Journal of Personality Assessment

ISSN: 0022-3891 (Print) 1532-7752 (Online) Journal homepage: http://www.tandfonline.com/loi/hjpa20

The Impact of Managed Care on the Practice of

Psychological Testing: Preliminary Findings

Chris Piotrowski , Ronald W. Belter & John W. Keller

To cite this article: Chris Piotrowski , Ronald W. Belter & John W. Keller (1998) The Impact
of Managed Care on the Practice of Psychological Testing: Preliminary Findings, Journal of
Personality Assessment, 70:3, 441-447, DOI: 10.1207/s15327752jpa7003_4

To link to this article: https://doi.org/10.1207/s15327752jpa7003_4

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JOURNAL OF PERSONALITY ASSESSMENT, 1998,70(3),441-447
Copyright O 1998,Lawrence Erlbaum Associates, Inc.

The Impact of "Managed Care" on the

Practice of Psychological Testing:
Preliminary Findings
Chris Piotrowski, Ronald W. Belter, and John W. Keller
Department of Psychology
University of West Florida

Although the impact of managed care constraints on assessment practices has re-
ceived recent attention, areview of the literature found no data-based articles that d-
dress this issue. We report survey data on 137 members of the National Register of
Health Service Providers in Psychology (Council for the National Register of Health
Service Providers in Psychology, 1996) on current testing practices. The majority
(72%) reported that their use of tests has changed in the last 5 years due to managed
care directives. These clinicians are doing less testing overall and restrict their pool of
assessment instruments. The Rorschach inkblot technique (Rorschach, 1942), the
Thematic Apperception Test (Murray, 1943), and the Wechsler Intelligence scales
(Matarazzo, 1972) were the instruments most noted for disuse. Apparently, practitio-
ners are relying more on short, brief self-report measures that tap targeted symptoms
or problem areas, and less on tests that demand considerable clinicians' time. Implica-
tions and limitations of the findings are discussed.

Over the past decade, managed health care has undoubtedly had a profound ef-
fect on the mental health field (Dana, Conner, & Allen, 1996). The managed
care model of capitation has severely restricted a wide range of services to cli-
ents, including psychological testing and assessment (Backlar, 1996; Miller,
1996). This devaluation of clinical assessment has had a deleterious impact on
psychological assessors and the assessment field in general. However, published
views of this issue have been scant. Acklin (1996) argued that the impact of
managed care on psychological testing is quite negative for both patients and
providers of professional mental health services; outright denials for
preauthorization of assessment or various testing instruments, coupled with a re-
duction in reimbursement, are undeniable threats to practicing psychologists. In
442 PIOTROWSKI, BELTER, KELLER

fact, Cerney (1994) expressed a grave concern for the viability of the assessment
field under managed care constraints.
In this regard, the future of clinical assessment is, perhaps, best summarized in
the views of Butcher and Rouse (1996):

In one respect, clinical assessment, because of its relatively low cost and objective
methods, appears to fit well in managed-caredelivery. On the other hand, in an era of
shrinking funds available for mental-health services, psychological assessment may
be eliminated from the health-care loop unless assessment psychologists can docu-
ment that psychological testing provides treatment-relevant and cost-effectiveinfor-
mation and is relevant and valid for treatment planning. (p. 101)

To date, there is a dearth of data-based studies on the issue of managed care and
psychological testing. Thus, we took the initiative to conduct a survey on how the
managed care environment has affected the assessment practices of clinicians. We
hope the findings will generate investigative efforts so as to obtain a realistic ap-
praisal of the impact of managed care on assessment practice.

METHOD

The sample for this study was obtained from the 1996 directory of the National
Register of Health Service Providers in Psychology (Council for the National Reg-
ister of Health Service Providers in Psychology, 1996). A random listing of 500
psychologists was obtained. We constructed a 12-item questionnaire that focused
on demographic data, several inquires on the use or lack of use of testing instru-
ments, and several open-ended questions on how managed care has affected the
testing practices of clinicians. The survey form was sent to the 500 potential re-
spondents during Fall 1996.
Of these 500 psychologists, 137 returned surveys complete with scorable data,
38 returned surveys indicating that they do not or have not done testing in the past,
and 25 surveys were returned as undeliverable by the postal service. Thus, our ad-
justed rate of response was 32%.

Profile of Respondents

Of the 137respondents on whom the results were based, 98 (72%) were men and 39
(28%) were women. Of the 134 individuals who responded to this item, 62 (46%)
had been in practice for 20 years or more, 54 (40%) had been in practice between 10
and 19 years, and 18 (13%) reported 9 or less years in practice. Of these respon-
dents, 100 (75%) consideredthemselves full time and 28 (21%) reported their prac-
tice as part time. The primary occupational settings for the sample were independ-
ent practice (73%; n = loo), outpatient clinics (9%; n = 13), hospital-medical
 MANAGED CARE 443

centers (9%; n = 12), inpatient psychiatric centers (4%; n = 51, HMO (1%; n = 2),
and unspecified (4%; n = 5).

RESULTS AND DISCUSSION

Readers are referred to Table 1for survey questions on which the results are based.
The data fromthis survey clearly indicatethat managed care has affected themanner
in which most psychologistsuse psychological tests. When askedif their use of tests
has changed in the past 5 years due to managed care, 72% (n = 97) responded "yes."
The majority of these respondents indicated that the change in testing practice in-
volved either doing less testing, using fewer tests, or both (75%, n = 73). Another
14% (n = 14) made specific reference to lower rates of reimbursement and approval
of charges fortesting,but only impliedthat they had reduced their testing activity as a
result. Three others reported that they no longer do psychological testing.
Among the psychologists who claimed to be affected by managed care, a sub-
stantial proportion (35%, n = 34) indicated that they continue to use the same type
of psychological tests, but do so less frequently or in shorter test batteries. Others,
who reported a change in type of test used (41%; n = 40), indicated a decrease in
their use of projective tests, IQ tests, and other tests that require significant invest-
ment of clinician time. These respondents reported using other measures that are
more brief and easier to score (e.g., Beck Depression Inventory; Beck, Steer, &
Garbin, 1988), thus requiring less clinician time. The remaining 24% (n = 23) ei-
ther left this item blank or included comments that were not specific to type of test
used.
Among the 28% (n = 38) of psychologists who iindicated that managed care has
not affected their use of psychological tests, a variety of reasons may account for
the lack of impact. A small proportion of these respondents (16%; n = 6) indicated
that they did little psychological testing previously. Another 18% (n = 7) reported
that they work in an institutional setting in which thleir testing activities are not im-
pacted by reimbursement issues. A large number (40%; n = 15) reported that their
previous use of tests was limited to specific objective tests (e.g., Minnesota

TABLE 1
Survey Questions on Which the Results are Based

As a result of managed care, has your use of psychological tests changed in the past 5 years? Yes or
No? If yes, how?
Are the kind of tests you currently rely on different due to managed care? Yes or No? If yes, how?
List up to four psychological test instruments that are most important in your current practice.
List up to four psychologicaltest instxuments you no longer use due to managed care constraints.
What is the major positive impact of managed care on your use of psychological testing?
What is the major negative impact of managed care on your use of psychoiogical testing?
444 PIOTROWSKI, BELTER, KELLER

Multiphasic Personality Inventory-2; Butcher, Dahlstrom, Graham, Tellegen, &

Kaemmer, 1989) that some managed care organizations continued to authorize for
payment. A small number (13%; n = 5 ) reported that they retained their usual test-
ing practices, but simply absorb the lost income due to reduced reimbursement, or
that they avoid managed care patients altogether.
Respondents were asked to list up to four tests "that are most important in your
current practice" and up to four tests "you no longer use due to managed care con-
straints." Frequency of current use and disuse of various tests identified by respon-
dents are presented in Table 2. These data shouldbe interpretedcautiously, as many
respondentseither did not respond to this query orlistedless than four instruments.
It is interesting to note that the five tests most frequently identified as "no lon-
ger used" by respondents were also the five tests identified as being "most impor-
tant'' in current practice. Moreover, these instruments were found to be among the
most frequently used tests in the past (Archer, Maruish, Imhof, & Piotrowski,
1991; Frauenhoffer, Ross, Gfeller, Searight, & Piotrowski, 1998; Piotrowski &
Keller, 1992). Apparently, many assessors continue to value these instruments, but
are not able to implement these measures as part of a patient's evaluation due to
managed care constraints. Perhaps clinicians limit their use of these tests in situa-
tions in which reimbursement is not an issue, such as private payers or in forensic

TABLE 2
Number of Respondents Who Consider Test Most Important to Current
Practice and Tests No Longer Used

Current Most
Important No Longer Used

Instrument N % N %

MMPVMMPI-2h4MPI-A 89 65 13 9
WAIS-IUWISC-III 85 62 25 18
Rorschach 46 33 27 20
Millon Inventories 29 21 7 5
TAT 21 15 26 19
Beck Depression Inventory 20 14 >5 -
Wechsler Memory Scale-R 15 11 25 -
WRAT-R 12 9 >5 -
Neuropsychological batteries 11 8 6 4
Achenbach CBCL 9 6 >5 -
Bender-Gestalt 8 6 6 4
Human Figure Drawings 8 6 5 4
Symptom Checklist-9KR 8 6 >5 -
Note. Data based on total sample (n = 137).MMPI = MinnesotaMultiphasic Personality Inventory;
WAIS = WechslerAdult Intelligence Scale;TAT =Thematic ApperceptionTest;WRAT =Wide Range
Achievement Test; CBCL = Child Behavior Checklist; R = Revised.
 MANAGED CARE 445

assessment. These data are not contradictory, but reflect the complex pattern of re-
actions by psychologists to managed care in their use of psychological tests.
When asked to identify the major positive impact of managed care on their
practice, 61% of the total sample (n = 83) simply responded "none," indicating a
substantial majority could find nothing positive about the impact of managed
care on their use of psychological testing. An additional 15% (n = 20) left this
item blank. Nineteen respondents (14%) gave responses indicating that better
quality of clinical care, such as more effkient selection of tests, was a positive
impact of managed care. Another 4% (n = 6 ) cited lower cost to the client as an-
other positive impact.
When asked to identify the major negative impact of managed care on their as-
sessment practice, 51% of the total sample (n = 70)identified issues that related to
a decrement in the quality of care provided to patients, such as unavailability of
testing, and either inadequate or inaccurate assessment or both. Another 19%(n =
26) identified issues of negative impact on clinicians, such as decreased income
and increased administrative hassles. The remaining 30% (n =r 42) provided re-
sponses that were incomplete or could not be categorized.
In summary, it seems clear that the majority of psychologists responding to this
survey felt strongly that managed care constraints have negatively affected the use
of psychological tests in clinical practice. Accordingly, the response of most of the
respondents has been to (a) continue to use the same type of tests previously used,
but to do less testing or (b) do less resting, but also discard more time-consuming
tests such as projectives, IQ tests, and personality inventories, in favor of brief,
easily scored, self-report measures and checklists. On the other hand, there also ap-
pears to be a small minority of clinicians who are steadfastly maintaining their pre-
vious practices, despite reduced reimbursement and increased administrative
demands of managed care organizations to authorized payment.
There are some limitations to our findings. First, the response rate was lower
than previous surveys on testing practices. Second, our sample represented a heter-
ogeneous group of practicing psychologists. Thus, generalization of these findings
is restricted to an unknown degree and is not comprehensive enough to draw deter-
minative conclusions. Future research in this area would benefit by surveying
other sectors of the clinical psychology and personality assessment community.

IMPLICATIONS

Undoubtedly,economicreality will dictate, to a large extent, changes in psycholog-

ical assessment practices, particularly the amount of time that psychologists may
responsibly devote to assessment activities.The findings of this survey suggest that
evaluation of patients, in the near future, will focus more on testing rather than com-
prehensive assessment. That is, a clinician's selection of tests or assessment instru-
ments will, most probably, focus on targeted symptoms or psychological states
(e.g., anxiety, depression, hostility), as opposed to personality dynamics or
intrapsychic processes. Moreover, assessment proponents find themselves on the
horns of an ethical dilemma: whether to restrict the collection of potentially useful
clinical data as dictated by managed care constraints, or to base an individual's as-
sessment needs ahead of reimbursement concerns. Although the impact of man-
aged care directives on the field of psychological assessment appears to be rather
ominous,just how will practicing psychologists adapt to the situation?
We propose the following possibilities. Many clinicians will: fa) dispense with
testing altogether or refer out for assessment needs to psychologists with an assess-
ment-only practice (see Acklin, 1996); (b) have an abbreviated assessment proto-
col for managed care clients, yet offer full assessment on a fee-for-service basis;
(c) increase use of automated testing services and computer-administered assess-
ment tools; (d) increase the use of brief, symptom-focused instruments; and (e)
change focus of practice from client based to consultation based, such as forensic
or organizational assessment. It seems that assessment practices of the future will
be quite different than in the past.

REFERENCES
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 MANAGED CARE 447

Murray,H. A. (1943). ThematicApperception Test manual. Cambridge,MA: Harvard University Press.

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Chris Piotrowski
Department of Psychology
University of West Florida
1 1000 University Parkway
Pensacola, FL 325 14-575 1

Received February 24, 1997

Revised October 3 1. 1997