Copyright 2000 by the American Psychological Association, lac. 0735-7028/00/$5.00 DOI: L0.1037//0735-7028.31.5.547
Professional Psychology: Resean 2000, Vol. 31, No. 5, 547-552
Psychologists' Reactions to Medicaid Managed Care: Opinion and Practice Change After 1 Year Daniel W. Russell, Arlene de la Mora, Linda S. Trudeau, Norman A. Scott, and Nancy A. Norman
Mark F. Schmitz Rutgers, The State University of New Jersey
Iowa State University How do .psychologists adapt over time to a new managed care program? Reactions of lowan psychologists to a managed mental health care program for Medicaid recipients were examined. The program was generally perceived negatively, although perceptions improved over time. Psychologists in private practice decreased the proportion of Medicaid patients they treated. Psychologists who continued to treat Medicaid patients reported decreased levels of job autonomy and satisfaction. A new managed care program presents psychologists with difficult ethical decisions, in which the quality of care provided to clients must be weighed against the negative aspects of participating in a managed care program.
that managed care can provide the least restrictive level of care necessary to meet patients' needs; return patients as quickly as possible to communities; and encourage the most effective care of patients, in the best setting, by the most appropriate professional (Lawrence, Mattingly, & Ludden, 1997; Trugerman, 1996). Others see managed care as the "corpse in the living room" (Pipal, 1995, p. 323), "a growing crisis and a national nightmare" (Karon, 1995, p. 5), or "a euphemism for social control in the healthcare arena" (Shapiro, 1995, p. 443). A series of studies published in Professional Psychology: Research and Practice (Benedict & Phelps, 1998) presented data from three large surveys of psychologists concerning managed mental health care. The vast majority of these psychologists expressed negative views of managed mental health care. For example, Phelps, Eisman, and Kohout (1998) reported that nearly 80% of respondents in their national survey indicated that managed care had a negative impact on their practice. Furthermore, participation in managed care programs was found to be associated with negative effects on morale, decreases in income over time (Rothbaum, Bernstein, Haller, Phelps, & Kohout, 1998), and the creation of serious ethical dilemmas for practitioners (Murphy, DeBernardo, & Shoemaker, 1998). How do practicing psychologists adapt over lime to managed mental health care programs? In this study, we examined how psychologists' reactions to a managed mental health care program changed over a 1-year period. Using data collected as part of our evaluation of the managed mental health care program for Medicaid patients in Iowa, we analyzed psychologists' initial evaluations of the program 6 months after implementation and changes over time in reactions to the program 1 year after the initial assessment. These latter data allowed us to examine directly how psychologists adapled to managed mental health care, regarding changes in their practice and perceptions of their jobs along such dimensions as job autonomy, job satisfaction, and burnout.
Few issues have generated as much controversy as managed care. Views are passionate and range from a benevolent and positive assessment to malevolent disdain. Some writers suggest
DANIEL W. RUSSELL received his PhD from the University of California, Los Angeles in 1980. He is a professor in the Department of Psychology and the Institute for Social and Behavioral Research at Towa State University. His research interests include mental health services and the influence of interpersonal relationships and loneliness on health. ARLENE DE LA MORA received her MS from Iowa State University in 1998. She is a doctoral student in the Department of Psychology at Iowa State University. Her research interests include attitudes and health behavior. LINDA S. TRUDEAU received her MA in rehabilitation counseling from the University of Iowa in 1975. She is a doctoral candidate in human development and family studies with a specialty in marriage and family therapy at Iowa State University. She also is a research assistant at the Institute for Social and Behavioral Research at Iowa State University and a temporary instructor in the Human Development and Family Studies Department at Iowa State University. Her research interests include processes and outcomes of treatment and prevention programs for mental health and substance abuse. NORMAN A. SCOTT received his PhD in counseling psychology from the University of Maryland, College Parkin 1971. He is an associate professor and codirector of the program in counseling psychology in the Department of Psychology at Iowa State University. His research interests include clinical decision making and the evaluation of ethical dilemmas. NANCY A. NORMAN received her MS in technology of management from American University in 1971. She is the associate director of the Institute for Social and Behavioral Research at Iowa State University. Her research interests are in the area of community health care programs. MARK F. SCHMITZ received his PhD in sociology from Iowa State University in 1996. He is an assistant professor in the School of Social Work, Rutgers, The State University of New Jersey. His research interests include diagnosis of mental illness and genetic and environmental influences on adolescent behavior and mental illness. THIS RESEARCH WAS CONDUCTED under a contract from the Department of Human Services, State of Iowa. We thank Carolyn Cutrona and Doug Epperson for their comments on an earlier version of this article.
Survey of Licensed Psychologists in Iowa
CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Daniel
Questionnaires were mailed to all licensed psychologists in Iowa (N = 382) during July and August 1995. For 48 of these individuals, the questionnaire either was returned by the postal
W. Russell, Institute for Social and Behavioral Research, Iowa State University, 2625 North Loop Drive, Suite 500, Ames, Iowa 50010-8296. Electronic mail may be sent to
[email protected]. 547
548
RUSSELL ET AL.
service with an indication that the person had moved or was
on a 7-point Likert scale ranging from strongly disagree to strongly
undeliverable for some other reason (e.g., the person had died, the
agree. After reversing responses to the first question, we calculated
person was retired and no longer in practice). Therefore, there was
total scores by summing together responses to these two items. This
a potential sample of 334 respondents. Approximately 2 weeks
total score was found to be reliable at both the Time 1 (a = .77) and
after the initial mailing, reminder postcards were sent to all indi-
Time 2 (a = .93) assessments.
viduals who had not returned a completed questionnaire. If a
Another set of three questions was designed to assess job
completed questionnaire had not been received 2 weeks after the
satisfaction. These items were taken from a measure developed by
mailing of the postcard, a second questionnaire was mailed. These
Jerrell (1983) to assess job satisfaction among rural mental health
procedures resulted in completed questionnaires being received
practitioners. Examples of these questions include "I feel satisfied
from 153 individuals, representing a response rate of 46%.
with the opportunity to accomplish something worthwhile" and "I
Approximately 1 year later, in July and August 1996, a second
feel satisfied with the opportunity to use my skills and abilities."
survey was conducted of the 153 individuals who had completed the
Respondents indicated how often they felt the way described on a
first questionnaire. By using Ihe same survey procedures, a total of
7-point scale ranging from once a year to every day. The lotal
107 completed questionnaires were received, for a response rate of
score computed on the basis of these items was found to be reliable
70%. One issue that arises in interpreting these data concerns whether
at both Time 1 (a = .79) and Time 2 (a = .80).
the individuals who responded to our second survey differed from the
A final set of four items was designed to assess levels of
individuals who responded only to our first survey (n = 46) on the
bumout, using questions selected from the Maslach Burnout In-
variables that were assessed at Time 1. Statistically significant differ-
ventory (Maslach & Jackson, 1981). Examples of these items
ences emerged on only one variable: sex of the respondent. Male
include "I feel emotionally drained from my work" and "Working
psychologists (76%) were more likely than female psychologists
with people all day is really a strain on me." Psychologists indi-
(59%) to respond to the second survey, ^(1, N = 147) = 4.71, p
tp
