private practice? As a result of declining earnings
over the last few decades, some predict that private
practitioners will need to expand their roles to areas
such as alternative medicine, telehealth, psycho-
pharmacy, and life coaching, for example (Comas-
Diaz, 2006).
It may even be the case that, because of cost,
today’s Ph.D. clinicians will be replaced by tomor-
row’s master’s-level mental health professionals
(Baker et al., 2009; Eby et al., 2011; McFall,
2002, 2006)! We will have more to say about the
impact of managed care on the practice of clinical
psychology next.
The Costs of Health Care
Health care costs continue to rise. According to
the World Health Organization (http://www.who.
int/whosis/database/core/core_select_process.cfm?
countries=all&indicators=nha), the United States
spends more money on health care, both as a percent-
age of its gross domestic product (GDP) as well as per
capita, than any other nation in the world. It is esti-
mated that the United States spent $2.5 trillion dollars
on health care in 2009, approximately $8,086 per
person (http://www.cms.hhs.gov/NationalHealth
ExpendData/). This represented about 17.6% of the
GDP in 2009. However, from 2009 to 2019, it is
predicted that the proportion of the GDP devoted
to health care costs will rise to 19.6%.
How do these projections affect services for
mental health? The initial attempt to address high
costs for health care in general and mental health
care in particular was termedmanaged care.The old,
traditional, fee-for-service mental health care sys-
tem was“unmanaged”in the sense that there was
little control over which doctoral-level practitioners
could be used, the amount paid for services, the
quality of services, and the frequency of service uti-
lization. Insurance plans become“more managed”
as provider networks become more selective, as uti-
lization of services is evaluated with regard to
appropriateness and effectiveness, and as managed
care organizations institute quality improvement
programs (Bobbitt et al., 1998).
Therefore, the managed care approach shifted
economic control from practitioners to those that
ultimately pay the bills (e.g., employers). The focus
became cost containment, with corporations
expanding into a kind of medical-industrial com-
plex and emphasizing a marketplace mentality
(Kiesler & Morton, 1988). These and other features
of managed behavioral health care are summarized
in Table 3-3.
There are several models of managed care, all
of which attempt to control costs and reduce use of
services while at the same time ensuring their qual-
ity. We will briefly mention three major types of
managed care systems: HMOs, PPOs, and POSs. A
health maintenance organization (HMO) employs aT A B L E 3-2 What Future Practicing Clinical
Psychologists Need to Know
Here we list several key areas of knowledge that seem
especially relevant to future practicing clinical
psychologists:
- Knowledge of new and evolving health care deliv-
ery systems such as managed care organizations
(MCOs). - Sensitivity to ethical issues relevant to managed care
settings, including confidentiality and informed
consent. - Experience in multidisciplinary environments, such as
medical settings. - Managed-care-relevant clinical skills, including brief
interventions, treatment team approach, and
focused assessment. - Expertise in“applied”research, such as program
evaluation, cost-effectiveness, and medical cost
offset. - Management and business skills—for example,
contracts, utilization review, marketing. - Technology such as computers, databases, and
telemedicine. - Empirically supported and evidenced-based
practices (EBPs) in clinical assessment and
intervention. - Training in supervision; it is likely that fewer clinical
psychologists will be directly delivering services in
the future. - Sensitivity to cultural differences and knowledge of
empirical findings concerning EBPs appropriate for
ethnic subgroups.
72 CHAPTER 3