Objective: The authors compared data from psychiatrists and psychologists in California to determine whether long-standing differences in clinical practice remain after the introduction of managed care and other changes in mental service delivery. Methods: Responses from practicing clinicians in California who participated in the 1998 National Survey of Psychiatric Practice and the 2000 California Survey of Psychological Practice were compared on items related to patient caseload, practice profile, and insurance or reimbursement arrangements. Results: Data from 97 psychiatrists and 395 psychologists were available for the study. Psychiatrists reported spending more hours on most aspects of practice and working more total hours per week than psychologists. The weekly caseloads reported by psychiatrists included a greater percentage of persons treated for psychotic conditions than did the caseloads of psychologists. Psychologists reported that their weekly caseloads included a greater percentage of persons treated for anxiety disorders, personality disorders, and other disorders. Psychiatrists reported receiving a greater average payment for services from public insurance, and psychologists reported treating a greater average percentage of patients who did not have insurance coverage. Significant differences in income sources and fee arrangements were observed, and the net reported income of psychiatrists was nearly 80 percent greater than that of psychologists. Conclusions: Long-standing differences in clinical practice patterns remain between psychiatrists and psychologists despite managed care staffing arrangements and treatment strategies that streamline the practices of both provider groups. The significant income and wage differences between psychiatrists and psychologists may be partly due to supply dynamics of the mental health workforce that adversely affect psychologists. (Psychiatric Services 53:977- 983,2002)
Psychiatrists and psychologists represent two of the largest groups of clinicians providing mental health services (1). They provide specialized mental health treatment services and are reimbursed for these services through financing mechanisms not available to other providers (2). Nearly 70 percent of total outpatient specialty mental health ex-penditures in the 1980s were for psychiahists and psychologists (3,4).
Important differences in clinical practice exist between psychiatrists and psychologists. Psychiabists are licensed to prescribe medications, whereas psychologists generally are not. Psychologists conduct psychological and neuropsychological testing, the results of which are used in clinical settings for differential diagnosis and treatment planning and in judicial proceedings to award benefits, decide placements, or issue verdicts. Differences in the relative importance ascribed to biological, psychological, and social determinants of mental disorders have also been found between these provider groups (5). Research conducted in the 1980s and the early 1990s documented additional differences between psychiatrists and psychologists. Psychiatrists' patients were found to have more functional limitations and to receive more diagnoses of severe mental disorders than psychologists' patients (6). Psychologists were found to treat a clientele that was, on average, younger, more educated, and more likely to be employed (.3,6).
These studies were undertaken before mental health financing and delivery was dominated by managed care delivery systems. In the past decade, psychiatry and psychology practices have undergone dramatic restructering. Successive implementation of new benefits, authorization, and reimbursement schedules have reduced the duration of inpatient treatments and the scope and duration of outpatient psychotherapy and concurrently have increased medication management visits (7-10). Reductions have also been observed in the use of both psychiatrists and psychologists in health maintenance organizations (HMOs) and the use in carve-out firms of distinct patterns of referral to both provider groups on the basis of patient diagnoses (11,12). National survey data from psychiatrists provide indirect evidence that these changes in clinical practice may be unevenly distributed by providers' age, expelience, and gender (13,14).
At the same time, annual salary surveys conducted among psychologists have shown that a majority attribute reductions in yearly income to managed care (15). To date, no comparative study has assessed whether previous differences in clinical practice remain, or the extent of service diversification within these provider groups in the aftermath of changes in financing, organization, and treatment provision. These comparative data would illustrate how each provider group has responded to changes in the mental health care delivery system.
In this study we compared the clinical practices of psychiatrists and psychologists in California on a series of practice profile, patient caseload, and financing dimensions. Demographic characteristics and characteristics of the health care market in California make examination of provider groups in that state of particular relevance. First, in 1999 California ranked 13th in terms of the percentage of persons with four or more years of college education and 17th in median family income, factors that have been shown to significantIy influence the use of mental health services 05-18). These data suggest that the use of mental health services in California may not differentially influence the caseloads of psychiatrists and psychologists relative to those of providers in other states.
Second, California has one of the highest HMO concentrations in the nation; 50 percent of its eligible and insured population are covered under various HMO arrangements (19,20). Given the dominance of managed care, this pattern of HMO penetration may reflect future national trends. Finally, the California health care market includes a high proportion of both psychiatrists and psychologists per 100,00 population (21,22). A comparison of these provider groups may yield further evidence of how workforce supply dynamics differentially affect treatment patterns, workloads, wages, and income.
David P. Pingitore, PhD, ABPP, has over 30 years of experience in Professional Psychology as an administrator, faculty, researcher and clinician. Dr. Pingitore is Board Certified in Clinical Psychology through the American Board of Professional Psychology. Licensed to practice in California, Hawaii, and Nevada, Dr. Pingitore has conducted over 200 forensic psychological and neuropsychological assessments for the civil and criminal arenas. He has served as a consultative examiner for the Social Security Administration for over 20 years and was a member of the medical staff of two community hospitals during his professional career.
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