Dilemmas of Funding Predoctoral Internship Programs in Community Health Settings

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Dilemmas of Funding Predoctoral Internship
Programs in Community Health Settings

• Eugene J. DAngelo, PhD, ABPP
• Childrens Hospital /Harvard Medical School
• Boston, MA

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The opinions expressed in this presentation are
the sole responsibility of the presenter and do
not represent the position of the Board of
Directors for the Association of Psychology
Postdoctoral and Internship Centers (APPIC) or
its member organizations.
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Outline of Presentation

• Example of the Problem Match positions and the
  Massachusetts experience
• Determining the costs for internship training
  The challenge for agencies
• Advocacy strategies Challenges in creating an
  agenda for SPTA and national initiatives
  regarding training

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Psychology Internship Training Aspires to be of
Highest Quality
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• As part of the profession, internship training
  programs aspire to provide
• A range of quality clinical experiences
• Supervision
• Didactic programming that focuses on both skills
  and professional experiences
• Thoughtful assessment of intern competencies
• Professional mentorship

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Carl Rogers and Psychology Internships (1939)
That the internship should be a prerequisite to
the doctors degree just as much as certain
course requirements or the completion of a
definite research. (p.143) Rogers, C.R. (1939)
Needed emphasis in the training of clinical
psychologists. Journal of Consulting Psychology,
3, 141-143.
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The Harsh Realities of Funding to Maintain
Program Viability
Show me the money!!
Jerry McGuire, 1996
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The Challenge is to Balance Economic Viability of
Internship Programs with the Need to Maintain
Quality Training Experiences
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Whose Responsibility Is It To Pay For Internship
Training?

• Academic Programs?
• Insurance Companies?
• Internship settings?
• Federal Government?
• Interns?
• Consumers?

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What is a Community Health Setting?

• Community-focused programs that are
  service-oriented and do not have, as their
  primary mission, professional education. Funding
  relies primarily on clinical revenues.
• Community Mental Health Center
• Nonprofit Community Clinic
• Community Health Center
• Child and Family Guidance Center
• Community-based, Non-teaching Hospital

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APPIC Member Positions Available in the
Predoctoral Internship Match The Massachusetts
Experience

• Year Number of Match Positions
• 148
• 2000
  113
• 2008
  108

Sources APPIC Directories 1994, 2000, 2008 and
Okun,B. (2000). Training transformations. MPA
Quarterly, 44 (2-3), 17-20.
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The Massachusetts Experience Sources of Loss
33 out of 40 (82.5) Match positions lost between
1994 and 2008 were from Community Health Settings
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Community Health Settings Typically Survive Off
of Direct Service Revenues as a Major Source of
Income
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The Challenge Quality Internship Training Costs
Money
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A Quick Review Determining the Cost of
Internship Training
Fixed costs of internship training Loss/gains for
both clinical service delivery and
reimbursement The role of non-revenue funds that
may offset costs in internships found in
community health settings
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Estimating the Fixed Costs of Internship Training

• Intern salaries and benefits
• Program expenses (training staff, costs of
  supervision, teaching seminars, meetings with
  interns, career counseling)
• Administrative support
• Office space and building expenses (office
  furniture, rental of space, utilities, parking,
  etc)
• Instruments/materials used by interns (assessment
  equipment, books, etc.)

After Klein, D Nicholson, I (2006). Costs of
predoctoral clinical psychology internship
training in a Canadian health care setting.
Canadian Psychology/Psychologie Canadienne, 47,
333-342.
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Financial Balance Sheet for Internship Programs
Are Influenced by

• Number of hours from staff schedules redirected
  to supervision
• Amount of time staff are released from clinical
  responsibilities to teach seminars
• Number of direct service hours required by agency
  to be provided by both staff and trainees
• Schauble, P., Murphy, M, Cover-Paterson, C,
  Archer, J (1989). Cost effectiveness of
  internship training programs Clinical service
  delivery through training. Professional
  Psychology, 20, 17-22.

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The Bottom Line Impact of Training on Clinical
Productivity

• To what extent does a centers participation in
  internship training reduce staff clinical
  revenues/service delivery?
• Can interns generate sufficient revenue/services
  to offset the loss of revenues/services for staff
  who participate in internship training?

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Direct Clinical Service Funding for All Types of
Internship Programs

• Range 0 to 100

Source 2008 APPIC Survey
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The Importance of Non-service Revenues for
Training Programs

• Service contracts with community agencies (e.g.,
  school systems, court systems, etc.)
• Contracts with departments in community hospitals
  to provide consultative services
• Community service grants (Federal, state, and
  local)

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The Calculated Risk of Internship Training

• (Intern revenues non-clinical revenue income) -
  (Fixed costs of training loss of staff
  revenues) Internship Program Financial
  Viability

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The Dilemma of Direct Service Reimbursement for
Clinical Services Provided By Psychology Interns
in Community Health Settings
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Community Health Care Settings, Managed Care, and
Reimbursement for Services

• Managed Care reimbursement is typically
  available for clinical services provided by
  licensed staff members who meet specific
  eligibility requirements for providership.
• Psychology interns do not meet eligibility
  criteria for providership.

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Expectations of Managed Care Entities (MCE)
Regarding Providership

• Provider meets criteria of the National Committee
  for Quality Assurance (NCQA) in order for MCE to
  Maintain Accreditation
• Licensed professional
• Minimum number of years of clinical experience
• Employee of the community health setting (W-2)
• Willingness to abide by contractual arrangements
  of the managed care entity
• Fee schedules
• Outcomes assessment

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The Need to Prepare the Next Generation of Mental
Health Professionals to Work with Managed Care
An Example
It is estimated that it takes physicians
approximately two years after their residency to
become sufficiently skilled to work within a
managed care environment.
Blumenthal, D. (1996). Managed care and medical
education (editorial). JAMA, 276, 725-727.
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The Fiscal Challenge

• How to establish a process of reimbursement for
  internship clinical services that is fair and
  provides some basis for a community health
  setting to consider developing an internship
  training program?

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Political Action Initiatives State, Provincial,
and Territorial Psychological Associations
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All politics is local

• Thomas P. Tip ONeill
• (D-Massachusetts)
• 55th Speaker of the House of Representatives

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The SPTA Challenge to Develop a Policy Strategy
for Funding Initiatives

• State, provincial, and territorial psychological
  associations (SPTA) have espoused an ongoing
  commitment to support advocacy regarding funding
  to sustain psychology internship programs.
• However, it is important to recognize that it is
  difficult to develop a comprehensive advocacy
  strategy that would result in support for a wide
  array of internship programs because funding is
  often contingent on the setting in which the
  program resides.
• As such, a single approach may not exist to
  identify funding streams to support internship
  training.

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General Considerations When Generating A
Strategy to Influence Policy

• Recognition that there is no quick solution
• Acknowledgment that the solution may need to
  occur in steps
• Know who the stakeholders are and what they value
• Identify what needs to be kept the same versus
  can be changed to keep stakeholders happy
• Realize who might be in the best position to
  offer a compromise

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Possible SPTA Efforts Regarding Internship
Funding and Development

• Legal analysis of the NCQA standards and provider
  contract requirements for agencies (versus
  private providers) may need to be undertaken to
  determine possible alternative interpretations
  for existing regulations about providership
• Speak directly with MCE representatives and, as a
  beginning strategy, focus may need to be placed
  on various forms of recognized standards for
  internship training that can be used as initial
  credentialing criteria for internship settings
• Access to care is not MCEs major emphasis, it is
  clinical outcomesdata needs to be generated
  demonstrating that an interns providing
  supervised clinical care in a particular agency
  has outcomes comparable to a licensed provider
• Work to have the Psychology practice and
  educational communities need to genuine
  collaborate on these issues of Match imbalance.
• State agencies (e.g., Department of Mental
  Health) should be made aware of state/territorial
  internship placement problems that may adversely
  affect the professional workforcestate pressure
  on MCEs for increasing their responsibilities in
  this domain
• Create mentoring opportunities for programs
  considering internship training to work to meet
  recognized standards for training
• Attempt to increase focus for GPE funding towards
  community training programs

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What Community Health Settings May Need to
Consider

• Evaluate why your program wants to develop an
  internship
• Determine what the true costs of an internship
  training program will be at your setting
• Identify sources of non-clinical revenues to
  support your internship
• Assess to what extent your setting can meet the
  nationally recognized training criteria for the
  program (e.g., APA accreditation, APPIC
  membership)get assistance in trying to meet
  these criteria through mentoring relationships
• Evaluate and report the clinical outcomes for the
  services provided by your interns
• Consider models of training that emphasize
  efficiency of training while not compromising
  quality

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Partners in a Common Effort

• Success will most likely be realized through the
  partnership between SPTAs as local advocates for
  internship programs and those agencies who aspire
  to provide this important training opportunity.

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National Initiatives
GPE funding should expand for use by Community
Health Settings. National level effort to promote
reimbursement for supervised trainee services by
MCEs. Continued support for the Education
Directorate and their advocacy initiatives. Take
advantage of federal funding for community health
centers.
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Jerry McGuire Gets the Last Word
A positive anything is better than a negative
nothing!!
Presented at the 2009 APPIC Membership Meeting
and Conference Portland, OR, April 18, 2008