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The Influence of Payment Method on Psychologists’ Diagnostic Decisions Regarding Minimally Impaired Clients

The Influence of Payment Method on Psychologists’ Diagnostic Decisions Regarding Minimally Impaired Clients

re psychotherapy clients who pay via health insurance more likely to receive Diagnostic

and Statistical Manual of Mental Disorders (4th ed. [DSM–IV], American

Psychiatric Association, 1994) diagnoses than identical clients who pay out of

pocket? Previous research (Kielbasa, Pomerantz, Krohn, & Sullivan, 2004) indicates

that when psychologists consider a mildly depressed or anxious client, payment

method significantly influences diagnostic decisions. This study extends the scope of

the previous study to include clients whose symptoms are even less severe. Independent

practitioners responded to vignettes of clients whose profiles deliberately included

subclinical impairment and a high level of functioning. Half of the participants

were told that the clients would pay via managed care; the other half were told

that the clients would pay out of pocket. As in the earlier study, payment method had

a highly significant impact on diagnosis such that relative to out-of-pocket clients,

managed care clients were much more likely to be assigned DSM–IV diagnoses. In

addition, a noteworthy percentage of participants assigned diagnoses regardless of

payment method. Ethical implications are discussed.

Keywords: diagnosis, managed care, independent psychotherapy practice, ethics,

payment

A recent study (Kielbasa, Pomerantz, Krohn, & Sullivan, 2004) found that the

method by which a private practice client pays for psychotherapy very significantly

influences both the likelihood that the psychologist will assign a diagnosis

and the specific diagnosis that the psychologist chooses. Specifically, when comETHICS

& BEHAVIOR, 16(3), 253–263

Copyright © 2006, Lawrence Erlbaum Associates, Inc.

Correspondence should be addressed to Andrew M. Pomerantz, Southern Illinois University

Edwardsville, Department of Psychology, Edwardsville IL 62026. E-mail: apomera@siue.edu

pared to identical clients paying out of pocket, clients paying via managed care

were much more likely to receive diagnoses and were more likely to receive adjustment

disorder diagnoses in particular. In the Kielbasa et al. (2004) study, the fictional

vignettes to which participants responded included mildly depressed and

anxious clients whose symptoms placed them very near the threshold for Axis 1

disorders in the Diagnostic and Statistical Manual of Mental Disorders (4th ed.

[DSM–IV], American Psychiatric Association [APA], 1994). The purpose of this

study was to replicate the Kielbasa et al. (2004) study using vignettes of clients

whose level of pathology was even less severe. In other words, when considering a

generally high functioning client whose symptoms may fall below the threshold

for any DSM–IV disorder, will psychologists be influenced by payment method

when making diagnostic decisions?

This study, as well as its predecessor (Kielbasa et al., 2004), stems from a growing

body of literature examining the effects of managed care and other forms of

third-party payment on the independent practice of psychology. This literature includes

numerous empirical surveys of practitioners regarding the impact of managed

care on their practices (e.g., Bell, 1999; Murphy, DeBernardo, & Shoemaker,

1998; Phelps, Eisman, & Kohout, 1998; Rothbaum, Bernstein, Haller, Phelps, &

Kohout, 1998), most of which have concluded that the impact has been quite negative.

In addition, the literature includes nonempirical commentaries on the impact

of managed care on psychotherapy (e.g., Karon, 1995; Miller, 1996), most of

which describe managed care as having a detrimental effect. However, diagnosis

has not been the primary focus of these surveys and commentaries. Instead, they

have focused primarily on the therapy process, and to a much more limited extent,

assessment techniques. Very few studies in this field have yielded conclusions regarding

diagnostic issues; these studies have found that independent practitioners

strongly believe that managed care influences psychologists to alter diagnoses to

ensure reimbursement and to protect confidentiality (Murphy et al., 1998) and that

accurate diagnosis in a managed care system is problematic for many mental

health counselors (Danziger & Welfel, 2001). Thus, with the exception of these

isolated studies and the Kielbasa et al. (2004) article, the impact of payment

method on specific diagnostic decisions made by clinicians has not been the focus

of empirical research, particularly for clients who present with mild or subthreshold

symptoms.

Kielbasa et al. (2004) considered numerous interpretations for the finding that

managed care clients are far more likely to receive diagnoses than out-of-pocket

clients, including the common requirement of a diagnosis by managed care companies

to justify reimbursement as described by Ackley (1997), Chambliss (2000),

and Kutchins and Kirk (1997), among others. Peck and Scheffler (2002) similarly

discuss “intentional upcoding,” by which clinicians exaggerate symptoms to increase

the chances or amount of reimbursement from third-party payers (p. 1094).

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