In the health care reform movement, what is moving us?
Article Type: Report
Subject: Health care industry (Services)
Psychotherapists (Practice)
Health care reform
Author: Hixson, Ronald
Pub Date: 09/22/2011
Publication: Name: Annals of the American Psychotherapy Association Publisher: American Psychotherapy Association Audience: Academic; Professional Format: Magazine/Journal Subject: Psychology and mental health Copyright: COPYRIGHT 2011 American Psychotherapy Association ISSN: 1535-4075
Issue: Date: Fall-Winter, 2011 Source Volume: 14 Source Issue: 3
Topic: Event Code: 360 Services information; 200 Management dynamics Computer Subject: Health care industry
Product: SIC Code: 8000 HEALTH SERVICES
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 277270203

Health care reform is constantly in the minds of most people. We all worry about what tomorrow will bring to our practice. Social reform movements have a history of taking time. Since reform can take years to reach legislation or affect delivery, providers can get complacent, which can turn into apathy. When this happens, providers disregard the benchmarks that suggest future changes, continuing to use clinical based policies and procedures, paying only lip service to the growing business based factors pushing change in health care. Many feel that we have lost control of our destiny, which may make us part of the problem rather than part of the solution.

The changes of the past did not start in the health care industry because there was no industry 100 years ago. What created this change was the union of large hospitals and medical groups with Corporate America, also known as Wall Street. While the members of this union existed in small and weak parts prior to 1950, it took a whirlwind of unprecedented events to take place in order to gain the needed traction which has changed the way we practice today. A few examples of these events include inventions, increased manufacturing productions, and the increased availability to travel physically or through the Internet. It has taken people of vision to create change through ideas, a commitment to the integrity of the idea/project, and the willingness to sacrifice time, energy, and the activities of today for the promise of something greater tomorrow.


Manufacturing and the airlines are presented as an example and comparison of how industries in America have developed. Both are wealth producing sectors of the national economy. The Industrial Revolution is said to have taken place from 1760 to 1850 and involved agriculture, textile and metal manufacturing, and transportation. It had a significant impact on the economic and social climate. This led to increases in the production of food and raw materials, increases in efficiency and profits, and an increase in commerce, both foreign and domestic.

The changes that took place in the textile industry must certainly center around the inventions and their inventors, though not necessarily be limited to them. These inventions that were perfected and employed led to tremendous change in the world of work. Gone were the days of the Domestic System, yielding to the new ways of the Factory System. These factories which were to spring up throughout the countryside were large, dusty, poorly illuminated and ventilated and dangerous (Montagna, Joseph A. (2011).

Coal mining has always been dangerous work. Coal was moved through horizontal tunnels by baskets, and hauled up a vertical shaft to the surface. Later, ponies and carts on rail carried coal to the surface. Other improvements included addition of the ventilation system, the use of gunpowder to blast, and the use of safety lamps. Factory growth led to people locating around the factories. This caused those communities to grow which caused other businesses to move there as well. The invention of the steam engine led to movement of water sleds of coal traveling up and down rivers to deliver to factories. In addition, steam engines were used to power mills and steamboats, and later factories.

Airline Industry

After the Wright brothers created the first airplane it took several decades before people started booking flights. The military needs, Charles Lindbergh's flight across the Atlantic, and the U.S. Postal Service's need to expand their distribution resources to lower costs and add speed to delivery contributed to the growing demand in small and large corporations, which led to changes in aircraft design. Eventually the interest of the public in using airplanes for traveling increased despite the different cycles of business and the roller coaster ride of the national economy.

The Federal Aviation Administration (FAA) was created after the Federal Aviation Act was passed in 1958 due to a major increase of in-air collisions that were taking place. The 1970s saw dramatic increases in costs, particularly increases in fuel prices. The 1980s were marked by the deregulation of the industry, which resulted in the growth of smaller carriers and the mergers of larger carriers. The 1990s saw a dramatic increase in the number of passengers, including first time passengers, as prices were cut and the cities served by airlines increased. (Mullins, 2008).

These few examples demonstrate how change in other industries takes time but can be rapidly developed by inventions, improvements in product designs, additional services, the growth of public awareness, and the rise of demand. The key difference between the fledgling health care industry and other industries in the United States is that health care is viewed as a service industry created for healing bodies and minds and not for making profits, which is the primary goal of other industries. That explains, at least in part, why health care providers have traditionally shunned the business side of health care. They were, and many still are, driven by the service or clinical aspects of their mission and vision.

Changes in the Demand for Services

At first health care was a cottage industry; more mom and pop type of services. Nearly all were medical doctors, with a few midwives and where others were offering nursing services and social services. The industry grew with the requirements of a need for a medical corps in the military, advances in trauma care in war zones, and in natural disasters. Private practice in mental health started with Sigmund Freud in Vienna, Austria. For years only medical doctors did psychotherapy in private practice. Centering on private practice (practicing healing and/or heath care independent of a group, hospital, or organization) was first introduced by shamans and ladies working as nurses and midwives, then physicians and social workers.

The business world, which initially shied away from any attempt to harness the services of physicians and nurses, found hospitals more receptive to organization and unlimited investment capital. Corporate America has been more astute to the values of a financial statement, management training seminars and continuing education, and empire building. Leaders did not shy away from manipulating the market to increase unit profits. Expanding market share was constantly on their minds. Businesses are built on the profit margin, which comes from lowering costs or increasing units sold without increasing costs. The building of a business is carved out of lessons learned with measuring and quantifying, event planning, forecasting profits and losses, timeline management, organizational development, communication audits, and determining strategies and scenarios where goals of the organization can be reached with greater margins of profit and less liabilities and risks. No matter what type of business we are in, we could use the experience from someone who has owned a small or large company and who appreciates what sacrifices it takes to survive and to succeed. Research is done for manufacturing, designing, the automobile industry, banking, insurance, health care, the pharmaceutical industry, energy industry, and many more. It is well-accepted in the business industry that those who do not plan for the future, plan to fail.

The growth of small business takes time. Seven Eleven started from a mom& pop convenience store in 1927 and in 1946 it changed from Tote'm to Seven Eleven to reflect the hours of operation. Today, under the corporate name of Southland Ice Company of Dallas, TX, they license, operate, and franchise over 7,600 units in Canada and the United States.

A pioneer with a vision

There are seldom any benchmarks that alert us to change like technology. Television meteorologists use it to explain forecasts and weather fronts. There was a man who foresaw many of the changes we are now experiencing. He stood up because he saw that there was a demand for mental health services that was not being met. He learned, from personal experience, that people like to talk with a therapist, not to a wall. Secondly, people wanted help with solving problems, not just listening to someone offer reflections or questions. Finally, he created a better mouse trap. In other words, he created another model of delivery that met the needs of the health care professionals and blended it with the increasing demands of the marketplace. Nicholas A. Cummings, Ph.D., Sc.D. formed the Biodyne Model for delivering mental health. While many have criticized this model, with the advent of managed care, private practitioners have found the model advantageous to the patient, the practice, and the constant changes of managed care. Today we are just now appreciating what he warned us of decades ago: Wall Street owns the health care industry.

Dr. Cummings is a distinguished professor emeritus, clinical psychologist, and president of the Foundation for Behavioral Health at the University of Nevada at Reno. He is the distinguished founder of the Nicholas A. Cummings Doctor of Behavioral Health Program at Arizona State University. Cummings is a past-president of the American Psychological Association. He was a member of the 82nd Airborne Division and jumped into France a dozen times, the last one he was so severely injured he was passed over by the trauma team who considered him dead. He recovered, left the service, and entered the University of California at Berkley. He completed his doctorate in clinical psychology at Adelphi University. In the late 1950's he replaced Timothy Leary as Director of Psychology at Kaiser Permanente in San Francisco, California.

He was a consultant on the Mental Heath Commission for both President Kennedy and President Carter. In addition he served as a consultant to the Health, Education, and Welfare (now Department of Health and Human Services), the U.S. Subcommittee on Health, and the U.S. Finance Committee. He has been a practicing psychotherapist, an educator, a consultant, a writer, an author, an administrator, and an entrepreneur. He has been the President of the American Psychological Association, on the board for the National Alliance of Professional Psychology Providers, and founded a non-profit foundation to recognize quality health care providers, leaders, and administrators, and he founded four professional psychology schools in California.

He is well versed in the business side of therapy as no other person before him and perhaps since. Cummings firmly believes that mental health providers need to join their medical colleagues in bonding together to support political action committees that can push the health care agenda in Congress. He has urged mental health providers to become more aware of the political arena and how it operates, and the need for mental health providers to become activists for their profession. Cummings wrote and implemented the first comprehensive prepaid psychological benefits. Additionally, he conducted research demonstrating that the medical costs saved by psychological services more than offset the cost of the behavioral interventions. He also wrote the legislation in six states mandating reimbursement for psychological services if psychiatric services were covered. Cummings founded American Biodyne as an alternative model to managed care of mental health services. This model served to control costs by providing focused, efficient psychotherapy by highly trained providers, and 15% of all practitioners' time was devoted to clinical case conferencing and other quality control measures. When he sold Biodyne in 1990 his company covered over 14 million lives.

A new system of delivery for mental health services

The Biodyne Model of Integrated Behavioral Health was built within the practice of medicine to work side-by-side with physicians of all specialties in ferreting out neurological and mental health disorders and then making recommendations for treatment. Many therapists integrate with their medical colleagues now to enhance medical diagnosis and treatment in communities. Cummings created the Biodyne Model to work within a hospital setting, as well as in community clinics that house different specialties of care. This model for delivery suggests that psychologists be in the ER and hospital and clinics to assist physicians in a similar role as nurses who offer support to triage and integration with hospital and clinical services.

The Biodyne Model refers to the method of conducting therapy using techniques meant to facilitate rapid connection with the patient's issues that have implications for how to approach the problem and suggest a treatment. This method is referred to as Focused Psychotherapy throughout the Life Cycle (Cummings and Sayama (1995). The goal of this approach is to work on one issue at a time over a short period of time. This approach is similar to the way physicians operate during an office visit. The patient comes in with symptoms of a problem, the doctor assesses, offers a diagnosis, and sometimes offers a treatment plan (referral and/or medication). Later the patient returns with a new set of symptoms and the process is repeated. PCPs seldom spend more than 10 minutes with a patient and can see up to 60 patients a day, depending on location and staff support.

In the Biodyne Model, when the psychologist receives the referral the patient is seen briefly (15-20 minutes) in the hallway, ER, or in the doctor office, which is used to motivate the patient to return for a full 45 minute session. The psychologist consults with the primary care physician (PCP) or referring physician and shares the results of the assessment with recommendation. At that point several choices for disposition are available:

* 85%-90% of the hallway hand-off patients would return for focused psychotherapy, usually 3 to 6 sessions, and more if needed. This contrasts with 20% who follow through on a traditional PCP referral.

* Long term would be referred on to regular practice psychotherapy. This could range from 20% to 40% of the patients, depending upon how extensive the program was needed.

* Refer the patient back to the PCP for medical/medication evaluation/treatment. With such immediate and effective intervention, only 10% of the patients had to be referred back to the PCP for psychotropic medication.

* Cummings argues that when psychotherapists work with primary care physicians there will be a 40% to 60% reduction of medical costs that had resulted from patients reflecting emotional problems through physical symptoms that mimicked actual physical diseases. The savings from the quick decrease of symptoms exceeds the cost of psychotherapy.

Dealing with Wall Street

In a recent phone conversation with Dr. Cummings the following questions were covered:

Q: It seems that we have company in our offices watching us do our work, critiquing our efforts and results, and overpowering us financially and politically. Is it possible to put up a firewall to protect ourselves?

Cummings: All healthcare professions need to stop fighting among themselves and unite against arbitrary and excessive regulations that actually impede practice. The National Association of Professional Psychology Providers (NAPPP) convened such a meeting in 2009 that included 14 of our national mental health societies (e.g.: social work, counseling, MFT, psychology, addictionology, etc.). The meeting was surprisingly successful as the 14 groups grasped the need and coalesced into a potentially effective force. However, by the second meeting 6 months later age old rivalries began to surface and the group fell apart, never to reconvene. Until we can put our internecine warfare aside and unite as an effective force, our practices will continue to be negatively impacted by well-meaning but excessive regulation.


Q: With the projected push for medical homes for the delivery process, is private practice, in any discipline, still a viable and relevant agent for health care delivery?

Cummings: The enactment of the Medical Home model has attracted a surprising number of adherents in a rapid amount of time. Yes, it will spread and impact our practices, but I believe the model has certain inherent flaws. First, it puts the PCP in charge of mental health delivery. Primary care physicians are already overloaded and do not have the time or resources to provide the direction and supervision required. Secondly, PCPs lack the training in mental healthcare that this leadership will require. And finally, PCPs have already demonstrated the overwhelming propensity to prescribe psychotropic medications rather than refer the patient for psychotherapy. As will be seen, patients who need and want psychotherapy will have to seek it out, something that will become even more difficult because of reimbursement issues that will become even more complicated for someone wanting to go outside the system.

Q: Tell us about the success the graduates from the Arizona State University are having now that they have been trained in the business of psychology?

Cummings: Entrepreneurship and management are integral parts of the Nicholas A. Cummings Doctor of Behavioral Health Program at Arizona State University, which includes intensive training in focused intermittent psychotherapy. In the beginning the students are enthusiastic about the clinical training, but remain skeptical about the "business" aspect. Soon, however, they enthusiastically espouse the entrepreneurship training and overwhelmingly it becomes the focus of their culminating project which replaces the traditional doctoral dissertation. We have graduated our first class of 58. Most complete the program in two years, but some complete it in 18 months by going through the summer. Within a very short period following graduation, and some even before graduation, graduates were snapped up by everything from hospitals, clinics, public health, and the military to very successful advanced positions. The DBH Program accepts only licensed practitioners on the MA-level with no less than 5 to 7 years of practice experience. With the growth and development of the health care industry come hard lessons that many see as threatening to our practice. Before those in private practice jump ship, spend time finding out how the current third party payers have opportunities that can meet some of your needs, such as groups of providers in a network under one umbrella. The home care program does not necessarily mean we go to the homes. What it can mean is that the group or the practice can become part of a provider network for a population or area/region of your state. While there is much to be concerned about, there are possibilities that are developing for the next wave of mental health providers that is still in its infancy. By becoming activists for change, by attending yearly conventions, and by developing more contacts for support and resources, we become part of the movement rather than part of the consequences.


Cummings makes the following recommendations for those contemplating entering the mental health field. When making your plans, consider these reflections:

* Hard won accomplishments are not achieved over a short period of time; it can take years and can cost a lot of money.

* When psychotherapists work with primary care physicians there will be far greater costs for medical services than for mental health. The savings from such a joint venture can be greater than the costs of psychotherapy.

* Visualize a business.

* The entrepreneur is a visionary who creates a business.

* Providers need to be passionate about their work.

* Discipline is the key as the commitment to reach a goal takes tremendous energy and time.

* Entrepreneurs are always expanding their knowledge of investments, inventory and risks and how to be prepared for an opportunity.

Do not chase every opportunity, do not take unnecessary risks.

* Focus on the goal line and do not let anything stand in your way. Like in sports, you need to finish the game, or project, without deviating or procrastinating.

* Allow your energy to be contagious with everyone on your team or in your office.

* Study other disciplines and how they approach decision-making and strategizing with different scenarios.

* Work off a "to-do list." Dr. Cummings calls it his "red line" method.

* Exercise--just like you encourage your patients to do, and for the same reasons, as our bodies wear out. Exercise and getting quality sleep is needed to rejuvenate the body and the mind (Thomas, Cummings, O'Donahue, 2002).

* Dr. Cummings promotes dressing professionally.

* Finally, always make your colleagues and staff members feel comfortable.


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By Ronald Hixson, PhD, LPC, LMFT, BCPC

RONALD HIXSON, PhD, LPC, LMFT, BCPC, is a licensed psychotherapist in private practice on the Texas-Mexico border. His background includes 10 years in the military mental health field (substance abuse, crisis center, community mental health, and teaching), and for the past 23 years, he has worked in an inpatient psychiatric hospital, a biofeedback outpatient clinic, an outpatient group practice, and then in private practice. His graduate degrees are in communication studies, psychology, business management, and health care administration. He has been a regular columnist for Annals, the quarterly journal for the American Psychotherapy Association, for the past seven years. He has served as chairman, Board of Professional Counselors, the Executive Advisory Board for the American Psychotherapy Association and is a board member of the American Mental Health Alliance. He is a trained hypnotherapist and a licensed sex offender treatment provider in Texas.
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