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Health Psychology 1995, Vol. 14, No. 6,493-499
Copyright 1995 by the American Psychological Association, Inc. 0278-6133/95/J3.00
Health Psychology and Public Policy: The Political Process
Patrick H. DeLeon United States Senate Staff
Robert G. Frank University of Missouri, Columbia
Danny Wedding Missouri Institute of Mental Health
and University of Missouri, Columbia
During the past 20 years, psychologists have successfully modified federal statutes, resulting in recognition of the profession's clinical and research expertise. Despite these successes, profes- sional psychology's training institutions have largely failed to address basic issues in health policy and the implications of national health policy for psychology. The importance of public health programs under Title VII of the Public Health Act and the significance of full inclusion of psychology in all federal health programs, including Titles XVIII (Medicare) and XIX (Medicaid), are poorly understood by most health psychologists. Federal health policy decisions, including management of excessive federal health spending, will dictate the growth and opportunities for health psychologists. Understanding federal health spending and recent federal initiatives such as Resource Based Relative Value Scale, Diagnostic Related Groups, and practice guidelines will be of benefit to health psychologists.
Key words: health care policy, health psychology
During the past 2 decades, the field of psychology has gradually developed a significant and sustained presence in shaping U.S. public health policy (DeLeon, Wedding, Wake- field, & VandenBos, 1992). During the 1970s and 1980s, psychologists enjoyed increasing success in modifying a range of federal statutes to expressly recognize the profession's clinical and research expertise. These changes in statutes allowed psychologists to gain autonomous inclusion in most federal programs in which the government serves as "the payer" for health (including mental health) services rendered to federal beneficiaries (DeLeon, VandenBos, & Kraut, 1984).
Despite these gains, training institutions—even those focus- ing on health psychology—have been slow to recognize the importance of preparing psychologists for participation in the public policy process (DeLeon, 1989). The values and skills developed within psychology's training programs will shape the future priorities of the profession. Yet, today, it is still rare for psychology's training programs—including those within the recently established professional school movement—to sup- port programs that systematically address society's public health priorities and perceived needs (DeLeon, Fox, & Gra-
Patrick H. DeLeon, United States Senate Staff; Robert G. Frank, Division of Clinical Health Psychology and Neuropsychology, School of Medicine, University of Missouri, Columbia; Danny Wedding, Missouri Institute of Mental Health, St. Louis, Missouri, and Depart- ment of Psychiatry, University of Missouri, Columbia.
Robert G. Frank is now at the College of Health Related Profes- sions, University of Florida Health Science Center.
The editorial assistance of Sharon Johnson in the preparation of this article is gratefully acknowledged.
Correspondence concerning this article should be addressed to Patrick H. DeLeon, Senator Daniel Inouye, Room 722, Hart Senate Building, Washington, DC 20510.
ham, 1991). As a result, psychology has not been fully recog- nized (i.e., supported) in key federal health professions train- ing programs, such as those included under Title VII of the U.S. Public Health Service Act (federal programs supporting the education and training of health professions) and Title XVIII (Medicare) of the Social Security Act. A direct conse- quence of the failure to educate psychology graduate students regarding the importance of public policy is the scarcity of administrative (or public policy) training positions for senior graduate students and postdoctoral fellows (DeLeon, 1988).
Organized psychology really has never understood the all-important personal nature of the public policy and political process (DeLeon, Frohboese, & Meyers, 1984; Vincent, 1990). Psychology does not sufficiently appreciate the long-term significance to its clinical, educational, and research endeavors that results from its members becoming an integral component of U.S. federal health programs, including obtaining high-level administrative responsibilities (DeLeon, VandenBos, Pollard, Solarz, & Weinberg, 1991).
Health Care Costs
During the past decade, U.S. health care costs have grown faster than any other segment of the economy (Frank, 1993; Frank & VandenBos, 1994). Health care expenditures now exceed 14% of the Gross Domestic Product (GDP)—up from less than 6% only 3 decades ago. If the current system continues unchanged, health care will consume over 16% of the GDP by the year 2000 and between 27% and 43% of the GDP by 2030. Simply stated, the U.S. economy cannot afford continued prolonged expenditures at this rate; thus, effective cost-containment strategies clearly have become of primary and dominant importance (Bingaman, Frank, & Billy, 1993).
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494 p. DELEON, R. FRANK, AND D. WEDDING
Far more than most psychologists realize, the federal govern- ment represents a major component of the U.S. overall health care system. In 1989, the federal government accounted for 29% of total health spending. Currently, 340 hospitals and other related health treatment facilities are administered by the Veterans Administration and the Department of Defense. When combined with innovative federal cost control initia- tives, the service delivery and reimbursement policies of the federal government actually guide reimbursement decisions for both the public and the private sectors. Unfortunately, our nation's escalating health expenditures are now beginning to have a major impact, albeit unintended and often unrecog- nized, on the limited federal resources ultimately available for all other domestic programs (Kerrey & Hofschire, 1993).
Budget constraints are not the only factor potentially limit- ing health psychology's growth. Complex legislative battles create unpredictable hazards. Attainment of autonomous statutory inclusion within the various federal health programs requires legislative success and, simultaneously, the appoint- ment of individuals sensitive to psychology's potential contribu- tions to clinical care. Achieving inclusion in key federal programs means little if the implementing regulations are not sensitive to psychology's goals. For example, professional psychology has made the obtainment of autonomous hospital privileges one of its top state level legislative priorities for the decade of the 1990s. Yet, this agenda was threatened when the Health Care Financial Administration (HCFA) promulgated the "Hospital Conditions of Participation" regulations that were based on the original 1965 Medicare statutory language. This language would have preempted any legislative or admin- istrative progress at the state level (Enright, Resnick, Ludwig- sen, & DeLeon, in press).
Psychology and the Big Picture
With regard to health care reform, organized psychology, including health psychology, has missed the big picture, focus- ing instead on narrower goals. This narrow focus was apparent in psychology's approach to the 1993-1994 debate on federal health reform. The entire thrust of psychology's agenda focused on mental health benefits. As the debate developed, more attention was directed toward health psychology. De- spite the acknowledgement that health psychology was ignored entirely in the profession's haste to emphasize the importance of including 50 individual psychotherapy sessions in the ben- efits package, it was only in the last months of the debate that equal effort was directed to assure health psychology services were included in the basic benefits package. Failure to assure inclusion of health psychology in the basic benefits package was surprising given that a recent article identified 70% of the members of the American Psychological Association (APA) as "health care providers" (Shapiro & Wiggins, 1994, p. 207). Clearly, the political strength of these members has not been unified.
It is clear that psychology's colleagues in medicine clearly do recognize the importance of actively influencing all levels of public policy and are not content to be passive responders. The American Medical Association led all other organizations in total contributions to its political action committees during the 1992 election. Within the all-important area of clinical train-
ing, the historical reluctance of psychology's training institu- tions to provide effective models of public health psychology or interdisciplinary training has nearly precluded the profession from being recognized by U.S. health policy leadership as possessing the skills necessary to address pressing societal needs. An additional problem of the limited vision exhibited in this approach is the failure of training programs to seek control of inpatient facilities such as state hospitals or nursing homes. These facilities offer unique opportunities for health psycholo- gists to develop significant training labs that positively exploit the profession's skills. Nursing homes virtually have been ignored by the health psychology profession even though behavioral management is a significant problem in nursing homes. Health psychologists can use this forum to develop relevant, effective training programs highlighting identification and modification of risk factors associated with long-term care. These settings offer health psychologists the opportunity to combine the modification of health behaviors—the hallmark of clinical health psychology (Chesney, 1993)—with the fastest growing segment of health care. By placing training programs in such facilities, psychologists will establish the profession in this critical health care niche.
In sharp contrast, by aggressively shaping (and subsequently responding to) perceived national priorities, psychology's col- leagues in medicine have been successful in lobbying Congress to provide more than $5.8 billion annually in training funds for their programs. In Fiscal Year 1994, the Medicare (direct and indirect) medical education payments approximated $5.2 bil- lion, with these funds being used, among other purposes, to provide resident and teaching physician salaries and fringe benefits (Dunivin, 1994). In the process, organized medicine has presided over a national change in values in which routine life activities have come under the domain of medicine. The "medicalization" and "biologicalization" of routine life activi- ties including teenage pregnancy, job stress, injury prevention, and, most recently, violence among minorities have offered medicine a broader platform. Increasingly, medicine has be- come involved in all aspects of the life continuum so that any proposed service delivery or training programs targeted to- ward health, life, death, and home care now fall almost exclusively within medicine's purview, notwithstanding the extent to which psychological (i.e., behavioral science) exper- tise might be more appropriate as in hospice care and long-term rehabilitative care.
Behavioral science expertise should be a prime consider- ation in developing U.S. health and educational programs, not merely an afterthought. However, this is unlikely to happen until psychologists learn to influence the public policy and political process. Psychologists must begin to collectively understand that as a practical matter, health and educational programs compete for limited governmental resources. To facilitate accomplishment of these goals, APA has established the Congressional Science Fellowship Program. This is one of the most exciting developments within professional psychology during the past several decades.
Since its inception in 1974, the APA-sponsored Congres- sional Science Fellowship Program has been responsible for facilitating the active involvement of individual psychologists in the policy-making and political process, thereby bringing psychology's expertise directly to bear on a wide range of
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SPECIAL SECTION: HEALTH PSYCHOLOGY AND PUBLIC POLICY 495
society's priorities. The program provides fellows with an intimate appreciation for the potential interrelationship be- tween psychology and evolving U.S. policy agendas (Lee, DeLeon, Wedding, & Nordal, 1994). Upon completing their Capitol Hill experience, approximately half of the fellows have taken policy-related positions with various federal agencies, Congress, public interest or policy research organizations, or all of these. The remaining fellows have returned to positions similar to those they held before accepting the APA assign- ment (B. L. Wilcox, personal communication, October 15, 1992).
Regulating Payment and Quality
Driven by changes in reimbursement, new models of health delivery are developing. Current estimates suggest as many as 40% of all Americans will receive care through managed delivery systems by the year 2000 (Weiner, 1994). These systems are characterized by two forms of payment: capitation or rate regulation. Capitated systems move risk to the provider. A lump sum is provided to cover all services; if providers can provide service for less than the capitated rate, they make a profit. Capitated models frequently include exempted services that are "carved out" for a separate capitation or regulated payment. The second common new method of payment, rate regulated payments, evolved from the Resource-Based Rela- tive Value Scale (RBRVS). It is important for clinical health psychologists to have a clear understanding of the develop- ment of RBRVS.
When Congress created Medicare in 1965, it established reimbursement principles for physicians' services on the basis of "reasonable charges." Payment was made for each service, creating a fee-for-service system. The fee-for-service system resulted in consistent increases in Part B of Medicare, the physician reimbursement system. From 1980 to 1989, Medi- care charges per enrollee increased from $376 to $1,040, an increase of 176%. The increases in costs reflected increases in the Medicare reimbursement rates and increases in the volume and intensity of services provided to Medicare beneficiaries. Because Medicare was developed on a fee-for-service model, overall Medicare expenses were affected by reimbursement rates and the volume and intensity of services provided to beneficiaries.
RBRVS
In 1989, with the Omnibus Budget Reconciliation Act (OBRA '89), Congress implemented sweeping reform of the physician payment system that consisted of three physician payment reforms: a new payment schedule, a Medicare Vol- ume Performance Standard to control the growth rate of physician expenditures, and new limits on the amounts physi- cians could bill in excess of Medicare reimbursement. Con- gress reformed the physician payment system for several reasons. For many years, medical specialties using procedures had enjoyed a significant advantage in income, relative to the "cognitive" specialties. The disparity in income between surgi- cal specialties and specialties that rely on cognitive activity was a primary reason for the decline of physicians in primary care. Moreover, physician payments for the same service varied
significantly in different geographic regions. In addition, Medi- care costs had consistently increased yearly, creating a worri- some trend.
With OBRA '89 Congress responded to these concerns by establishing a new payment system based on the RBRVS. The RBRVS was designed to pay physicians according to time, skill, and intensity of provided services. The fee schedule was to be implemented over a 5-year period that began in January 1992.
To implement the intent of the Congress under OBRA'89, the HCFA created a unit called a relative value unit (RVU) for each service. There were three components to the RVU. The first component reflected physician time and intensity, includ- ing activities before and after patient contact. The second component of the RVU was the practice expense or overhead component that included expenses such as office rents, em- ployee wages, physician compensation, and physician benefits. The last component, the malpractice component, reflected costs of obtaining malpractice insurance.
A geographic adjustment factor was used in the calculation of the fee schedule. This was designed to compensate for geographic variations in practice costs, practice expenses, and malpractice premiums. To control for volume and intensity in the provision of medical services, a conversion factor was established to modulate the entire process. The conversion factor was to be reviewed annually. Congress, acting on a recommendation from the Department of Health and Human Services, established the conversion factor according to the volume and intensity of services during the preceding year.
In implementing the intentions of the Congress, HCFA determined that psychological assessment should be included in Medicare's physician payment system; however, therapeutic services provided by psychologists should fall under a different, separate fee schedule—the Clinical Psychologists' Fee Sched- ule.
In evaluating the RVU for psychological assessment, HCFA determined that the physician work RVUs equaled 0. The value was set at 0 because it was not a physician service, but this decision is undergoing further evaluation. The practice expense RVU was set at 1.72, whereas the malpractice RVU was set at .20. Thus, the total RVU was set at 1.92.
Only assessment performed by psychologists falls under RBRVS. Psychotherapy services are reimbursed under the old Medicare system that preceded RBRVS, paying psychologists 80% of prevailing psychiatrists' rates, adjusted for inflation. Health psychologist services have become increasingly re- stricted. In contrast, all psychiatrists' services fall under RBRVS. Interestingly, of all the professions, only psychology continues to be regulated by the old Medicare system. Reform of the Medicare physician payment system has important ramifications for the practice of psychology as the same methodology accepted for physician payment likely will be applied to psychologists.
As health costs have approached intolerable levels, a small cadre of researchers began reporting that many health proce- dures were unnecessary. Brook, Kamberg, and Mayer-Okaes (1989) estimated one of every three health care dollars is spent on medical procedures and care that have little benefit. In late 1987, the leadership of HCFA acted on the growing body of literature questioning much of the practice of medicine and
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496 p. DELEON, R. FRANK, AND D. WEDDING
developed a plan to use population-based data to assess the effectiveness of practice methods. The HCFA plan called for the creation of shared databases, allowing for the collection of uniform information on medical outcomes. The HCFA plan also included an emphasis on training in clinical epidemiology and decisions analysis for health care providers. Finally, the plan called for the establishment of medical practice guide- lines—systematically developed statements used to assess the appropriateness of health care decisions, services, and out- comes.
The HCFA's program, named the Medical Treatment Effec- tiveness Program, was implemented through the National Center for Health Services Research. Through this program, four grants were awarded in Fiscal Year 1989 to examine the management of myocardial infarction, different procedures for treatment of cataracts, management of prostatic hyperplasia, and nonsurgical interventions for lower back pain. A second task of the Medical Treatment Effectiveness Program was the development of treatment guidelines for practicing physicians, based on science, that were to be practical and explicit. The guidelines were to be developed through an unusual collabora- tion among many key medical organizations including the American Medical Association, the American College of Physicians, the Institute of Medicine, academic medical cen- ters, and a variety of other groups.
In November 1989, Congress amended the Public Health Service Act to create the Agency for Health Care Policy and Research (AHCPR). Under terms of Public Law 101-239 (OBRA'89), this agency was given broad responsibilities for supporting research, data development, and other activities that "enhance the quality, appropriateness, and effectiveness of health care services." Although the needs of the Medicare program were important to the mission of the agency, Medi- care was not the exclusive focus of the new agency.
The AHCPR replaced the National Center for Health Services Research and incorporated many of that agency's activities. The prime mission of AHCPR was to place a greater emphasis on the assessment of outcomes and effectiveness. In addition, the new agency was mandated to lead a joint effort between public and private institutions to develop, dissemi- nate, and evaluate guidelines for clinical practice. The man- date of AHCPR to use a public-private approach represents an important innovation in American health care.
Health care providers play a major role in establishing practice guidelines. Clearly, acceptance by practicing clinicians and clinical researchers requires that they have a major role in establishing acceptable standards of practice. The develop- ment of the practice guidelines is a three-stage process: development, intervention, and evaluation. Intervention and evaluation, under ideal circumstances, are used to revise the guidelines. Practice guidelines represent a dynamic process influenced by emerging scientific information, public values, and social practices.
The development of practice guidelines is a difficult and challenging task. Guidelines are based on supporting scientific information and common clinical practice. The Institute of Medicine of the National Academy of Sciences has recom- mended that clinical guidelines address clinical conditions rather than specific treatments or procedures (Field & Lohr,
1990). The identification of attributes of practice guidelines rests on four principles. The first principle is that the definition of each attribute must be clear. Second, each attribute must be compatible with professional usage. Third, each attribute must have a clear rationale or justification for selection. Last, each attribute must be sensitive to practical issues. Overall, the guidelines must have credibility with practitioners, patients, payers, and policy makers.
A total of 16 clinical guidelines, in a variety of areas, have been commissioned by AHCPR. Most of the areas fall within medicine; several overlap with behavioral or psychological aspects of illness. Many of the existing guidelines address areas of practice common to health psychologists, including acute pain management; diagnosis and treatment of depressed outpatients in primary care settings; prediction, prevention, and early intervention of pressure ulcers; low back problems; poststroke rehabilitation; screening for Alzheimer's and re- lated dementias; urinary incontinence in adults; management of cancer-related pain; and HIV positive asymptomatic patient evaluation and early intervention.
Interest in practice guidelines has grown explosively within organized medicine, and every specialty group has attempted to develop its own. Medicine has not been alone in expressing interest in practice guidelines. Insurers, health maintenance organizations, utilization management firms, and similar groups have recognized the potential of practice guidelines to serve as a basis for payment (or for refusing payment) for health care services. Blue Cross and Blue Shield Association began the Medical Necessity Project, which is designed to identify obsolete medical procedures and to establish guidelines for diagnostic tests and treatment. The Health Insurance Associa- tion of America and the Group Health Association of America also have sponsored programs on guideline development. The American Psychiatric Association has produced two guide- lines, one on eating disorders and one on major depression, and is developing additional guidelines. Unfortunately, the practice community within organized psychology fought efforts by psychology to develop guidelines. Consequently, psychology is in the awkward position of either disparaging psychiatry's guidelines when no alternative exists for psychologists or accepting the psychiatry guidelines, which will place a pre- mium on the medical approach. The demise of health reform virtually assures future reimbursement decisions will be tied to clinical practice guidelines in the near future.
Future Challenges: Funding for Training
Since the mid-1960s, the Health Professions Legislation (Title VII of the U.S. Public Health Service Act) has been the hallmark of the federal government's efforts to educate and train health professionals. During the first decade after its inception, this legislation focused primarily on increasing enrollments in the various health professions schools (medi- cine, osteopathy, dentistry, and so on). In the mid-1970s, however, the focus switched to problems associated with specialty and geographical maldistributions, with financial support being provided to those schools interested in taking on various "special projects," such as training professionals to serve senior citizens or to serve in rural America.
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SPECIAL SECTION: HEALTH PSYCHOLOGY AND PUBLIC POLICY 497
By not systematically focusing on the federal government's evolving priorities, our training institutions have missed signifi- cant opportunities for support. For example, in Fiscal Year 1991, all of psychology competed for approximately $2 million of clinical training support, whereas, in sharp contrast, the Title VII appropriations exceeded $185.4 million that year; in Fiscal Year 1993, the entire National Institute of Mental Health clinical training account, including a major AIDS initiative, was only $5.95 million, whereas other professions funded under Title VII received in excess of $200 million.
As health psychology has developed and health psycholo- gists have become involved in traditional U.S. health training and health delivery systems (e.g., by obtaining faculty positions within schools of medicine, dentistry, nursing, and public health) and as behavioral medicine, wellness, and health promotion and disease prevention activities have gained greater clinical acceptability, Congress has given increased attention to the contributions that psychologists can make to the broader health delivery system (VandenBos, DeLeon, & Belar, 1991). As a direct result, psychology gradually has been able to be legislatively included in some of, but not all, Title VII initia- tives.
Psychology's first recognition within Title VII was under the general Project Grant authority. No project was ever actually funded (to the authors' knowledge); however, the Department of Health and Human Services's 1979 Allied Health Personnel Report to Congress did include a section on clinical psychol- ogy. Public Law 97-35 (OBRA'81) provided for psychology's inclusion within the National Health Service Corps Scholar- ship program and the Individual Federal Insured Loan pro- gram, which is now called the Health Education Assistance Loan program. Interestingly, during Fiscal Year 1990, more than 600 psychology graduate students, from 51 institutions, borrowed in excess of $3.26 million under the Health Educa- tion Assistance Loan program. Public Law 97-35 also included clinical psychology under that section of the Health Profes- sions legislation that directs the Secretary to collect data on health professions personnel. Public Law 97-414 (Orphan Drug Act, 1983) authorized psychologists to serve within the U.S. Public Health Service Regular Corps, which is the sole statutory requirement for being appointed Surgeon General of the United States. Before the enactment of this legislation, those few psychologists who were appointed to the Regular Corps had been approved because of the underlying statute's very broad authority.
During the 98th Congress (1983-1984), President Reagan vetoed the proposed Public Health Service Act Amendments of 1984, which would have made psychology eligible for the Health Careers Opportunity Program (or Educational Assis- tance to Individuals From Disadvantaged Backgrounds) and the Health Professions Student Loans program. However, Public Law 98-511 (Education Amendments of 1984) did provide recognition for psychology under the Indian Educa- tion Act Fellowship program. In addition, Public Law 98-551 (Health Promotion and Disease Prevention Amendments of 1984) specifically included psychology in the program authority for establishing health promotion and disease prevention programs by the U.S. Public Health Service.
Public Law 99-129 (Health Professions Training Assistance
Act of 1985) included psychology within the Health Careers Opportunity Program and, perhaps most important, expressly indicated that psychology was no longer to be considered one of the allied health professions. Previously, from time to time individual psychology grants had been funded under the broad and inclusive authority of the allied health definition. Finally, Public Law 100-607 (Health Omnibus Programs Extension Act of 1988) expressly included psychology in the Title VII definition section of the health professions schools. Public Law 100-607 also directed that a psychologist be appointed to the all important National Advisory Council on Health Professions Education that oversees all of Title VII initiatives. This statute further included psychology under the newly authorized Rural Health Interdisciplinary Training program.
Although psychology gradually has obtained explicit recogni- tion under various Title VII initiatives, very few of its training programs have applied for these new resources. In what must be considered a significant policy "step backward," the Health Professions Education Extension Amendments of 1992 (Public Law 102-408) not only placed psychology, along with clinical social work and marriage and family therapy, under a new definition of graduate program in mental health practice but also eliminated the National Advisory Council on Health Professions, on which psychology had earlier obtained legisla- tive recognition. Some minor progress was made under this legislation; Area Health Education Center programs were authorized to use psychology programs, if they so desired.
There are still a number of very important Title VII programs for which psychology is simply not eligible. For example, the Health Professions Student Loan program, the Exceptional Financial Need Scholarship program, the Health Education and Training Centers initiative, the Centers of Excellence in Minority Health Education and Care, and the Financial Assistance for Disadvantaged Students program are all prohibited from accepting applications from psychologists. Furthermore, as psychology becomes involved in seeking federal support for its postdoctoral training initiatives, this initiative will undoubtedly fall within the Title VII authority. Public Law 102-573, the Indian Health Amendments of 1992, expanded psychology's recognition under its programs and authorized a new Quentin N. Burdick American Indians Into Psychology program at the University of North Dakota under which federal funds can be used to recruit and retain Ameri- can Indians interested in a psychology career. Hopefully, this particular legislative success will serve as a model for psycholo- gy's efforts during future reauthorizations of the Title VII legislation.
Health Psychology in the 103rd Congress and Beyond
During the 103rd Congress (1993-1994), the primary topic was reform of the nation's health care system. Amidst the clamor and disappointment at the failure of Congress to enact health reform legislation, the passage of technical corrections to the Medicare program, Public Law 103-432, was lost. During the 102nd Congress, the technical corrections to the Medicare Act failed to pass when President Bush vetoed the budget bill. Public Law 103-432, however, contained a provision defining psychologists as approved Medicare providers in states allow-
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ing psychologists to admit patients. This provision, long sought by psychologists, prevents attempts by medical groups to use Medicare regulations as an additional means of limiting hospital practice by psychologists.
Although the 103rd Congress will not be remembered for its legislative activity, several key programs were reauthorized, many after the legislation had been blocked in the 102nd Congress. The National Institutes of Health (NIH) was reau- thorized (Public Law 103-333). Throughout the legislation and conference report the NIH was instructed to direct more attention and resources to behavioral aspects of illness. Sev- eral institutes were directed to establish behavioral initiatives. For example, The National Heart, Lung, and Blood Institute (NHLBI) was encouraged to establish a behavioral cardiology specialized center for research unit. Along the same line, NHLBI was encouraged to initiate clinical trials on behavioral interventions to reduce morbidity and mortality for heart attack victims suffering from depression or social isolation. The NHLBI also was directed to study the effectiveness of relaxation procedures, especially transcendental meditation, in improving physical and mental health and the effects of these procedures in the reduction of health costs. The Na- tional Institute of Aging was scolded for failing to implement biobehavioral field trials on interventions designed to increase the independence of older individuals.
Similar language exists for virtually every NIH institute and other key federal programs such as the Center for Disease Control and the National Health Service Corps. The inclusion of language favoring behavioral research and treatment is critical to health psychology. At the same time, the lack of specific recognition of health psychology, or even psychology in general, is ominous. For many years, psychologists have believed the key to success in federal advocacy was based on participation in broad coalitions that stressed the importance of behavioral interventions. The result of this approach is that health psychology and other psychology specialties are viewed as equivalent to other mental health professions. Psychiatry has escaped this homogenization process and continues to be viewed as a medical specialty, above the other mental health disciplines. A clear consequence of this approach occurred during the 102nd Congress when psychologists were merged with marital and family therapists (only 34 states regulate marriage and family therapists through licensing or certifica- tion) and social workers under the category mental health professionals in Title VII (Public Law 102-408). At the state level, a similar pattern has emerged in the regulation of mental health professions. Colorado recently reorganized all mental health professions (psychology, social work, professional coun- selors, social workers, and marital and family counselors) under a single administrative board.
The Future
For health psychologists, policy makers' tendency to homog- enize psychology with other mental health professionals is particularly concerning. By definition, health psychologists work at the cutting edge of medicine and psychology. Clinical health psychologists often work with disorders that do not fit the purview of mental health professionals. Moreover, the
clinical domain of health psychologists often exceeds accepted payment categories. Homogenization of mental health profes- sions, especially if psychology continues to be merged with master's level professions, will increase the difficulty justifying health psychology services.
The failure of the federal government to pass legislation reforming the U.S. health care system has placed enormous burdens on the states (Frank, Sullivan, & DeLeon, 1994). State health reform efforts will be limited by many of the same political interests that hampered federal health reform. In addition, states are prohibited from regulating self-insured plans by the Employee Retirement Income Security Act (Frank et al., 1994). Thus, effective state reform is unlikely unless the federal government acts to limit the Employee Retirement Income Security Act, an action that would be strongly opposed by several key political groups.
With federal and state reform unlikely, reform of the health care system will be driven by market forces (Frank & Vanden- Bos, 1994). Current trends are toward capitation and vertically integrated systems (that bear risk and provide health services). These vertically integrated systems will, in turn, form inte- grated service networks (ISNs). ISNs will consist of huge service delivery systems offering the entire spectrum of health services to many individuals, often in several states, and are likely to be formed by large hospital companies with significant capital. Recently, a few physician groups have successfully negotiated with ISNs. Most often, physicians, psychologists, and other health providers will be employees of ISNs. ISNs will have the ability to determine services, who shall offer the service for capitated contracts. Managed care, as it is now known, will evolve from the common current model that simply coordinates care, taking only minimal risk to ISN-driven systems that take risk and are entirely integrated. In this world, health psychologists will face many new challenges. Clinical practice will increasingly be driven by the need to demonstrate financial and clinical efficacy. Government will assure quality but is less likely to determine benefit packages. Services will be either purchased at additional cost as part of a health plan or will be included in the health plan because the service is of clear clinical and financial value.
In the evolving health delivery system, training in health psychology, with an emphasis on the scientific assessment of clinical interventions, will increase. Yet health psychologists also will be tested as they attempt to learn how to assure that their skills and contributions are understood by corporate health policy makers. At the same time, federal programs such as Medicare and Medicaid will remain critical models for payment, likely to be copied by private health systems.
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Announcement of Special Issue on Minority Health
Health Psychology is pleased to announce the publication and separate mailing of an extra issue to come out in late December 1995 or early January 1996. This special issue, entitled "Behavioral and Sociocultural Perspectives on Ethnicity and Health," is guest edited by Norman B. Anderson and is based on the proceedings of a conference on minority health sponsored by the Division of Health Psychology of the American Psychological Association. The editors of Health Psychology are ex- cited about this series of articles and hope it will provide psychologists and other health profession- als with a better understanding of the concerns in this important area.
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