Psychological Assessment In The Era Of Managed Behavioral Health Care

Numerous articles (e.g., Ficken, 1995) have commented on how the advent of managed care has limited the reimbursement for (and therefore the use of) psychological assessment. Certainly, no one would argue with this assertion. In an era of capitated behavioral health care coverage, the amount of money available for behavioral health care treatment is limited. Managed behavioral health care organizations therefore require a demonstration that the amount of money spent for testing will result in a greater amount of treatment cost savings. As of this writing, this author is unaware of any published research that can provide this demonstration. Moreover, Ficken asserts that much of the information obtained from psychological assessment is not relevant to the treatment of patients within a managed care environment. If this indeed is how MBHOs view psychological assessment information, it is not surprising that MBHOs are reluctant to pay for gathering it.

Current Status

Where does psychological assessment currently fit into the daily scope of activities for practicing psychologists in this age of managed care? In a survey conducted in 1995 by the American Psychological Association's Committee for the Advancement of Professional Practice (Phelps, Eisman, & Kohut, 1998), almost 16,000 psychological practitioners responded to questions related to workplace settings, areas of practice concerns, and range of activities. Even though there were not any real surprises, there were several interesting findings. The principal professional activity reported by the respondents was psychotherapy, with 44% of the sample acknowledging involvement in this service. Assessment was the second most prevalent activity, with only 16% reporting this activity. In addition, the results showed that 29% were involved in outcomes assessment.

Taking a closer look at the impact that managed care has had on assessment, Piotrowski, Belter, and Keller (1998) surveyed 500 psychologists randomly selected from that year's National Register of Health Service Providers in Psychology in the fall of 1996 to investigate how managed care has affected assessment practices. One hundred thirty-seven usable surveys (32%) were returned. Sixty-one percent of the respondents saw no positive impact of managed care; and, consistent with the CAPP survey findings, 70% saw managed care as negatively affecting clinicians or patients. The testing practices of 72% of the respondents were affected by managed care, as reflected in their performing less testing, using fewer instruments when they did test patients, and having lower reimbursement rates. Overall, they reported less reliance on those tests requiring much clinician time—such as the Weschler scales, Rorschach, and Thematic Apperception Test—along with a move to briefer, problem-focused tests. The results of their study led Piotrowski et al. to describe many possible scenarios for the future of assessment, including providers relying on briefer tests or briefer test batteries, changing the focus of their practice to more lucrative types of assessment activities (e.g., forensic assessment), using computer-based testing, or, in some cases, referring testing out to another psychologist.

In yet another survey, Stout and Cook (1999) contacted 40 managed care companies regarding their viewpoints concerning reimbursement for psychological assessment. The good news is that the majority (70%) of these companies reported that they did reimburse for these services. At the same time, the authors pointed to the possible negative implications for the covered lives of those other 12 or so companies that do not reimburse for psychological assessment. That is, these people may not be receiving the services they need because of missing information that might have been revealed through the assessment.

Piotrowski (1999) summed up the current state of psychological assessment by stating,

Admittedly, the emphasis on the standard personality battery over the past decade has declined due to the impact of brief therapeutic approaches with a focus on diagnostics, symptomatology, and treatment outcome. That is, the clinical emphasis has been on addressing referral questions and not psychodynamic, defenses, character structure, and object relations. Perhaps the managed care environment has brought this issue to the forefront. Either way, the role of clinical assessment has, for the most part, changed. To the dismay of proponents of clinical methods, the future is likely to focus more on specific domain-based rather than comprehensive assessment. (p. 793)

Opportunities for Psychological Assessment

The foregoing representations of the current state of psychological assessment in behavioral health care delivery could be viewed as an omen of worse things to come. In my opinion, they are not. Rather, the limitations that are being imposed on psychological assessment and the demand for justification of its use in clinical practice represent part of health care customers' dissatisfaction with the way things were done in the past. In general, this author views the tightening of the purse strings as a positive move for both behavioral health care and the profession of psychology. It is a wake-up call to those who have contributed to the health care crisis by uncritically performing costly psychological assessments, being unaccountable to the payers and recipients of those services, and generally not performing assessment services in the most responsible, cost-effective way possible. Psychologists need to evaluate how they have used psychological assessment in the past and then determine the best way to use it in the future.

Consequently, this is an opportunity for psychologists to reestablish the value of the contributions they can make to improve the quality of care delivery through their knowledge and skills in the area of psychological assessment. As has been shown throughout this chapter, there are many ways in which the value of psychological assessment can be demonstrated in traditional mental health settings during this era of managed behavioral health care. However, the health care industry is now beginning to recognize the value of psychological assessment in the more traditional medical arenas. This is where potential opportunities are just now beginning to be realized.

Psychological Assessment in Primary Care Settings

The past three decades have witnessed a significant increase in the number of psychologists who work in general health care settings (Groth-Marnat & Edkins, 1996). This can be attributed to several factors, including the realization that psychologists can improve a patient's physical health by helping to reduce overutilization of medical services and prevent stress-related disorders, offering alternatives to traditional medical interventions, and enhancing the outcomes of patient care. The recognition of the financial and patient-care benefits that can accrue from the integration of primary medical care and behavioral health care has resulted in the implementation of various types of integrated behavioral health programs in primary care settings. Regardless of the extent to which these services are merged, these efforts attest to the belief that any steps toward integrating behavioral health care services—including psychological testing and assessment— in primary care settings represents an improvement over the more traditional model of segregated service delivery.

The alliance of primary and behavioral health care providers is not a new phenomenon; it has existed in one form or another for decades. Thus, it is not difficult to demonstrate that clinical psychologists and other trained behavioral health care professionals can uniquely contribute to efforts to fully integrate their services in primary care settings through the establishment and use of psychological assessment services. Information obtained from psychometrically sound self-report tests and other assessment instruments (e.g., clinician rating scales, parent-completed instruments) can assist the primary care provider in several types of clinical decision-making activities, including screening for the presence of mental health or substance abuse problems, planning a course of treatment, and monitoring patient progress. Testing can also be used to assess the outcome of treatment that has been provided to patients with mental health or substance abuse problems, thus assisting in determining what works for whom.

Psychological Assessment in Disease Management Programs

Beyond the primary care setting, the medical populations for which psychological assessment can be useful are quite varied and may even be surprising to some. Todd (1999) observed that "Today, it is difficult to find any organization in the healthcare industry that isn't in some way involved in disease management. . . . This concept has quickly evolved from a marketing strategy of the pharmaceutical industry to an entrenched discipline among many managed care organizations" (p. xi). It is here that opportunities for the application of psychological screening and other assessment activities are just beginning to be realized.

What is disease management, or (as some prefer) disease state management? Gurnee and DaSilva (1999, p. 12)

described it as "an integrated system of interventions, measurements, and refinements of health care delivery designed to optimize clinical and economic outcomes within a specific population. . . . [S]uch a program relies on aggressive prevention of complications as well as treatment of chronic conditions." The focus of these programs is on a systems approach that treats the entire disease rather than its individual components, such as is the case in the more traditional practice of medicine. The payoff comes in improvement in the quality of care offered to participants in the program as well as real cost savings.

Where can psychological assessment fit into these programs? In some MBHOs, for example, there is a drive to work closer with health plan customers in their disease management programs for patients facing diabetes, asthma, and recovery from cardiovascular diseases. This has resulted in a recognition on the part of the health plans of the value that MBHOs can bring to their programs, including the expertise in selecting or developing assessment instruments and developing an implementation plan that can help identify and monitor medical patients with comorbid behavioral health problems. These and other medical disorders are frequently accompanied by depression and anxiety that can significantly affect quality of life, morbidity, and, in some cases, mortality. Early identification and treatment of co-morbid behavioral health problems in patients with chronic medical diseases can thus dramatically affect the course of the disease and the toll it takes on the patient. In addition, periodic (e.g., annual) monitoring of the patient can be incorporated into the disease management process to help ensure that there has been no recurrence of the problem or development of a different behavioral health problem over time.

A Concluding Note

It is difficult to imagine that any behavioral health care organization—managed or otherwise—would not find value in at least one or two of the previously described applications. The issue becomes whether there are funds for these applications. These might include funds for assessment materials, reimbursing network providers or other third-party contractors (e.g., disease management companies) for their assessment work, an in-house staff position to conduct or oversee the implementation of this work, or any combination of the three. Regardless, it is highly unlikely that any MBHO is going to spend money on any service that is not considered essential for the proper care of patients unless that service can demonstrate value in short-term or long-term money savings or offset costs in other ways. The current restrictions for authorizing assessment are a reflection of this fact. As Dorfman (2000)

succinctly put it,

Until the value of testing can be shown unequivocally, support and reimbursement for evaluation and testing will be uneven with [MBHOs] and frequently based on the psychologist's personal credibility and competence in justifying such expenditures. In the interim, it is incumbent on each psychologist to be aware of the goals and philosophy of the managed care industry, and to understand how the use of evaluation and testing with his or her patients not only is consistent with, but also helps to further, those goals. To the extent that these procedures can be shown to enhance the value of the managed care product by ensuring quality of care and positive treatment outcome, to reduce treatment length without sacrificing that quality, to prevent overutilization of limited resources and services, and to enhance patient satisfaction with care, psychologists can expect to gain greater support for their unique testing skill from the managed care company. (pp. 24-25)

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