Psychology and Medical Rehabilitation: Moving Toward a Consumer-Driven Health Care System

Changes in health care will provide both opportunities and threats for rehabilitation psychologists. We must demonstrate the relevance of our clinical services to important outcomes or risk being excluded as treatment providers. With shifts to nonhospital settings, we can provide increasing clinical and administrative leadership. However, we must redefine models of treatment to include home care and telepsychology, practice guidelines and critical paths, involvement of paraprofessionals, case management, injury prevention, and health promotion. We should be involved when datasets are established to define disability-related health policies and reimbursement and be proactive in Medicare, Medicaid, and managed care reform to develop treatment packages to decrease long-term handicap. Collaboration with consumers is critical. We must frame research questions to address current policy issues. Our skills can help improve the effectiveness of human behavior, whether it be patients with illness, consumers with disability, health care providers, health systems managers, or legislators.     

Ethics and Changing Mental Health Care: Concerns and Recommendations for Practice

Recent developments in health care delivery in the United States have left many professionals baffled by the continuing changes in practice sparked by the relatively new managed care environment. Psychologists who practice in medical settings are struggling to balance the seemingly competing needs to deliver quality care to clients and patients, while meeting the demands of third-party payers and trying to remain true to their ethical responsibilities. Critical elements of managed care, which many suggest compromise the ethical provision of quality care, include utilization review, financial incentives, and threats to confidentiality. Recommendations are proposed so that mental health professionals may be proactive in protecting their ethical responsibilities in this changing environment.     

The next wave of change for psychology and mental health services in the health care revolution

Recent national changes in the de facto system of health and mental health care are described. Although the percentage of people without health insurance (always or sometimes) has not decreased, the organization of insured care has changed dramatically. Of the insured population, 75% are under some form of managed care. For 88% of the managed care population, mental health care has not been integrated with health care: the so-called carve-out. The author argues that system integration (carve-ins), for a variety of reasons, will begin soon and will occur very rapidly. A tilt toward carve-ins will have substantial impact on psychologists' training, service delivery, and research.     

The Future of Psychology in Medical Specialities: Introduction to the Special Issue

The continuing evolution of the health care delivery system in the United States presents threats and opportunities to psychologists in medical settings. This special issue explores the future of psychology in psychiatry, family medicine, rehabilitation, geriatric medicine, and pediatric medicine. The challenges facing neuropsychology and pain management are explored also. Finally, the professional issues of ethics in managed care, psychology in the public sector, and training future psychologists are addressed. Each paper summarizes concerns and provides recommendations for clinical practice, research, and training.     

A comparison of health disparities among transgender adults in Colorado (USA) by race and income

Transgender individuals face heightened risks for discrimination, harassment, and violence that impact their psychosocial well-being and physical health. However, few studies have thoroughly examined the general physical and mental health of transgender adults or within-group health differences by race/ethnicity and income. To that end, after controlling for health insurance status, age, and engagement in exercise, this study asks: (a) Are transgender people of color more likely than White transgender individuals to experience poor health outcomes? and (b) Is lower annual household income among transgender adults associated with poorer health outcomes? The study analyzes secondary data from a survey of transgender adults (N = 417) in one state in the western United States using multiple linear regression and logistic regression models. Results showed that transgender people of color had significantly greater odds than their White counterparts of having arthritis/rheumatoid arthritis/gout/lupus/fibromyalgia, or asthma but lower odds of being told by a provider that they had depression. Having a lower income was significantly associated with worse general health as well as multiple indicators of poor physical and mental health, including depression, anxiety, and suicidal ideation. We discuss implications for health care delivery for transgender people and for future research.     

Contributing to System Change in Kentucky

SUMMARY

Currently a change that requires monitoring and action is the state public payers' movement toward managed behavioral health care and the re-structuring of Medicaid to reflect this movement. In this article the response of one state, Kentucky, to managing Medicaid costs, quality and access is reported. The author's participation in a multi-disciplinary effort to identify outcomes and outcome measures for the state's managed behavioral healthcare system is described. The proposed Medicaid waiver for mental health and substance abuse and the resulting implications for occupational therapy are discussed.     

The Future of Psychology in Family Medicine

Psychology has been integral to the field of family medicine since its inception as a medical specialty in the 1960s. Psychologists and other behavioral scientists contribute to family medicine in teaching clinical skills, in defining research questions, in developing research methodology, and in creating integrated physical/mental health care delivery systems. Future developments in the field of psychology in family medicine are likely to emphasize development and evaluation of screening measures which identify mental health problems in primary care, development of early intervention for those mental health problems, and more precise measurement of process and quality of care and health outcomes. Psychologists have an important role to fulfill in educating physicians on alternatives to pharmacologic and medical interventions for common presenting problems in primary care. However, current economic forces shaping the practice of medicine may work against further enhancing the efficacy of the physician in dealing with psychosocial issues. The future role of psychology in family medicine is not yet delineated, and while the move toward parity of reimbursement for mental and physical health care delivery may enhance this collaboration, there is a need to continue to evaluate how the psychological well-being of patients is influenced in the evolution of new models of care delivery.     

Building and Maintaining Clinical Programs

This paper describes the basic elements of practice development and management within the academic medical setting. These include assessment of the market environment, both in the community and within the medical setting, product development, marketing, budget basics, quality, managed care negotiations, and finding time to do research in a financially-driven health care system.     

Ethnicity and the stigma of disabilities

Abstract

Recent studies reveal significant differences in the attitudes held by people of various ethnic groups toward people with disabilities. We surveyed university students and community members on a scale of desired social distance from people with disabilities. Study 1 revealed that Asian-American participants were more likely to stigmatize and less likely to differentiate between individuals with physical and mental illness than were their African-American, Latin-American or European-American counterparts. Study 2 compared U.S. born with Asian born Asian-Americans and found that nativity was a useful predictor of attitudes toward people with disabilities. Asian born participants were more likely to stigmatize disabilities overall (except mental illness and old age) than U.S. born participants presumably because of the level of assimilation. These cultural differences may have health care and psychosocial implications for those who are disabled and for health care providers.     

Report of the Working Group on Clinical Services

Prepared by the Working Group on Clinical Services from the November 1995 Georgetown conference sponsored by the Association of Medical School Psychologists, this paper focuses upon issues related to the effects of health care reform and changes to the health care system on psychologists practicing within academic health care settings. Discussion of the changes in the health care economic system and the call for cost-effectiveness produced five specific suggestions for psychology to establish accountable, data-based models of behavioral health care.     

How changes in population demographics will impact health psychology: incorporating a broader notion of cultural competence into the field.

U.S. population demographics are undergoing striking changes that will impact health care and the research and practice of health psychology. An increase in the number of people who are older; belong to an ethnic minority group; have disabilities; identify as lesbian, gay, bisexual, or transgendered; or live in poverty will influence definitions of aging, health, and illness, and will challenge current psychological and medical treatment models. The authors argue that health psychologists need to become context competent for the field to be relevant and viable over the course of this new century. Health psychologists need to become aware of the multiple, overlapping contexts in which people live and apply this knowledge on a regular basis to research, practice, education and training, and policy in health psychology.     

The challenge of “Healthy People 2000”

The federal Office of Disease Prevention and Health Promotion (U.S. Public Health Service) has again prepared a compilation of goals and objectives for the health of the Nation's people, applicable to anticipated achievements within the decade ending in the year 2000. This effort involved work groups from numerous federal agencies, testimony in regional hearings from 800 citizens, and enrollment of a consortium of 300 national organizations. The final product, Healthy People 2000, was released in September 1990, and contains 298 measurable objectives. Content regarding children, genetic disorders, developmental disabilities, and disabilities in general is less featured and less specific than was hoped for. Ten objectives of relatively direct concern to geneticists are discussed, plus 23 others of interest in the maternal and child health field. On balance, it is suggested that the Healthy People 2000 objectives can be useful and stimulating for workers in genetics, child health care, and disabilities' services. Regrettably, there was no simultaneous proposal of legislation that would provide new federal programs, funding, or assistance to states.     

Alcohol and Substance Use Disorders: Algorithms and Critical Pathways for Healthcare Delivery

Contemporary health care delivery is being driven by a changing health care market environments as well as by the availability of enhanced models of service delivery. Providers are using clinical algorithms and critical pathways to standardize clinical care and improve clinical services to patients. The article highlights the application of contemporary clinical models and demonstrates their utility in the context of substance use and abuse disorders. Clinical algorithms and critical pathways are advanced as guidelines in diagnostic and therapeutic processes for the delivery of quality health care to patients. Specific recommendations for the development and implementation of such initiatives are discussed in detail.     

Education and Training of Children's Mental Health Professionals: The Existing and Potential Role of Schools of Public Health

Since the early 1980s, increasing attention has been devoted in the literature to the conceptualization, development, and implementation of integrated and comprehensive mental health systems of care for children and adolescents. In establishing this new children's mental health paradigm of community-based systems of care, there are presently very few well-trained professionals and leaders focused on collaborative (including interagency) initiatives in the delivery of children's mental health services. Nevertheless, the field of public health offers an interdisciplinary setting for the education and training of individuals in children's mental health services. This national survey of all 27 accredited schools of public health in the United States and Puerto Rico examined the existing capacity for and potential to expand educational and training opportunities in the organization, financing, and delivery of children's mental health services.     

The Reinvention of Behavioral Health Services in the VA System

The Veterans Health Administration under the direction of Kenneth Kizer, M.D., has faced the challenge of providing high-quality health care while controlling costs. Under Dr. Kizer's direction, VA hospitals are moving toward managed patient centered primary care. Hospital organization, funding, and clinical practices have been changed. Reorganization has meant a variety of possibilities for psychologists employed in the VA system.     

Military psychology in the age of managed care: The Wilford Hall model

Military medicine is currently being overhauled through Tricare, a comprehensive, managed care program designed to reduce costs and increase clients' access to health care. This article presents reforms initiated by the psychologists at Wilford Hall Medical Center, the largest military hospital in the world, in response to Tricare. These reforms have resulted in adult, outpatient services that are immediately accessible, effective, and cost efficient. The Wilford Hall approach to psychological services is offered as model that can be used in other outpatient settings. Additionally, potential limitations of this approach to psychological care are presented.     

Cultural aspects of mental health and mental health service delivery with a focus on Nigeria within a global community

With an endless range of subgroups and individual variations, culture bears upon what all people bring to the clinical setting. Culture could account for health-seeking behaviour, type of services and support system and variations in how people communicate their health concerns. Culture may underlie presentation of sets of symptoms that are peculiar to certain societies – culture-bound syndromes. Culture also influences the meanings that people impart to their illness and also stigma associated with such illnesses. Culture must be viewed from the patients, clinicians and health system dimensions. Changes in mental health service delivery in last few decades have yielded culturally competent mental health services. The aim of this paper was to discuss culture and mental health with a focus on Nigeria and from a global perspective.     

Pediatric Psychology: Child Psychological Health in the Next Century

The future of pediatric psychology is reviewed and placed in brief historical context in relation to children's psychological health care. Contemporary trends affecting the delivery of psychological services, research, and clinical training are highlighted, with suggestions for future development. Pediatric psychology is a child-based, developmentally-focused multidisciplinary practice directed toward psychosocial and neuropsychological issues of health and illness in children and youth. Pediatric psychologists need to develop strong professional identities as health care psychologists combined with a collegial and collaborative arrangement with physicians to ensure the future growth and development of pediatric psychology in the next century as a major vehicle to promote children's health care.