In the early 1990s there were many predictions that the solo practice
of
psychology was dead, and the future belonged to managed care and
psychologists in large group practices. As managed care disrupted
the
delivery of mental health care, Cummings, Pallak, and Cummings (1996)
even
titled a book, Surviving the Demise of Solo Practice: Mental Health
Practitioners Prospering in the Era of Managed Care. Yet, as
the new
millennium begins, a different pattern is developing. The quality
of
services available in corporate health care has plummeted and consumers
are
increasingly rejecting managed care services in favor of self-paying
independent professionals. The emerging pattern is that the independent
practice of psychology, based primarily on self-payment, is growing
and
becoming the gold standard for quality mental health services.
Currently, self-pay clients comprise a large share of the psychotherapy
market. A reader’s survey by Psychotherapy Finances in 1997 found
that 44%
of their psychotherapist/reader's income came from direct payment from
patients (Fee, 1997). Practice Strategies reported in 1997 found
in a random
sample survey that 47% of therapist incomes came from direct pay patients
(Practice fees, 1997), 32% from managed care insurance, and 16% from
other
insurance. Although I believe that these estimates for self-pay
are high,
they demonstrate that there is a substantial self-pay market.
The Guild is based on the simple principle that consumers will self-pay
for
psychotherapy because it is a valuable service. I founded the
Guild in 1995,
and 56 local therapists agreed to contribute $65 monthly dues to a
marketing
organization that focused directly on reaching out to patients.
The
marketing emphasized the difference between traditional, confidential
psychotherapy and managed-care, ultrabrief psychotherapy. At
that time, such
a cooperative psychotherapy-marketing program was a new and untested
idea,
and it took several years to develop a successful strategy. Over
the first
three years, the membership declined from 57 to 47, but in the past
two years
has grown to 56 because the members are finding that the Guild
generates a
substantial number of referrals, and they support the principles the
Guild is
based on. Last year’s membership renewal rate was 94%, and we
gained ten new
members. Not only do the members support the philosophy of the
Guild, but
they also have seen enough referrals that they are willing to pay the
current
dues of $80 per month.
Boulder's Guild has been independently replicated in Connecticut, St.
Louis,
and Georgia. In addition, the Guild model is endorsed by the
American Mental
Health Alliance (AMHA), a not-for-profit, practitioner owned and directed,
multidisciplinary network of over 1500 mental health professionals
in 13
states. Dr. Charles Zadikow, President of AMHA-USA states that
"Developing
Guilds has become a high-priority initiative in at least 6 of the AMHA
chapters. From its beginnings, the goals of AMHA have included
the ethical
needs to protect the privacy and confidentiality of their clients,
to help
maintain their dignity and freedom of choice, as well as to assist
in
preserving what is best about their profession. AMHA believes
that the Guild
is a perfect vehicle for their requirements and, as a collaborative
marketing
effort, offers their practitioners a way to maintain integrity, to
build
their practices without managed care, and to help educate the public
about
the real value of psychotherapy."
Increasingly, consumers are self-paying for mental health services.
Some of
the Guild members have developed managed-care-free practices and others
are
expanding the portion of their practice that is managed-care-free.
In
addition, in the year 2000 the Guild is joining an Employee/Corporate
Wellness Program with medical professionals who are also marketing
directly
to consumers to increase their self-pay practices. At a time
when
professionals working with managed care are becoming more demoralized
and
experiencing declining incomes, the Guild is growing, morale is improving,
and many are reporting that their incomes are rising.
2. The Guild demonstrates the value of educating the public about the
benefits of psychotherapy. This affirms the cooperative marketing
work that
has been recommended by many of the leaders of Division 42 and conducted
by
the APA. By pooling the resources of many professionals, the
Guild has had a
major impact on the local community through dozens of newspaper articles,
advertising, free public presentations, direct mail to referral sources,
a
community newsletter, and an intensive distribution of its Directory.
The
Guild is showing that by educating consumers, many professionals can
have a
direct benefit on their practices.
3. There is enough money in the self-pay market to support many therapists
in
the community.
4. The developing self-pay clients are in three categories: some have
no
insurance, others prefer the choice and confidentiality that comes
from
foregoing their limited insurance benefits, and still others have tried
their
managed care therapy and been dissatisfied.
5. Mental health disciplines can benefit from joining together because
consumers want the choice of a full range of qualified professionals.
6. While the Guild does not solve the problem of the low-income patient
or
the seriously mentally ill patient who usually cannot afford the cost
of
therapy, it does preserve a standard for quality mental health care
that is
under the control of the patient. Hopefully, public pressure
will encourage
the managed care system and the public mental health system to strive
to
offer the same quality that self-pay patients can obtain.
7. Many professionals advocate responding to managed care through practice
diversification and leaving the traditional role of psychotherapy.
In
contrast, the Guild is succeeding by promoting traditional, client-focused
psychotherapy.
8. Managed care has removed the patient as the customer of their services,
and in place, it has declared that employers and the government are
their
customers. The Guild shows that the practice of psychotherapy
can succeed
when the patient is treated as the customer.
Employers are slashing behavioral health expenses. (1996) Psychotherapy
Finances, 22(10), 1.
Fee, Practice and Managed Care Survey. (1997). Psychotherapy
Finances,
23(5), 5.
Hay Group. (1998) Survey funded by the National Alliance for the
Mentally
Ill, the National Association of Psychiatric Health Systems, and the
Association of Behavioral Group Practices press release. 5/7/98.
Washington, DC.
Olfson, M. & Pincus, H. A. (1994). Outpatient psychotherapy
in the United
States, II: Patterns of utilization. American Journal of Psychiatry,
151,
1289-1294.
Practice fees, incomes and trends report. (1997). Practice Strategies,
3(12), 1.