In the Beginning
A number of national issues will significantly impact future trends in clinical research. Just as clinical psychology and research got their first big push from the Veterans Administration just after World War II, so too will the future be guided primarily by major economic and social issues. We tend to go where the money is (traineeships, fellowships, research grants) and to work on the socially relevant/important problems of our time. The VA impetus was but the first example of how clinical research trends start.
Of course, clinical psychology is an enormously large area, making prediction of specific trends difficult. I present only my own views but believe that the current crisis in higher education and the projections of changes to occur under the Clinton Administration will impact what we do in the next decade.
Health Care Reform
The proposals for health reform (and more specifically managed care) will surely influence the direction of psychology, and, to the biggest extent, clinical psychology. My intention is to provide a brief overview of several important points.
Mash and Hunsley (1993) noted that we have seen enormous changes in mental health service delivery over the past 20 to 30 years. These changes have led to our mental health services being managed by third party payers, like insurance companies and specific employer programs. A number of projections now indicate that by 1995, about half of all Americans will receive their mental health benefits under some form of managed care.
Two of the most common types of managed care are Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs). Mash and Hunsley defined HMOs as organizations that typically provide “services through a health care company, a group practice formed by several health care practitioners, or an employer’s own staff of practitioners.” Whereas, PPOs are defined as being “represented by service providers who have contracted with organizations to provide their services at a reduced rate in return for a high volume of referrals.”
An increasingly popular arrangement is the “managed-fee-for-service plan.” This plan incorporates all kinds of care coordination strategies under one umbrella. A good example is the EAP (Employee Assistance Plan) “designed to provide assessment and monitoring, education, crisis-intervention, short-term counseling, and referral and follow-up services to assist employees and their dependents with their personal problems. Employers often contract for EAPs with individual practitioners, HMOs, or PPOs.” The bottom line is to have the most efficient services at the lowest costs. Shortterm therapy will be the mode of treatment, and some people feel that psychologists will be just too expensive.
Although we have used different terms in the past, “managed care” has been kicked around for over 30 years. Why is it becoming more of a reality now? Because health care reform is now linked to the “economy!” Whether you are for or against managed care, most people agree that something has to be done with the current health care system. In a recent issue of the Health Psychologist, Kaplan noted three major problems with the health care system in the United States.
Expensive, Inaccessible, and Unproven Health Care
First, it’s unaffordable. The 1992 expenditure for health care was $800 billion. We spent more than $3,000 per person, per year. Second, it’s inaccessible. Overall, 40 million people have no health insurance at all. Finally, there is no accountability.
“Despite the fact that we spend more money on health care than any other country, we are unable to document that these expenditures result in increased life expectancy, better quality of life, or improvements on any other health indicator” (Kaplan, 1992).
Research and Practice
Kaplan suggests that Clinton’s policy changes may affect health psychologists by increased spending on prevention and investments in clinical research. “All indications are that basic and applied research will be well supported during a Clinton administration …. According to some documents, there may be a stronger emphasis on clinical research, particularly, research that informs medical decision making or provides information on how to lower costs.”
Kaplan notes that two components in the Clinton plan are of particular interest to health psychologists. First, the plan calls for core benefits that will include prevention care. This implies a potential major increase in the amount of preventive care delivered which in turn suggests more school-based clinics, community health centers, and training programs. The second component, an intensified health-education system, is reinforced by Clinton’s public statements that health behavior is a major contributor to ill health and high health care costs. He has proposed programs to reduce unhealthy behavior and encourage personal responsibility for health.
Among the several implications for clinical practice, according to Kaplan, is the fact that the emphasis on universal health insurance may encourage providers to welcome preventive care since universal health insurance means that a larger pool of people share the cost of services. But strict limits on coverage are likely, and there is the challenge of how we would pay for this system. Since Clinton favors raising money through an employer mandate, every employer would be required to offer health care coverage for their workers.
Managed competition, says Kaplan, is another important concept in the Clinton proposal…. Managed competition forces competition — between insurance companies — under a set of structured rules. For example, employers would be required to provide employees a choice between competing alternatives. Employees would choose plans that best meet their needs, and since at least a portion of the insurance premium would come from the employee’s paycheck, there would be an incentive to choose the plan that provides the most value.
Perhaps the most important concept in the plan, according to Kaplan, is global budgeting which attempts to limit the systematic increases in health care expenditures as a proportion of the gross national product. Global budgets would set limits on how much could be spent for treating individuals.
However, the global budgets will force competition. The competition is likely to increase the need for clinical research.
“Under global budgets, it makes the most sense to pay for services that are most effective in making people well. Currently, it is difficult to decide which services should be supported because we have insufficient evidence about the efficacy of the alternatives. This ignorance has spawned a whole new industry of ‘outcomes research’ designed to evaluate the costs, risks, and benefits of competing treatments” (Kaplan, 1992).
I believe that these external forces (namely managed care) will not only affect clinical research but also clinical practice. Kaplan mentioned some: Increased prevention efforts, enhanced community approaches, and health education reform. However, Mash & Hunsley (1993) have said that it seems inevitable that managed care will dramatically influence the future development of all major forms of psychotherapy.
Societal Issues and Research
In terms of societal issues, one point is less of a prediction — of trends in clinical research — than a plea for all of us to work together to define the future trends in psychological research.
As most of you know, the American Psychological Society convened a Behavioral Science Summit in Tucson in January 1990. “The Summit conferees, representing almost 70 organizations, unanimously endorsed the development of a national research agenda that would help policy makers in federal and other agencies set funding priorities for psychological and related sciences” (APS Observer Special Issue, Feb., 1992).
In January 1991, the Steering Committee of that summit reported its progress at the next Behavioral Science Summit in Houston. Through these meetings, the Human Capital Initiative (HCI) was proposed. The HCI is “a sustained, national research effort, to enhance the understanding of human development and behavior. The [HCI] is intended to support research relevant to a set of…six critical problems that are facing our nation, communities and families today, and that can helped by psychological science.” They include:
- Worker Productivity
- Schooling and Literacy
- The Aging Society
- Drug and Alcohol Abuse
- Mental and Physical Health
Because I am convinced that the clinical practice endeavor will change dramatically with the health care reform, this is an opportune time for applied researchers to ban together with our experimental colleagues to forge new research trends that will address, and be part of, the Human Capital Initiative. To the extent that we are successful, these trends will (and should) impact on clinical practice in the future. Within our department, we are working on a long-range plan of faculty hires that are based on building “critical masses” of researchers who would address several of these areas. The strength of the critical mass comes from bringing together researchers from different areas within the department. Many of the future trends will come from these types of collaborative efforts.
One Unifying Trend
I realize now, after putting together this presentation, that one major trend affecting clinical research is the loss of psychopathology as the unifying theme of the clinical research endeavor. There is no one clinical research theme. In fact, there are many subareas that rightly have research themes unto themselves. The unifying theme relates more to our approach to clinical research. That is, we must engage in an increased emphasis on collaborations across areas of psychology (and, to a certain extent, across departments). We can advance our own sub-area’s research theme by working with others who have something to say about the topic that we research rather than strictly working with others who belong to our subarea group. The Human Capital Initiative demands this kind of collaboration, and, if you haven’t read thoroughly the HCI document, I would suggest you do so. It’s a unifying call to all of us to work together on the critical problems of our time.