Trends in Service Delivery: Psychological Practice in Rehabilitation Settings Ineke M. Pit-ten Gate, .MA; Frank Padrone, PhD; Arlene Feinblatt, PhD; Leonard Diller, PhD
Editor's note: The following article summarizes results from a survey of psychologists who are members of ACRM. These psychologists were asked how managed care is affecting reha bilitation psychology. Because all disci plines share the same broad changes in the healthcare environment, the information provided will be of inter est not only to rehabilitation psycholo gists, but also to those who work in other areas of rehabilitation medicine. Perhaps you would like to conduct a similar survey of ACRM colleagues within a specific discipline for purpos es of comparison. Of course, if you choose to conduct such a survey, you are invited to submit your results to Rehabilitation Outlook for possible publication.
Current psychological services in medical rehabilitation settings have been caught in many changes in third party payment regulations sweeping the United States. Questions regarding reimbursement, quality of care, down sizing of staff, reduced lengths of stay, and altered goals are commonplace (DeAngelis, 1995; Johnstone et al., 1995). Although many psychologists are concerned that managed care will impede the quality of existing psycho logical care because of restricted access, some already are exploring new markets (DeAngelis, 1995; Gaus & DeLeon, 1995). We designed a questionnaire to investigate the current practices and changes in service delivery that are a result of managed care practices. This questionnaire was mailed in April 1995 to 141 psychologists who are members of the American Congress of Rehabili tation Medicine (ACRM). Forty-nine psychologists responded. However, nine questionnaires were incomplete: Six were not completed because respondents were no longer working in clinical rehabilitation settings, and three were not completed because respondents did not have access to necessary data. Thus, the respondent pool was reduced to 40 (28.4%).
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Results Demographics: Frequency distribu
tions for demographic characteristics are presented in Table 1. More than half (22) of the respondents worked at rehabilitation units within hospitals. Other respondents worked either at freestanding rehabilitation facilities or in university-based programs. In most settings, staff was dedicated to both inpatient and outpatient services. In others, staff was dedicated exclusively to either inpatient or outpatient ser vices. Two-thirds of the respondents worked in settings located in the region east of Chicago, and 40% of the respondents worked in cities with a populations larger than 1 million. Only 17 (42.5%) of the respondents identi fied whether their institution was for profit or not-for-profit. Even fewer identified their institution as private or public. Most respondents served patients with stroke, neurological disorders, traumatic brain damage, or orthopedic or spinal cord injuries in inpatient as well as outpatient programs. Less than 50% of the respondents reported ser vicing patients with cardiac problems, epilepsy, developmental dis�bilities, cancer, infectious diseases, learning disabilities, or industrial injuries. Sev enty-three percent of the respondents reported having outpatient services and 45% reported having inpatient ser vices for patients with chronic pain. In general, respondents did not report that the diagnostic groups they served had changed over the previous 3 years, nor did they report significant changes regarding the size of their rehabilita tion facilities. Staff issues: Although the size of psychology staffs varied, more than 60% of the respondents reported a staff of fewer than 5 psychologists. (Staff sizes ranged from 2 to 35.) Two thirds reported changes in staff posi tions over the past 3 years. As many staff additions as reductions were reported. most staff additions occurred when new programs were added. One third of the respondents repot r ed later al shifts from inpatient to outpatient services. These shifts appeared most
American Congress of Rehabilitation Medicine
Table 1. Frequency Distributions for Demographic Characteristics
Variable
(N
Frequency
Facility* Unit within a hospital Freestanding University-based program For-profit Not-for-profit Unidentified Public Private Unidentified
City population
100,000 100,000 > 250,000 > 500,000 > 1,000,000
< >
Location East of Chicago Unidentified
Staff assignment Inpatient services only Outpatient services only Inpatient and outpatient
40)
%
22 12 8
55.0 30.0 20.0
6 11 23
15.0 27.5 57.5
4 7
29
10.0 17.5 72.5
7 6 4 7 16
17.5 15.0 10.0 17.5 40.0
26 5
65.0 22.5 12.5
6 4 30
15.0 10.0 75.0
9
West of Chicago
=
services
* Percentages under this variable do not total
100.0 because
categories are not
mutually exclusive.
often in settings with small psychology departments (fewer than 5 psycholo gists). Overall, the patterns in the psy chology departments mirrored changes in.other department. Service delivery: Sixty percent of the respondents reported changes in the quality of services over the previ ous 3 years. Although most reported that patients still are served adequate ly, two reported fluctuations in the adequacy of services, whereas four reported that services were no longer adequate. Changes related to care included having less intense programs, earlier discharges, and less follow-up care of patients. More than 80% of
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respondents from inpatient facilities reported a decrease in lengths of stay. Except for a slight expansion of outpa tient services for stress management, respondents reported no change regarding treatment modalities within psychology, (e. g., individual psy chotherapy, group psychotherapy, cognitive remediation). Results showed that psychologists in inpatient and outpatient services devoted increased time to writing reports, oth er written communication, and phone review and appeals. Payment issues: Psychologists reported that Medicare is their main source of payment for services. Private insurance was the second most com mon method of payment, and Medi caid was third. Workers' compensation and other sources were less common payment sources. Seventy percent of respondents reported problems regard ing payment for services; these includ ed reimbursement issues such as lack of coverage reimbursement for less than usual fees, or staff not being included as approved providers. A summary of the findings regarding staff, service delivery, and payment issues is presented in Table 2. Current concerns: Changes in third-party payments were reflected in the financial and administrative issues of the psychological practices we sur veyed. Thirty percent of the respon dents reported that changes in man aged care already have resulted in a decrease in the number of services administered by psychology staffs. Respondents did not report decreases in services paid for by Medicaid and Medicare; however half expressed their concern about reimbursement of services in the future. In addition, 20% expressed general concerns regarding the impact of managed care. More than 50% of the respondents reported concern about the challenge to the role of psychologists within rehabilitation, and the possible takeover of psychologists' traditional duties by other disciplines. Adopted solutions and helpful information
Half of the responding psychologists reported changes in service delivery in order to anticipate or adapt to changes prompted by managed care. Some reported privatization of services (4), exploration of new markets (2), or reorganization of departments (10) in order to reduce costs. In some cases
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Table 2. Summary of Findings Regarding Psychology Staff Issues, Service Delivery, and Payment Issues Staff issues There is much instability in staff assignments
(66% report staff changes).
Service delivery
A decrease in the length of stay was reported by
80% of the respondents. 60% of the respondents.
Changes in the quality of services were reported by
The trend is that more time is being devoted to insurance issues.
Payment issues Problems with payment were reported by
70% of the respondents.
A decrease in the number of services under managed care was reported by the respondents. Concerns regarding reimbursement were reported by
(3), only services to billable patients were encouraged by the facility. One" third of the respondents reported that their facilities had instituted marketing and lobbying efforts that were directed particularly at case managers and administrative officers. Although a number reported adopting solutions, 7 respondents reported experiencing confusion and helplessness regarding managed care, (e.g., "The system is becoming increasingly insane," "I wish I knew"). Respondents expressed a need for data on trends regarding outcomes and costs. Other specific suggestions included either clarifying the use of Current Procedural Terminology (CPn codes or educating other healthcare professionals, administrators, and case managers about psychological services and the need for information regarding successful strategies used by col leagues. Respondents suggested that the American Psychological Associa- . tion could play an important role in collecting and distributing information, and in clarifying the role of psychology in clinical pathways. Discussion
This study represents an initial attempt to examine the impact of rapid changes in third-party payment for psychological services in medical rehabilitation settings. Although the sizes of settings differed, most offered inpatient and outpatient programs to patients with stroke, neurological dis orders, traumatic brain damage, ortho pedic injuries, or spinal cord injuries. Sources of payment, in order of fre quency, were Medicare (40%), private insurance (23%), and Medicaid (18%). These figures may vary somewhat from national data generated from more
50% of the
30% of
respondents.
comprehensive medical programs, (e.g., a greater incidence of Medicaid and Medicare is reported at rehabilita tion facilities). This data may suggest the presence of an aging population in rehabilitation settings and a greater concern with spinal cord injuries and traumatic brain damage. Questions regarding the type of facility were left unanswered by a striking number of respondents: Twenty-three failed to indicate whether their facility was not for-profit or for-profit, and 29 respon dents failed to indicated if their facility was pubiic or private. These resuits might indicate that psychologists with in rehabilitation settings are relatively unsophisticated regarding administra tive issues. Staffing patterns in the survey responses reflected instability. Hori zontal movement in staff patterns (i.e., a shift from inpatient to outpatients services) may reflect adjustments to populations who enter rehabilitation in a more impaired condition and have reduced lengths of stay. In an effort to reduce costs, managed care companies have reduced the length of inpatient stay and have limited services, although treatment modalities appear to be unchanged. Changes in quality of services, sometimes to undesired, inad equate levels of care, were reported. Psychologists also reported that they are spending more time dealing with insurance and payment issues. Coverage and communication demands also are sources of concern. Seventy percent of the respondents reported experiencing problems-with payment and uncertainty about the extent of reimbursement in the future. Furthermore, psychologists reported that their roles are being challenged by less expensive providers. They also
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Service Delivery reported that they were adapting to these pressures by modifying service delivery and implementing marketing and lobbying efforts. Respondents expressed a particular need for help in dealing with payment and administra tive issues. The limitations of this study include the geographical skew in the location of respondents' facilities, as well as the size of the populations they service, and may have included more persons interested in, informed about, or restricted by third-party payment issues. Moreover, we do not know how these results compare to the situa tion of psychologists in rehabilitation settings who either failed to respond to this survey or who were not includ ed in this survey. The ability to gener alize these results therefore may be limited. The results of this study suggest that it would be useful for ACRM to sample constituent disciplines to survey their concerns about the rapid change tak ing place in rehabilitation practice. Findings could be used to plan pro grams in which members could
continued
express views pertinent to their disci plines within an interdisciplinary forum. These programs also would give professional rehabilitation groups outside of the psychology arena a view of other disciplines' struggles with managed care. References
DeAngelis, T.
(1995,
February). Medicaid,
health alliances head state reform efforts.
American Psychological Association Moni tor, 26(2), 33. Gaus, C.F., & DeLeon, P.H. (1995). Thinking beyond the limitations of mental health
care. Professional Psychology: Research and Practice, 26, 339-340. Johnstone, B., Frank, R.G., Belar, C., Berk, S., Bieliauskas, L.A., Bigler, E.D., Caplan, B., Elliott, T.R., Glueckauf, R.L., Kaplan, R.M., Kreutzer, J.S., Mateer, C.A., Patterson, D., Puente, A:E., Richards, J.S., Rosenthal, M., Sherer, M., Shewchuk, R., Siegel, LJ., & Sweet, ].J.
(1995).
in the Netherlands. She was formerly a research fellow at New York Uni versity Medical Center, Rusk Institute of Rehabilitation Medicine. Frank Padrone is director of inpa tient psychology at New York Univer sity Medical Center, Rusk Instittute of Rehabilitation Medicine, and a mem ber ofACRM. Arlene Feinblatt is supervisor of the outpatient psychology department at New York University Medical Center, Rusk Institute of Rehabilitation Medicine. Leonard Diller is director of psycholo
gy at New York University Medical
Center, Rusk Institute of Rehabilita tion Medicine, and a past president of ACRM.
Psychology in health
Professional Psy chology: Research and Practice, 26, 341365. care: Future directions.
Ineke M. Pit-ten Gate is a researcher in pediatric rehabilitation psychology
Direct all correspondence to Ineke M. Pit-ten Gate, Copse Lodge, 212 Bear wood Road, Wokingham, Berkshire, RG41 4SH, United Kingdom. .E-mail
[email protected] Ill
ACRM Annual Essay Contests Entries Due April 15 Bernard M. Baruch Essay Contest for Medical Students
This contest awards a first-, second-, and third-place prize to medical stu dents who submit essays on any sub ject relating to physical medicine and rehabilitation. Topics should reflect the interdisciplinary character of reha bilitation. Essays must not exceed 3,000 words. First Prize-$200 and Baruch Medal Second Prize-$100 Third Prize-$50 The 41st Essay Contest for Profes sionals in Rehabilitation
This annual award is presented for an outstanding review article on a subject that has an interdisciplinary focus and relates to physical medicine and reha bilitation. Essays must not exceed 5,000 words. Winning Essay-$200 and certificate
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The Annual Conrad Jobst Founda tion Award
This annual award is presented to the individual who submits the best scientific paper pertaining to peripher al vascular disease or circulation in the extremities. Essays must not exceed 5,000 words. Winning Essay-$250 and plaque Rules and regulations
The following guidelines apply to all of the essay contests: Essays must not exceed the stated word limit (not including head ings, references, figures, tables). Total word count must appear on the title page. A permanent mailing address and phone number must accompany all submissions. The manuscript must reflect origi nal work and must not have been published or submitted for publi cation in other journals.
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Essays must have one author only. Candidates can win each essay award only one time. Previous winners are not eligible. Essays will not be returned. Please remember to make a copy for your records. Winners will be determined by the ACRM Awards and Prizes Commit tee. Winners will be announced by May 30, 1997, and awards will be presented at the ACRM 74th Annu al Meeting September 12-14, 1997, in Boston, MA. The American Congress of Rehabil itation Medicine reserves the right to withhold prizes if contributions do not meet the winning criteria. An original and four copies of the essay must be submitted to ACRM, 4700 W. Lake Avenue, Glenview, IL 60025-1485, no later than April15, 1997.11
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