% Psychologists in Agreement
3

 

 

         

5 .
0 .
Not at All Very Little Moderately Greatly
Response
Figure 9: Responses to Item D15: Do you feel that participation in managed
care programs has Increased your professional liability exposure?
80

 

% Psychologists in Agreement

 

 

 

Greatly Moderately No Impact Moderately Greatly
Increased Increased Decreased Decreased

Response

Figure 10: Responses to Item 02: What impact has working with third-party
payers had on the demand for your services?

63

60

 

509

4o-

30—

20“

% Psychologists in Agreement

10-

 

 

 

Greatly Moderately No impact Moderately Greatly
Increased Increased Decreased Decreased

Response

Figure 11: Responses to Item 021: What impact has obtaining phone authoriza-
tion had on your workload?

90

 

ao-
70~
60—
50~
4o-
30-
20-

% Psychologists in Agreement

10~

 

 

         

Greatly Moderately No Impact Moderately Greatly
Increased Increased Decreased Decreased

Response

Figure 12: Responses to Item D22: What impact has report writing had on your
workload?

64

Increase In the demand for their services as a result of participating ln managed care
programs. Most psychologists also Indicated that their workload had moderately
increased because of obtaining phone authorizations (50.3%) (Figure 11) and

because of report writing (44.1%) (Figure 12).
ImpacthanagedﬁammnelLeatmem.
Blli I' I0 I“! [I I I

Items}: What type of impact have third-party payers had on the develop-
ment of treatment relationships?

The majority of respondents (72.1%) reported a negative Impact of third-party
payers on the development of treatment relationships between themselves and their
clients. Only 2.2% reported a moderate positive impact, and 25.5% reported no
impact. Most also reported a moderately negative effect on the overall quality of

treatment they provided (see Figure 13).

 

 

 

 

 

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70 -
E
o
E 60 -
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.E
.9 40 ~
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Negative Impact Positive Impact No Impact
Response

Figure 13: Responses to Item C3: What type of impact have third-party payers
had on the development of treatment relationships?

65

nem_CA: What effect does the Involvement of third parties have on the
overall quality of treatment that you provide?

The majority of psychologists (75%) reported that the involvement of third
parties had a negative impact on the overall quality of the treatment they provided.
Only 2.2% Indicated a positive relationship, and 21.8% said there was no impact

(see Figure 14).

 

80

70-

60-

50~

4o-

30~

20-

% Psychologists In Agreement

10—

 

 

   

4 ‘
Negative Impact Positive Impact No Impact

 

Response

Figure 14: Responses to Item C4: What effect does the Involvement of third
parties have on the overall quality of treatment that you provide?

Item: Are guidelines forthird—party reimbursement a consideration in your

choice of diagnosis?

In response to this item, 17.9% of the psychologists reported that the
guidelines for third-party reimbursement were a consideration in their choice of

diagnosis. On the other hand, 34.6% said the guidelines were a very little

66

consideration, 31.4% a moderate one, and 14% a great consideration (see Figure

15).

 

4O

35~

30-

25~

20-

15~

10—

% Psychologists in Agreement

 

 

 

Greatly Moderately Very Little Not at All
Response

Figure 15: Responses to Item CS: Are guidelines for third-party reimbursement
a consideration in your choice of diagnosis?

new: Do you feel any pressure to adjust your treatment decisions in order

to stay on provider panels with PPO or HMO contracts?

In response to Item C6, 26.3% of the psychologists said they did not feel any
pressure to adjust their treatment decisions in order to stay on provider panels with
PPO or HMO contracts. Another 33.5% said they felt very little pressure, 28.5%
moderate pressure, and 10.1% great pressure (see Figure 16).

m: Does the acceptance of third-party funds create dilemmas for you
when making case decisions?

Of the psychologists participating In this study, 14.5% Indicated that the

acceptance of third-party funds had never created dilemmas for them when making

67

case decisions, and 55.9% said It had rarely created dilemmas. Another 6.1% said

ocmsionally, and 13.4% said frequently.

4O

 

35-

30-

25“

20~

15~

10-

% Psychologists in Agreement

 

 

     

I

Great Moderate Very Little Not at All
Response

Figure 16: Responses to Item C6: Do you feel any pressure to adjust your

treatment decisions in order to stay on provider panels with PPO or
HMO contracts?

BMW: How do psychologists view managed care and

their Interactions with managed care agents?

Itemm: Please rate your ease in contacting managers on the phone.

In response to Item D1, 8.9% of the psychologists experienced only minimal
waits when contacting managers by telephone, and 31.3% experienced occasional
waits (20% or less of the time) of more than 10 minutes. Another 18.4% of the
respondents experienced waits of more than 10 minutes roughly 20% to 50% of the

time, and 13.4% experienced such waits more than 50% of the time.

68

mm: Please indicate the time It takes for managers to return messages
(voice mail, etc.).

In response to this Item, 6.7% of the psychologists reported that their
messages were returned promptly (within a few hours); 17.9% said messages nearly
always were returned within 24 hours; 28.5% said messages usually were returned
within 24 hours, occasionally longer; and 23.5% said it took more than 24 hours
(20% to 50% of the time). Finally, 19.6% of the psychologists reported it took more
than 24 hours 50% of the time, or messages were not returned at all.

1193133: Please Indicate the timelines that you experience in obtaining

authorization for emergency services, medical consults, and ancillary

services.

In response to this Item, 15.6% of the psychologists reported obtaining
authorization for emergency services, medical consults, and ancillary services in a
prompt manner, and 31 .3% said they nearly always received authorization within 24
hours. Another 16.2% said they usually obtained such authorization within 24 hours,
ocmsionally longer; 12.8% usually within 48 hours; and 5.6% said it usually took
more than 48 hours to receive authorization.

113mm: 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).

As shown In Figure 17, 15.6% of the subjects received authorization for
treatment within 1 week; 24% usually within 1 week, occasionally longer, 19.6%

nearly always within 2 weeks; and 19.6% occasionally longer than 2 weeks. Another

16.2% said it usually took longer than 2 weeks to receive authorization for treatment.

69

 

30

25-

20—

15«

10-

% Psychologists in Agreement

 

 

     

Within 1 week Usually within one Nearly always within Occasionally > 2 Usually > 2 weeks
week 2 weeks weeks

Response

Figure 17: Responses to Item D4: Please Indicate the amount of time it takes for
you to receive authorization for treatment.

Itemﬂz: Please indicate your experience with managers when you request
authorization (for additional therapy sessions).

As shown in Figure 18, 14.5% of the psychologists experienced reasonable
and appropriate dialogue when requesting authorization from managers; 55.9% said
that justiﬁcation was required but the request was accepted. Only 6.1% Indicated
that managers had granted or denied their request for authorization for additional
sessions without providing justiﬁcation, 13.4% reported experiencing difﬁculty
obtaining authorization for additional sessions, and 3.4% reported that managers

were contentious and rigid when asked to authorize additional therapy sessions.

70

 

% Psychologists In Agreement

 

 

 

   

Dialogue Justification Sessions Difﬁculty Managers
reasonable & required by granted or obtaining more contentious and
appropriate accepted denied w/o sessions rigid
justiﬁcatioin
Response

Figure 18: Responses to Item D7: Please indicate your experience with
managers when you request reauthorization.

Item_D_8: Please indicate the extent to which the manager collaborates with

you throughout the course of a case.

Only 5% of the psychologists reported that the extent to which the manager
collaborated with them throughout the course of a case was always collegial.
However, 48.6% said It was generally collegial, 29.1% said occasionally collegial,
and 10.6% said the extent of collaboration was rarely collegial (see Figure 19).

IleleQ: Please rate the professionalism of the managers of the companies
which you work with most often.

As shown In Figure 20, just 1.7% of the psychologists rated the
professionalism of the managers of the companies with which they worked most as
highly professional. Another 23.5% said the managers were professional, 44.7%

said they were adequate, 19% Indicated managers were occasionally

71

 

60

50-

4o-

30—

20-

% Psychologists in Agreement

10~

 

 

   

Always collegial Generally collegial Occasionally Rarely collegial
collegial

Response

Figure 19: Responses to Item D8: Please indicate the extent to which the
manager collaborates with you throughout the course of a case.

 

50
45 .
40 .
35 ~
30 ~
25 ~
20 J

154

% Psychologists in Agreement

10-

 

 

 

Highly Professional Adequate Occcasionally Unprofessional
Professional unprofessional

Response

Figure 20: Responses to Item D10: Please rate the professionalism of the
managers of the companies which you work with most often.

72

unprofessional, and 6.7% rated managers as unprofessional and lacking knowledge

or skill.

ItemDJJ: Utilization review personnel or case managers use criteria that are

 

As shown in Figure 21, 18.4% of the psychologists indicated that utilization
review personnel or case managers used criteria that were written in clear and
concise terms; 23.5% said the criteria were unwritten but that the policy was clear
and consistent. Another 31.8% of the respondents Indicated that the criteria were
unwritten and that the policy was unclear and inconsistent, and 1;7;.9% indicated

that no criteria were stated, either orally or in writing.

 

35

30-

25~

204

15*

10-

% Psychologists in Agreement

 

 

 

Written - clear 8 Unwritten - policy is Unwn‘tten - policy is No stated criteria
concise terms clear & consistent unclear &
inconsistent

Response

Figure 21: Responses to Item D11: Utilization review personnel or case
managers use criteria that are

73

Itemﬂla: Please indicate the average promptness of payment after billing.

As shown in Figure 22, 9.5% of the psychologists indicated that, on average,
payment was received within 30 days after billing, 35.2% said between 30 and 60
days, 25.1% usually between 30 and 60 days and occasionally longer, and 19.6%
usually between 60 and 90 days and occasionally longer. Just 7.3% said it usually
took, longer than 90 days to receive payment.

40

 

0)
0'1

25~

% Psychologists in Agreement
3 z; B

01

 

 

 

0

Within 30 days Between 30 Usually Usually Usually longer
and 60 days between 30 & between 60 & than 90 days
60 days 90 days

Response

Figure 22: Responses to Item 013: Please indicate the average promptness of
payment after billing.

W: In working with managed care, do psychologists

have less control in making treatment decisions?

Table 1 contains the responses to Items D12 and D16 through 020. As
shown in the table, most psychologists (51 .4%) said they believed they had very little
control over clinical decisions. However, most of them (74%) indicated that they

thought they had a moderate amount of control in determining the length of

74

treatment, and 46.4% in determining the client’s treatment plan. The majority
(55.3%) thought they maintained a great amount of control in using their own
judgment In clinical matters, and 55.3% in using their own treatment approaches.
However, in establishing their fees and payment arrangements, most psychologists

(42.5%) thought they had no control.

Table 1: Psychologists’ responses to lack of control items (In %).

 

 

 

 

 

 

 

Item Great Moderate Very Little No
Control control Control Control

D12: Clinical decisions 14.0 30.7 51.4 1.1
016: Determining the overall length of 17.3 41.3 27.9 10.1
treatment
D17: Determining the client’s treatment 44.1 46.4 4.5 1.1
plan
D18: Using your own judgment in clinical 55.3 36.9 4.5 0.6
matters
019: Using your own treatment 55.3 33.5 8.1 1.2
approaches
020: Establishing fees and payment 11.7 16.2 26.3 42.5
arrangements

 

 

 

 

 

 

 

W: Do psychologists encounter ethical dilemmas
in their work with managed care?
EthicaLDIlemmasExpeLIencsd
Responses to the six ethical-dilemma items from the questionnaire are shown
In Table 2. The psychologists’ responses to item C8 Indicated that most of them

(59.2%) had never given a less severe diagnosis in order to conform with third-party

75

reimbursement guidelines, whereas 37.9% had done so. The responses to item C1 0
Indicated that 36.9% of the psychologists had never given a more severe diagnosis
in orderto conform with third—party reimbursement guidelines, whereas most of them
(59.8%) had done so. Participants’ responses to item C12 Indicated that 22.3% of
them had never reported a case as individual treatment In order to conform with
third-party reimbursement guidelines when other treatment was actually provided,
whereas the majority of respondents (74.9%) had reported a case as Individual
treatment when other treatment was actually provided.

Table 2: Psychologists’ responses to items concerning ethical dilemmas
experienced (in %).

 

 

 

 

 

Item Never Rarely Occasionally Frequently
CB: Given a less severe diagnosis 59.2 22.3 13.4 2.2
C10: Given a more severe 36.9 22.3 29.1 8.4
diagnosis
C12: Reported as individual 22.3 20.7 40.2 14.0
treatment when other treatment
was provided
C14: Modality of treatment was 52.0 20.7 15.1 2.8

selected when another treatment
modality was warranted

 

C16: A treatment approach 29.1 23.5 32.4 7.8
selected when another treatment
approach would have been more

appropriate

C18: A client given less treatment 8.9 16.2 43.0 27.4
than the client needed

 

 

 

 

 

 

 

 

76

On item C14, 52% of the respondents indicated that they had never selected
a treatment modality in order to conform with reimbursement guidelines when
another treatment was warranted; 38.6% had done so. In response to item C16,
29.1% of the psychologists said they had never selected a treatment approach In
order to conform to reimbursement guidelines when another treatment approach
would have been more appropriate, whereas the majority of respondents (63.7%)
had done this. Finally, In response to Item C18, 8.9% of the psychologists said they
had never given less treatment than the client needed In order to conform to third-
party reimbursement guidelines, whereas the majority ofthem (86.6%) had engaged

in that practice.

Responses to part II of the ethical-dilemma items (C9, 011, C13, C15, 017,
C19) were based on respondents’ answers to part I of the ethical-dilemma Items
(see Table 3). That Is, if psychologists responded afﬁrmatively to an item in part I
of the ethical-dilemma items, in part II they were asked to indicate for each item
whether they were (a) comfortable with the decision, (b) a little uncomfortable, (c)
moderately uncomfortable, (d) considerably disturbed, or (e) greatly disturbed.

On item 09, 7.4% of the respondents indicated they were comfortable with
their decision to give a less severe diagnosis In order to conform with third-party
reimbursement guidelines, and 27.4% were uncomfortable with their decision. In
response to item C11, 10.6% of the psychologists said they were comfortable with

the decision to give a more severe diagnosis in order to conform with third-party

77

 

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78

reimbursement guidelines; 49.7% experienced varying degrees of discomfort with
that decision. On item C13, 24.6% of the respondents Indicated they were
comfortable with their decision to report a case as Individual treatment In order to
conform with third-party reimbursement guidelines, when other treatment actually
was provided; 50.3% experienced varying degrees of discomfort with the decision.

According to the psychologists’ responses to item C15, 8.9% were
comfortable with their decision to select a treatment modality in order to conform with
reimbursement guidelines, whereas 36.3% were uncomfortable with their decision.
Responses to item 017 indicated that 7.3% of the psychologists were comfortable
with their decision to select a treatment approach in order to conform with
reimbursement guidelines, when another treatment approach was considered to be
more appropriate; on the other hand, 59.8% experienced discomfort. On item C19,
2.8% of the psychologists said they were comfortable with their decision to give less
treatment than the client needed in order to conform to third-party reimbursement
guidelines, whereas the majority (81 . 1%) experienced discomfort with that decision.

WM: Are psychologists satisﬁed in their work with
managed care?

This section of the PPS included six items concerning respondents”
satisfaction with utilization review personnel and case managers. Psychologists
responded to each Item using a 5-point Likert-type scale ranging from highly
satisﬁed (1) to very dissatisﬁed (5). When dissatisﬁed and very dissatisﬁed
responses were combined, it was found that the majority of psychologists reported

being dissatisﬁed with the competence and management skills of utilization review

79

personnel and case managers. Almost an equal number of psychologists reported
dissatisfaction (39.1%) as reported satisfaction (41.1%) with the ability to use their
own judgment in clinical decisions. Most psychologists reported satisfaction with the
opportunity to use their own treatment approaches (49.7%) and with the
acknowledgment they received from utilization review personnel or case managers
for doing their jobs well (56.4%) (see Table 4).

Table 4: Psychologists' responses to items concerning satisfaction with managed
care plans (in %).

 

 

 

 

 

Item Highly Satisﬁed Neither Dissatisﬁed Very
Satisﬁed Dissatisfied

818: The competence of 0.0 15.1 23.5 31.3 27.4
UR personnel
B19: The management 0.0 13.4 24.6 32.4 25.7
skills of UR personnel
B20: Your working relation- 1.7 25.7 33.5 25.7 10.1
ship with UR personnel
B21: The opportunity to use 10.1 31.3 17.9 24.0 15.1

your own judgment in
clincial matters

 

822: The Opportunity to use 11.7 38.0 15.6 19.0 11.2
your own treatment

approaches

823: The acknowledgment 0.0 5.0 17.3 12.3 44.1
you receive from UR per-
sonnel

 

 

 

 

 

 

 

 

 

Respondents also were asked for their overall opinion of the impact of
managed care on the practice of psychology (item D23). Few psychologists (2.8%)

viewed managed care as having a marked Improvement on the practice of

80

psychology, and 3.4% said it had no inﬂuence. Conversely, 36.3% of the psycholo-
gists said managed care had had a moderately adverse effect on the practice of
psycholOQY. and 55% of them said that managed care had had a marked adverse

effect.

8 II [II II 'I I'

Statistical analyses were run on data collected with the MBI and the PPS, in
order to test the hypotheses formulated for this study. The .05 alpha level was the
criterion established for statistical signiﬁcance. In this section, each hypothesis is

restated, followed by the results for that hypothesis.

Hypothesm: There will be a signiﬁcant relationship between age and
burnout.

The Pearson correlation coefﬁcient was used to test the relationship between
age and burnout (emotional exhaustion, depersonalization, and personal accom-
plishment). Results indicated that the relationship between age and emotional
exhaustion was statistically signiﬁcant (t: = -.259, p < .01). That is, age was
negatively correlated to emotional exhaustion. Thus, the research hypothesis was
supported for this relationship. However, the relationships between age and
depersonalization and personal accomplishment were not found to be signiﬁcant.
Therefore, the research hypothesis was rejected for those relationships.

Hypothesis): There will be signiﬁcant differences In the levels of
burnout when categorized by gender.

I-tests were used to test this hypothesis. The results indicated that there

were no signiﬁcant differences between males and females In the levels of emotional

81

exhaustion, depersonalization, and personal accomplishment (see Table 5). Forthe
comparison of emotional exhaustion and gender, the t-value of .035, with 177
degrees of freedom, was not found to be signiﬁcant at the .05 level of conﬁdence.
That is, the difference in means (males = 2.10, females = 2.09) was not signiﬁcant.
Therefore, the research hypothesis was not supported, Indicating that there was no
signiﬁcant difference in emotional exhaustion between males and females.
Likewise, for the comparison of depersonalization and gender, the t—value of 1.55,
with 177 degrees of freedom, was not found to be signiﬁcant at the .05 level of
conﬁdence. That is, the difference In means (males = 1.07, females = 0.88) was not
signiﬁcant. Therefore, the research hypothesis was not supported, indicating that
there was no signiﬁcant difference in depersonalization between males and females.
For the comparison of personal accomplishment and gender, the t-value of 1.39,
with 177 degrees of freedom, was not found to be signiﬁcant at the .05 level of
conﬁdence. That is, the difference in means (males = 5.41, females = 5.29) was not
signiﬁcant. Therefore, the research hypothesis was not supported, indicating that
there was no signiﬁcant difference in personal accomplishment between males and
females.

Table 5: Results of t-tests Investigating differences in levels of burnout between
males and females.

 

Aspect of Burnout Group Mean SD I 511 n

 

Emotional exhaustion Male 2.10 1.04

Female 2.09 0.89 0'035 177 '972

 

Depersonalization Male 1 .07 0.85

Female 0.88 0.79 1'55 177 '123

 

Personal accomplishment Male 5.41 0.57

Female 5.29 0.60 1391 177 '166

 

 

 

 

 

 

 

 

 

L

82

ﬂymjhesisj: There will be a signiﬁcant relationship between the
percentage of clients under managed care and burnout.

An average of the responses to four items concerning the percentage of
managed care clients was calculated. The Pearson correlation coefﬁcient was used
to test the relationship between the percentage of clients under managed care and
the three aspects of burnout (emotional exhaustion, depersonalization, and personal
accomplishment). The correlation matrix for this analysis is presented in Table 6.
The relationship between percentage of managed care clients and emotional
exhaustion was found to be signiﬁcant; the two were positively correlated (r = .188,
p < .05). Thus, the hypothesis was supported for this relationship. However, the
relationships between percentage of managed care clients and depersonalization
([ = .120, p > .05) and between percentage of managed care clients and personal
accomplishment (t = -.129, p > .05) were not found to be signiﬁcant. Thus, the
hypothesis regarding a relationship between percentage of managed care clients
and both depersonalization and personal accomplishment was not supported.

Table 6: Correlation coefficients for percentage of managed care clients and
aspects of burnout.

 

 

 

 

 

 

 

Emotional Depersonalization Personal
Exhaustion Accomplishment
Percentage of managed .188 .120 -.129
care clients 9 = .012 p = .113 p = .087
a

 

83

WM: There will be a signiﬁcant relationship between lack of
control and burnout.

Factor analysis was perform ed on the perceived control items, which revealed
one factor that was used in succeeding analyses. The Pearson correlation
coefficient was used to test the relationship between the lack—of-control factor and
the three aspects of burnout (emotional exhaustion, depersonalization, and personal
accomplishment). The correlation matrix for this analysis is presented in Table 7.
A signiﬁcant positive relationship was found between lack of control and emotional
exhaustion ([ = .221, p < .01) and between lack of control and depersonalization ([
= .169, p < .05). A signiﬁcant negative relationship was found between lack of
control and personal accomplishment ([ = -.261, p < .01). Thus, because the
relationships between lack of control and all three aspects of burnout were

signiﬁcant, the research hypothesis was supported.

Table 7: Correlation coefﬁcients for lack of control and aspects of burnout.

 

 

Emotional Depersonalization Personal
Exhaustion Accomplishment
Lack of control .221 .169 -.261
p = .004 p = .028 p = .000

 

 

 

 

 

 

W: There will be a signiﬁcant relationship between
Increased workload and burnout.

Factor analysis was performed on the workload items, which revealed one
factor that was used in succeeding analyses. The Person correlation coefficient was

used to test the relationship between the Increased workload factor and the three

84

aspects of burnout (emotional exhaustion, depersonalization, and personal
accomplishment). The correlation matrix for this analysis is presented In Table 8.
A signiﬁcant negative relationship was found between increased workload and
emotional exhaustion ([ = -.259, p < .01) and between increased workload and
depersonalization ([ = -.150, p < .05). The relationship between increased workload
and personal accomplishment (r = -.012, p > .05) was not found to be signiﬁcant.
Thus, the relationships found between increased workload and emotional exhaustion
and depersonalization supported the research hypothesis, whereas they hypothesis
was not supported regarding a relationship between increased workload and

personal accomplishment.

Table 8: Correlation coefﬁcients for increased workload and aspects of burnout.

 

 

F1
Emotional Depersonalization Personal
Exhaustion Accomplishment
Increased workload -.259 -.150 -.012
p = .001 p = .050 p = .873

 

 

 

 

 

 

 

BMW: Burnout can be predicted from the managed care

variables (percentage of managed care clients, lack of control, and

increased workload) when controlling for the effects of age.

The [2 = .207 statistic Indicated that the managed care variables accounted
for 20.7% of the variance in emotional exhaustion (p < .05). The [2 = .128 statistic
indicated that the managed care variables accounted for 12.8% of the variance in

depersonalization (p < .05). Also, the I:2 = .097 statistic indicated that the managed

care variables accounted for 9.7% of the variance in personal accomplishment (p <

85

.05). Hence, the managed care variables were found to be signiﬁcant predictors of

all three aspects of burnout. Therefore, Hypothesis 6 was supported.

5110101311

The study ﬁndings, Including the results of hypothesis testing, were presented
in this chapter. Chapter V contains a summary and discussion of the ﬁndings,
conclusions drawn from the ﬁndings, recommendations, and implications for further

research.

86

CHAPTER V

SUMMARY, CONCLUSIONS, IMPLICATIONS.
AND RECOMMENDATIONS
Intmdusﬂnn
This chapter contains a summary of the study, including the purpose, a
description of the population, and data-analysis techniques. Conclusions drawn
from the study ﬁndings are presented, as are limitations, implications for practice,

and recommendations for future research.

Summary

The major purposes of the study were to explore the views and practices of
psychologists concerning their work with managed care organizations, to examine
the levels of burnout among psychologists, and to assess the relationships between
managed care variables (percentage of clients under managed care, perceived
control, and workload) and burnout. The sample for this study comprised 179
licensed psychologists who worked in private practice settings and who were
members of the APA. Respondents included 105 males and 74 females.

Six research hypotheses were formulated and tested at the .05 level of
signiﬁcance. Analysistechniques included descriptive statistics, correlations, t-tests,

and multiple regression analysis. E-probabilities, t-values, and p-values were tested

87

for signiﬁcance at the .05 level of conﬁdence. The conclusions drawn from the

ﬁndings are presented in the following section.

Conclusions
In this section, each research question is restated, followed by the
conclusions regarding that question.
WM: Do psychologists experience burnout?
Most psychologists experienced low levels of burnout. Speciﬁcally, most of
them had high levels of emotional exhaustion and depersonalization, and low levels

of personal accomplishment.

W: Is the work of psychologists impacted by
managed care?

According to the psychologists, the ways in which their work was Impacted
by their participation in managed care plans were as follows:

- Exclusions from provider panels on which they had requested to participate.

- A feeling that participation in managed care programs had increased their
professional liability exposure.

- A moderate increase in the demand for their services.

- A moderate Increase in their workload due to the additional time it took for
them to obtain phone authorizations and the report writing required of psychologists
who participate in managed care programs.

- A negative impact by third-party payers on the development of treatment
relationships between psychologists and their patients.

- A negative impact on the overall quality of the treatment provided.

88

W: How do psychologists view managed care and
their Interactions with managed care agents?

Psychologists viewed managed care and their Interactions with managed care
agents as follows:

- When contacting case managers by telephone, psychologists occasionally
had to wait more than 10 minutes.

- Managers usually returned telephone calls within 24 hours, but occasionally
longen

- Authorization for emergency services, medical consults, and ancillary
services was obtained promptly, nearly always within 24 hours.

- Authorization for treatment usually was received within 1 week.

- Justiﬁcation was required, but requests typically were accepted when
psychologists asked for authorization for additional therapy sessions.

- The extent to which the review manager collaborated with psychologists
throughout the course of treatment always was collegial.

- The professionalism of the managers was adequate.

- Utilization review personnel or case managers used criteria that were
unwritten, and the policies were unclear and inconsistent.

- The average promptness of payment after billing was between 30 and 60
days.

W: In working with managed care, do psychologists
have less control in making treatment decisions?

The major areas In which psychologists had maintained greater control were:

- using their own judgment In making clinical decisions.

89

- using their own judgment in employing their own treatment approaches.
According to the psychologists, the areas in which they had less control were:
- determining the length of treatment.

- making clinical decisions.

- establishing their fees and payment arrangements.

W: Do psychologists encounter ethical dilemmas
In their work with managed care?

The ethical dilemmas psychologists encountered in efforts to conform to third-
party reimbursement guidelines were as follows:

- Reporting a more severe diagnosis.

- Reporting a case as individual when other therapy actually was provided.

- Selecting a treatment approach that was contrary to what they believed to
be most effective for the patient.

Interestingly, most psychologists who encountered these ethical dilemmas felt
uncomfortable with their decisions.

W: Are psychologists satisﬁed in their work with
managed care?

When asked about their satisfaction with various aspects of their work with
managed care programs, most psychologists reported:

- Satisfaction with the opportunity to use their own treatment approaches.

- Satisfaction with the acknowledgment of the UR personnel or case
managers for doing their jobs well.

- Dissatisfaction with the competence and management skills of the UR

reviewer and case manager.

90

- Equal satisfaction and dissatisfaction with the ability to use their own
judgment in making clinical decisions.

When asked about their overall opinion of the impact of managed care on the
practice of psychology, most reported that managed care had a marked adverse
effect on the practice of psychology.

Six research hypotheses were addressed in this study. The ﬁrst hypothesis
ccncemed the relationship between age and burnout. A correlational analysis
revealed that there was a signiﬁcant negative relationship between age and
emotional exhaustion. That is, younger psychologists were more likely to feel
emotionally overextended and depleted of their emotional resources than were older
ones. This ﬁnding is consistent with previous research (Cordes & Dougherty, 1993;
Maslach, 1982; Maslach & Jackson, 1981).

The second hypothesis examined differences in burnout based on gender,
using t-tests. No statistically signiﬁcant difference was found between male and
female psychologists on any of the three aspects of burnout.

Hypothesis 3 examined the relationship between percentage of managed
care clients and burnout, using correlational analysis. The ﬁndings Indicated that
there was a signiﬁcant positive relationship between percentage of managed care
clients and emotional exhaustion. That is, the more managed care clients on the
psychologists’ caseloads, the more likely they were to experience emotional
exhaustion—in other words, the more likely they were to feel emotionally
overextended and depleted of their emotional resources. This ﬁnding is similar to

that of previous research by Dupree and Day (1995), suggesting that high

91

percentages of burnout are found among mental health workers with higher
caseloads of managed care clients. However, no signiﬁcant relationship was found
between percentage of managed care clients and either of the other two aspects of
burnout (depersonalization and personal accomplishment).

Findings resulting from the testing of Hypothesis 4 indicated that a signiﬁcant
relationship existed between lack of control and all three aspects of burnout. That
is, the less control psychologists had in making treatment decisions, the more likely
they were to experience high levels of emotional exhaustion and depersonalization,
and low levels of personal accomplishment. Hence, they were more likely to get
overly Involved emotionally; to feel overwhelmed by the emotional demands imposed
by other people; to maintain a negative, callous, or excessively detached response
to their patients; and to feel less competent or successful in their work. This
conclusion was supported in the literature (Levant, 1994).

When testing Hypothesis 5, a signiﬁcant relationship was found between
increased workload and all three aspects of burnout. This indicates that the higher
one’s workload was as a result of participating in managed care, the more likely that
individual was to experience high levels of emotional exhaustion and
depersonalization, and low levels of personal accomplishment. Thus, the provider
was more likely to get overly involved emotionally; to feel overwhelmed by the
emotional demands imposed by other people; to maintain a negative, callous, or
excessively detached response to patients; and to feel less competent or successful
In his or her work. These results supported the relationship between burnout and

workload as noted in the literature (Levant, 1994).

92

Findings resulting from the testing of Hypothesis 6 indicated that burnout can
be predicted from the managed care variables (percentage of managed care clients,
lack of control, and Increased workload) when controlling for the effects of age. This

conclusion was supported in the literature.

| . 'I I'

This study had certain limitations that affected the generalizability of the
ﬁndings. The sample was not a national one, nor was it representative of all
psychologists who work in private practice, or psychologists in general. Also,
because the sample was homogeneous, it was not representative of psychologists
from diverse racial/ethnic backgrounds. Another major limitation is the lack of
reliability and validity data for the PPS. Additionally, It is important to note that
causality has not been established between managed care factors and burnout.

Speciﬁcally, it has not been proven that managed care causes burnout.

ll'l' EEI'

The ﬁndings generated from this study have implications for psychologists
who work in private practice. The most important implication of this study is that
psychologists’ involvement in managed care programs, as measured by percentage
of managed care clients, lack of control over treatment decisions, and increased
workload, appears to be related to the various aspects of burnout (emotional
exhaustion, depersonalization, and personal accomplishment). The results indicated
that the work of psychologists is impacted by managed care, and psychologists

maintain less control over decisions regarding various aspects of their treatment.

93

In their work with managed care, psychologists engage in unethical practices In
order to obtain reimbursement for treatment, and they are dissatisﬁed with some
aspects of their work with managed care plans. Given this, along with the increasing
participation in managed care plans, psychologists will need to prepare themselves
better, overall, for work within a managed care environment. Therefore, the
following recommendations are made:

1. Managed care policies and their impact on the outcome and rendering
of clinical services should be thoroughly examined to determine their effect on the
burnout level of psychologists in various practice settings.

2. New educational paradigms need to be focused on preparing
psychologists to work within a managed care milieu. One approach Is to redesign
graduate programs to reﬂect the changing health care environment and practice of
psychology (Troy 8 Shueman, 1996).

3. It is important that psychologists learn more time-effective or brief
forms of psychotherapy.

4. There needs to be a paradigm shift and an attitude adjustment for
mental health providers in private practice. Browning (1996) stated, "Success
requires converting adversarial, hostile, resistant attitudes so that the clinician
projects a cooperative, team-player spirit when approaching and working with
managed care organizations" (p. 140). He argued that the result will prove beneﬁcial
for providers as they receive increases in referrals from managed care companies.

5. Before seeking acceptance onto a provider panel, the provider needs

to understand its philosophy and determine If it is congruent with his or hers. Next,

94

for therapists to become more successful In gaining acceptance on provider panels,
providers need to learn what managed care wants and what managed care does not
want (Browning, 1996). In bidding for positions on provider panels, therapists should
provide speciﬁc information about their practices, such as locations, orientations,
therapy modalities, areas of specialization, outcomes research, and managed care
experiences.

6. Psychologists should learn how to develop effective diagnoses and
treatment plans that are congruent In keeping with the patients’ needs, and those
that are more likely to be approved by managed care agents.

7. To Inﬂuence policy, it is Important that psychologists conducttheir own
outcome research and form coalitions with other providers to compile data that

demonstrate the efﬁcacy of their treatment.

RecommendationsioLEuthLBesearch

Because of the limitations of this study, speciﬁc recommendations for future
research include the following:

1. This study should be replicated with a national population of
psychologists. The results of such a study should be compared with those from the
present research so that more accurate generalizations about psychologists’ burnout
can be articulated.

2. This study should also be replicated with a population of psychologists

who work in different work settings (e.g., hospitals, HMOs, medical settings, and/or

95

counseling centers) to determine the level of burnout that exists in other settings in
which psychologists work with managed care programs.

3. There is a need to increase the representation of racially/ethnically
diverse populations within the samples of future research to determine whether
differences exist based on race/ethnicity.

4. Efforts need to be made to develop an instrument with established
psychometric properties for measuring the views and practices of mental health

workers who work with managed care programs.

96

APPENDICES

97

APPENDIX A

THE PRACTICE OF PSYCHOLOGY SURVEY

98

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 Tracy Thompson, PO. Box 6344, East Lansing, NH,

48826-6344; (517) 432-3666.

Directions: rams assumes by We. space a mam the-appropriate
response. If you work in more than one environment, your respomes should reﬂect yoin'
primary practice, orthe setting where you spendthe (majority of your pofessional ﬁne.

 

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 3;, go to question A-l. If your answer is M, you do not need to proceed further.
Please return this questionnaire in the aivelope provided Thank you

SECTION A - DEMOGRAPHIC INFORMATION

 

A-l. In what year were you born?

' l9

A-Z. What is your gmder?
Male
Female

A-3. What is your racial ethnic background? (Check all that apply)

African American/Black Hispanic/Latino(a)
Asian/Pacific Islander Native American/Alaskan Native
Caucasian Other:

 

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

19

99

A-S.

A-6.

A-7.

A-8.

A-9.

Since receiving your Doctorate, how many years have you worked at least twenty hours per
week (or its equivalait) providing psychological servrces?

 

What type of licensure do you currmtly hold?

Full
Limited
None

I

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

 

What was your family's total annual income for 1996 (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

IIII

IIII

What percent of your family's total annual income for 1996 was derived from your professional
practice?

°/o

. 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

SECTION B - PRA CE INFORMATI N

B-l.

B-2.

In what type of community do you practice?
_ Urban
_ Suburban
Rural ‘

What is your primary work setting?

Solo independent practice Commtmity Mental Health facility
Group independent practice Government facility

Staﬂ‘ HMO Medical facility

Group HMO Other (specify )

 

100

B-3. What percentage of your work time in a week is devoted to the following tasks:

% Psychotherapy or direct service provision
Billing

Utilization Review/Documartation

Other

B-4. What is the average amormt of time that you work each week? (both billable and non-billable
time)

Billable hours
Non-billable hours
Total hours working week

B-S. If you have a solo independent practice, or are part of a group indepardait 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)

9399669,“

This section (8-6 through B-17) relates to you: current caseload; please answer d1 quesu'ons.
If it would be helpful, please feel free torefer to yot'u' appornunentboolr or ﬁles. -

8-6. How many cases make up your currert caseload? (Count each. member of a group as one case.
Count couples and families, if the members are primarily seen together, as one case.)

8-7. Is your caseload primarily.“ (check one only):
__ children
adolescents
adults
8-8. Please estimate the percentage of your current caseload that is:

% Male

B-9. Please estimate the percentages of your currmt caseload that are in the following groups:
(% should equal 100)

African American/Black Hispanic/Latino(a)
Asian/Pacific Islander Native Americm/Alaskan Native
Caucasian Other:

 

101

B-lO. Please estimate the percartage of your curratt active caseload that is:

B-ll.

B-l3.

B-l7.

°/o White collar (accountants, attorneys, managers, physicians, administrators, computer

specialists, teachers, personnel specialists)

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

% Students, or those not currmtly in labor force by choice (womar who are currently

staying at home, retirees)

% Unemployed (not studarts or those choosing to be out of labor force, retirees)
100%

Please estimate the percentage of your cases that pay at the following rates:

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

°/o Free
100%

. Please estimate the proportion of all your cases that require prior approval of treatment plans by a

third party before payment for services is approved:

%

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

°/o

. Please estimate the proportions of your cases that use the following types of finding 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 wit under the appropriate
funding source. Choose the most appropriate source, even if co-payments are made by the cliart.)

°/o Fee-for-service
°/o Contractual fee-for-service (i.e., Medicare or Medicaid, PPO)

% Capitated
% Other (specify )

 

 

100%

. Have you ever been excluded from a provider panel to which you requested to participate?

Yes
No

. Which of the following approaches do you may utilize (check all that apply)

 

El Behavioral El Humanistic
D Client-cmtered D Psychodynamic/Psychoanalytic
D Cognitive/bdiavioral 0 Systemic
D Ego psychology 0 Other (please specify)
Have you had to change your theoretical orientation in order to stay on provider panels?
Yes
No

102

The following section (B-18 through B-23) refers to interactions with third party payors or
managed care. Please use the scale below to indicate your level of satisfaction:

 

 

 

 

 

 

 

 

 

l 2 3 4 5 6
Highly Satisfied Neither Dissatisfied Very Not
satisfied satisfied nor Dissatisfied Applicable
dissatisfied

8-18. The competence of utilization review personnel or case managers;

8-19. The management skills of utilization review personnel or case managers;

B-20. Your working relationship with utilization review personnel or case managers;

8-21. Your ability to use your own judgmart in clinical matters;

8-22. The opporttmity to use your own treatmait approaches;

8-23. The acknowledgement you receive from utilization review personnel or case

managers for doing your job well.

SECTION C - THIRD PARTY PAYQRS

Please check the space to the left of the appropriate answer. Note: "Third 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.

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

Not at all
Very little
Moderately
Greatly

C-2. 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
Greedy decreased your caseload

C-3. What type of impact have third party payors had on the development of treatmart relationship
between you and your clients?

Highly positive
Moderately positive
None at all
Moderately negative
Highly negative

103

C-5.

C-6.

C-7.

What eﬂ‘ect 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

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

Not at all
Very little
Moderately
Greatly

Not applicable

Do you feel any pressure to adjust your treatmait decisions in order to stay on provider panels
with PPO or HMO contracts?

__ Not at all
Very little
Moderate
Great

Does the acceptance of third party funds create dilemmas for you what making case decisions?

Not at all
Very little
Moderately
Greatly

Not applicable

This secu'on (08 through 020) relates to your current caseload as reported in question 8-
13. If It would be helpful, please feel free to refer to you- appointment hook or files.

C-8.

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

Never

Rarely
Occasionally
Frequently

Not Applicable

C-9.

C-ll.

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 tmcomfortable
Moderately tmcomfortable
Considerably disturbed
Greatly disturbed

Not Applicable

. How often were cases given a more severe diagnosis in order to conform with third party

reimbursement guidelines?

Never

Rarely
Occasionally
Frequently

Not Applicable

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 tmcomfortable
Moderately uncomfortable
Considerably disturbed
Greatly disturbed

Not Applicable

. 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

. If you have reported a case as individual treatment in order to conform with third party

reimbursement guidelines, what other treatment was provided, were you:

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

Not Applicable

105

C-l4.

C-lS.

C-l7.

C-18.

How oftm was the modality of treatrnmt selected in order to conform with reimbursemmt
guidelines, whm another treatrnmt modality was warranted (for example, providing group
therapy, whm individual treatment might have bem more appropriate)?

Never

Rarely
Occasionally
Frequmtly

Not Applicable

If you have selected a treatrnmt modality in order to conform with reimbursemmt guidelines,
were you?

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

. How oftm was a treatrnmt approach selected in order to conform with reimbursemmt.

guidelines, whm another treatmmt approach would have bem more appropriate (for example,
providing brief or task-orimted treatmmt, whm your knowledge or experimce suggested mother
choice)?

Never

Rarely
Occasionally
Frequmtly

Not Applicable

If you have selected a treatrnmt approach in order to conform with reimbursemmt guidelines,
whm you considered another treatmmt-approach more appropriate, were you:

Comfortable with the decision
A little tmcomfortable
Moderately tmcomfortable
Considerably disturbed
Greedy disturbed

How oftm was a climt givm less treatmmt than the climt needed in order to conform to third
party reimbursemmt guidelines?

Never

Rarely
Occasionally
Frequmtly

Not Applicable

106

C-19. If you have givm less treatmmt than the climt needed in order to conform to third party
reimbursemmt guidelines, were you:

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

Not Applicable

C-20. The peer review processes which are used by insurance companies:

Enhance conﬁdmtiality

Have no eﬂ‘ect on conﬁdmtiality

Have the potmtial for breaches in conﬁdmtiality
Greatly jeopardize confrdmtiality

021. Do you feel that you, as the therapist, are the agmt of (check one only):

The patimt

The purchaser of the health care, including employers
The payor, if differmt from the patimt or purchaser
Both the patimt and the payor

The patimt, the purchaser, and the payor

SE OND-MANA EDCARE

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 represmts the
MAJORITY of your interactions.

D-l. Please rate your ease in contacting managers on the phone:

Readily available, with minimal wait time

Occasional (20% or less) waits over 10 minutes - usually less
Waits over l0 minutes betwem 20% to 50% of the time
Waits over 10 minutes over 50% of the time

Long waits typical

D-2. Please indicate the time it takes for managers to return messages (voice mail etc):

Prompdy, within a few hours

Nearly always within 24 hours

Usually widin 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

107

D3.

D7.

D-8.

Please indicate the timelines that you experimce in obtaining authorization for emergmcy
services, medical consults, and ancillary services:

Prompdy, 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 treatmmt
(from the time you mail or call in your request tmtil you receive a writtm or verbal

Within 1 week

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

Occasionally longer than 2 weeks

Usually longer than 2 weeks

2
B-
O
a.
5:

In gmeral, 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 experimce with managers whm you request reauthorization:

Dialogue reasonable and appropriate
Justiﬁcation required but accepted

Sessions granted or dmied without justification
Difficulty obtaining more sessions

Managers contmtious and rigid

Please indicate the extmt to which the manager collaborates with you throughout the course of a
case is:

Always collegial
Gmerally collegial
Occasionally collegial
Rarely-collegial- - --

Please indicate the extmt to which the manager collaborates with you throughout the course of a
case is:

Always collegial
Gmerally collegial
Occasionally collegial
Rarely collegial

108

D-lO.

D-ll.

D-12.

D-l3.

D-l4.

D-lS.

Please rate the professionalism of the managers of the companies which you work with most
oftm:

Highly professional

Professional

Adequate

Occasionally improfessional
Unprofessional, lacking knowledge or skill.

Utilization review personnel or case managers use criteria that are:

Writtm, in clear and concise terms

Unwrittm - but policy is clear and consistmt

Unwrittm - and policy is unclear and inconsistmt
There are no stated criteria, either verbally or in writing

Whm 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

Please indicate the average promptness of paymmt after billing:

Within 30 days

Betwem 30 and 60 days

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

What proportion of your total annual income from professional practice depmds on third party
paymmts?

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

Do you feel that participation in managed care programs has increased your professional liability
exposure:

Not at all
Very little
Moderately
Greatly

Not applicable

109

In the following section (D16 through D20), rate the extent of control that you feel as the
therapist in making decisions regarding the client. Please use the scale below:

 

 

 

 

 

 

l 2 3 4 5
Greatly Moderately Very little Not at all Not
Applicable
D—16. ' Determining the overall lmgth of treatmmt;
D-17. Determining the client’s treatmmt plan;
D-l8. Using your own judgmmt in clinical matters;
D-19. Using your own treatmmt approaches;
D-20. Establishing fees and payment arrangements.

D-21. What impact has obtaining phone authorization had on your workload?

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

IIIII

D-22. What impact has report writing had on your workload?

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

IIIII

D-23. Overall, what is your opinion of the impact of managed care on the practice of psychology?

Marked improvemmt in services .,
Moderate improvement in services

No inﬂumce on services

Moderately adverse inﬂumce on services
Marked adverse influmce on services

Again, thank you very much for your participationl
PLEASE PLACE THE COMPLETED FORMS IN THE STAMPED AND ADDRESSED ENVELOPE
AND RETURN THEM TO:
T racy L. Thompson

PO. Box 6344
East Lansing, MI 48826-6344

110

APPENDIX B

COVER LETTER

111

Tracy L. Thompson
East Lansing, MI 48826

Dear Colleague,

Thank you for agreeing to consider participation in this study. The practice of
psychology has undergone a number of changes In the past ten years. The
overall purpose of my dissertation is to examine the current structure of the
practice of psychology and the personal, subjective experiences of workers In
human services. I would like to invite you to assist me in the investigation of
these professional issues.

You have been selected as part of a national random sample of practicing
psychologists. Participation in the study is entirely voluntary. There is no risk
involved, and you are free to withdraw at any time. You will not be asked to give
your name or any other information which would allow you to be personally
identiﬁed. To Insure that anonymity is maintained, there Is no coding of any type
to identify the respondent. Data will not be released on individuals but will be
reported only in the aggregate.

Participation in the study will require you to ﬁll out the attached surveys]
questionnaires. Please complete the Human Services Survey ﬁrst and then ﬁll
out the Study on the Practice of Psychology survey.

You indicate your voluntary agreement to participate in this study by completing
and returning the questionnaires in the pre-addressed, stamped return envelope.

If you are interested in the ﬁndings of this study, please contact me, and I will be
happy to send you a copy of the results.

Thank you in advance for your time and your participation. You may contact me
with any further questions at (517) 432-3666.
Sincerely,

Tracy L. Thompson, MS.

112

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