Assessment And Managed Care Issues

Restrictions by managed care organizations have affected the amount of assessment clinicians are able to conduct (Piotrowski, 1999). Consistent with this assertion, Piotrowski, Belter, and Keller (1998) found that 72% of psychologists in applied settings are conducting less assessment in general and are using fewer assessment instruments, especially lengthy assessment instruments (e.g., Rorschach, MMPI, TAT, and Wechsler scales), due to restrictions by managed care organizations. Likewise, Phelps, Eisman, and Kohout (1998) found that 79% of licensed psychologists felt that managed care had a negative impact on their work, and Acklin (1996) reported that clinicians are limiting their use of traditional assessment measures and are relying on briefer, problem-focused procedures.

With the growing influence of managed care organizations (MCOs) in mental health settings, it is inevitable that reimbursement practices will eventually affect training in assessment techniques and approaches (Piotrowski, 1999). We hope this will not be the case because of the many important training functions facilitated in assessment training, mentioned earlier in this chapter. Also, since we are training for the future, we must train students for the time when managed care will not dictate assessment practice. If, as we indicated earlier, assessment serves important training functions, it should continue to be enthusiastically taught, especially for the time when managed care will be merely a curiosity in the history of assessment. However, managed care has served us well in some ways, because we have sharpened and streamlined our approach to assessment and our instruments as well. We have focused anew on issues of reliability and validity of our measures, not merely in nomothetic research, but in research that includes reference to a test's positive predictive power, negative predictive power, sensitivity, and specificity to demonstrate the validity of our measures. Psychologists have turned more and more to assessment in other areas, such as therapeutic assessment, disability assessment, assessment in child custody, and other forensic applications. The Society for Personality Assessment has reported an increase in membership and in attendance at their annual meetings. We are optimistic that good evaluations, done in a competent manner and meaningfully communicated to the patient and referral source, will always be in great demand.

Nevertheless, an investigation concerning the impact of managed care on assessment at internship settings found that there has been a decrease in the training emphasis of various assessment techniques; 43% of directors reported that managed care has had an impact on their program's assessment curriculum (Piotrowski & Belter, 1999). Although approximately one third of the training directors surveyed reported a decrease in their use of projectives, the Rorschach and TAT remain 2 of the top 10 assessment instruments considered essential by internship directors of the sites surveyed. These studies indicate that MCOs are making an impact on the way assessment is being taught and conducted in clinical settings. Therefore, it is essential that psychologists educate themselves and their students in the practices of MCOs. Furthermore, psychologists should continue to provide research demonstrating the usefulness of assessment so that MCO descriptions of what is considered appropriate do not limit advancements. Empirical validation can help to guarantee psychologists reasonable options for assessment approaches so that we do not have to rely primarily on the clinical interview as the sole source of assessment and treatment planning information.

It is important to remember that MCOs do not dictate our ethical obligations, but the interests of our clients do. It is the ethical psychologist's responsibility to persistently request compensation for assessment that can best serve the treatment needs of the client. However, even if psychologists are denied reimbursement, it does not mean they should not do assessments when they are indicated. Therefore, options for meeting both financial needs of the clinician and health care needs of the client should be considered. One solution may be the integration of assessment into the therapy process. Techniques such as the Early Memories Procedure, sentence completion tasks, brief questionnaires, and figure drawings may be incorporated into the therapy without requiring a great deal of additional contact or scoring time. Other possibilities include doing the assessment as the clinician sees fit and making financial arrangements with the client or doing a condensed battery. Maruish, in his chapter in this volume, deals in more detail with the issues discussed in this section.

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