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Problems and Limitations in Using Psychological Assessment in the Contemporary Health Care Delivery System

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Problems and Limitations in Using Psychological Assessment in the Contemporary Health Care Delivery System Professional Psychology: Research and Practice Copyright 2000 by the American Psychological Association, Inc. 2000, Vol. 31, No. 2, 131-140 0735-7028/00/$5.00 DOI: 10.1037/,~735-7028.31.2.131 Problems and Limitations in Using Psychological Assessment in the Contemporary Health Care Delivery System Elena J. Eisman Robert R. Dies Massachusetts Psychological Association New Port Richey, Florida Stephen E. Finn Lorraine D. Eyde Center for Therapeutic Assessment U.S. Office of Personnel Management Gary G. Kay Tom W. Kubiszyn Georgetown University Medical Center American Psychological Association Gregory J. Meyer Kevin L. Moreland University of Alaska Anchorage Fort Walton Beach, Florida Psychologists report limitations on psychological assessment services and problems gaining authoriza- tions and reimbursement for these services from third-party payers. Documentation and categorization of these problems and limitations is based on responses from well over 500 psychologists responding to a broad solicitation for feedback. This article explores the barriers to access for assessment services, including resistance to psychological assessment, difficulties in the preauthorization process, problems with reimbursement, the clinical decision-making process, and larger systems issues. The authors make recommendations for redress of these problems through work with the profession, other mental health professionals, managed care, and patients-consumers and through political action. Psychological and neuropsychological assessment services are un- to survive as a covered health care service. This article reviews issues der assault from organized health care delivery systems, managed in the current applications of psychological assessment in health care mental health care organizations, and health care payers. As a pro- settings and recommends appropriate responses. fession, psychology must respond to this attack with advocacy and a The message from health care delivery systems is clear. Critics credible explanation of the value and usefulness of assessment if it is argue that psychological assessment is time consuming, expensive, ELENA J. EISMAN received her EdD in 1975 from Boston University. She is GREGORY J. MEYER received his PhD in 1990 in clinical psychology from currently the executive director of the Massachusetts Psychological Associa- Loyola University Chicago. He is an associate professor of psychology at tion and a faculty member at the Massachusetts School of Professional Psy- the University of Alaska Anchorage and the coordinator of graduate chology. She maintains an independent practice in Newton Highlands, MA. clinical training. ROBERT R. DIES received his PhD from the University of Connecticut in KEVlN L. MORELAND received his Phi3 in 1981 from the University of 1968 and spent most of his academic career at the University of Maryland North Carolina at Chapel Hill. before leaving to enter full-time clinical and forensic practice in the Tampa THE OPINIONS EXPRESSED IN THIS ARTICLE 81"e those of the authors and do not Bay, FL, area in 1996. necessarily reflect the official policy of the U.S. Office of Personnel STEPHEN E. FINN received his PhD from the University of Minnesota in Management. 1984. He is a clinical psychologist who specializes in psychological as- THIS ARTICLE~S DEDICATEDto the memory of Kevin L. Moreland, who died sessment. He is president-elect of the Society for Personality Assessment tragically in an automobile accident August 31, 1999. and is an adjunct assistant professor at the University of Texas at Austin. A YERSXON OF THIS ARTICL~ was initially prepared by the Psychological LORRAINE D. EYDE received her PhD in 1959 in industrial organizational Assessment Work Group organized by the Board of Professional Psychol- psychology from Ohio State University. She is a personnel research psy- chologist at the U.S. Office of Personnel Management, where she is an ogy. The work group was chaired by Stephen E. Finn. We arc grateful to expert in leadership competency models. the following American Psychological Association staff members for their GARY G. KAY received his PhD in 1984 in neuro-clinical psychology from support and assistance: Geoffrey M. Reed, Christopher J. McLaughlin, Memphis State University. He is an associate professor of neurology and Mary Ann Wilson, and Russ Newman of the Practice Directorate; and psychology at the Georgetown University School of Medicine. He also Diannn C. Brown of the Science Directorate. We also thank Georgia maintains an independent practice with Georgetown Neuropsychology Sargeant for her editorial assistance. Associates in Washington, DC. CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Elena TOM W. KUBISZYNreceived his Phi) in 1979 in educational psychology from J. Eisman, Massachusetts Psychological Association, 195 Worcestor the University of Texas at Austin. He is an adjunct associate professor in the Street, Suite 303, Wellesley, Massachusetts 02481. Electronic mall may be Department of Educational Psychology at the University of Texas at Austin. sent to [email protected]. 131 132 EISMAN ET AL. and of limited utility in the context of current patterns of care. Although this article is focused on problems, there are many Unfortunately, past episodes of indiscriminate use of costly psy- psychologists employed within organizations (managed care orga- chological evaluations (Griffith, 1997) may have contributed to nizations [MCOs]) who provide credible services through policies this reaction. The practice of routine psychological assessments for and authorization procedures that adhere to the highest profes- all patients, an issue cited by managed care as a factor in skyrock- sional standards. Advocacy with some MCOs has produced eting health care costs, has all but been eliminated and is no longer marked improvement in the attitudes of policymakers at those an issue. However, the profession's lack of advocacy in encour- organizations. Some of these agencies have even become proactive aging, implementing, and disseminating research that demon- in reaching out to clinicians when new policy issues emerge that strates the efficacy and utility of assessment in treatment planning are related to psychological assessment. Nevertheless, the present has allowed the pendulum to swing too far in the other direction. article focuses on the remaining problems because we believe that There are several reasons why this devaluation of psychological these difficulties require continued advocacy. Throughout this assessment did not come to the attention of the American Psycho- article, the phrase "psychological assessment" is intended to refer logical Association (APA) much sooner. At first, psychologists to both psychological and neuropsychological evaluations in performing assessments dealt with such challenges as reduced time health care settings. allocations for their services by donating (through not billing) their time to complete their assessments. In addition, the perceptions of Problems Encountered by Practicing Psychologists leading psychologists conflicted, with some proposing that psy- chological assessment was flourishing whereas others maintained Resistance to Psychological Assessment that it was a dwindling clinical activity. Neither perspective is valid, according to a recent APA Practice Directorate practitioner More and more frequently, psychologists report that assessment survey that shows that psychological assessments represent the is neither authorized nor reimbursed by third-party payers even second most frequent service provided by psychologists across when it is indicated for ethical clinical practice and sound risk practice settings, and that all aspects of practice have been ad- management. These payers often argue that diagnostic interviews versely affected by managed care (Phelps, Eisman, & Kohout, are sufficient for many, if not most, of the conditions previously 1998). Furthermore, the Practice Directorate's Office for Managed evaluated through the use of psychological assessment. One pro- Care has been consulted about many issues related to the role of vider manual states: psychological assessment in managed care. Interestingly, in a However... [the MCO] cannot support the use of tests for behavioral report on the legal and ethical issues of practice in managed care health diagnostic purposes since the DSM-IV [Diagnostic and Statis- based on the work of this APA office, three out of six case tical Manual of Mental Disorders, 4th ed., 1994] makes no reference scenarios cited as problems encountered by practicing psycholo- to psychological or neurologicaltesting for diagnostic purposes. In- gists had to do with issues of clinical assessment (Higuchi & stead to make behavioral health diagnoses the DSM-IV emphasizes Hinnefeld, 1996). clinical interviewsand obtaining informationfrom persons who have In 1995, the APA's Board of Professional Affairs (BPA) observed the patient. charged the Psychological Assessment Work Group (PAWG) with two tasks: (a) to assess the scope of the threat to psychological and Psychologists counter that the application of diagnostic interviews neuropsychological assessment services in the current health care as the sole criterion for such decisions as differential diagnoses, delivery system and (b) to identify research studies that document treatment dispositions, and disability determinations is fraught the efficacy of psychological assessment in clinical practice. This with situational and examiner effects that limit
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