2. Dilemmas of Funding Predoctoral Internship Programs in Community Health Settings Eugene J. DAngelo, PhD, ABPP Childrens Hospital /Harvard Medical School Boston, MA

3. 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.

4. 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

5. Psychology Internship Training Aspires to be of Highest Quality

6. 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

7. 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.

8. Show me the money!! The Harsh Realities of Funding to Maintain Program Viability Jerry McGuire, 1996

9. The Challenge is to Balance Economic Viability of Internship Programs with the Need to Maintain Quality Training Experiences

10. Whose Responsibility Is It To Pay For Internship Training? Academic Programs? Insurance Companies? Internship settings? Federal Government? Interns? Consumers?

11. 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

12. The Massachusetts Experience APPIC Member Positions Available in the Predoctoral Internship Match: The Massachusetts Experience YearNumber of Match Positions 1994 148 2000 113 2008 108 Sources: APPIC Directories 1994, 2000, 2008 and Okun,B. (2000). Training transformations. MPA Quarterly, 44 (2-3), 17-20.

13. The Massachusetts Experience: Sources of Loss 33 out of 40 (82.5%) Match positions lost between 1994 and 2008 were from Community Health Settings

14. Community Health Settings Typically Survive Off of Direct Service Revenues as a Major Source of Income

15. The Challenge: Quality Internship Training Costs Money

16. 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

17. 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.

18. 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.

19. 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?

20. Direct Clinical Service Funding for All Types of Internship Programs Range: 0% to 100% Source: 2008 APPIC Survey

21. 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)

22. The Calculated Risk of Internship Training (Intern revenues + non-clinical revenue income) - (Fixed costs of training + loss of staff revenues) = Internship Program Financial Viability

23. The Dilemma of Direct Service Reimbursement for Clinical Services Provided By Psychology Interns in Community Health Settings

24. 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.

25. 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 o Fee schedules o Outcomes assessment

26. 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.

27. 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?

28. Political Action Initiatives: State, Provincial, and Territorial Psychological Associations

29. All politics is local Thomas P. Tip ONeill (D-Massachusetts) 55 th Speaker of the House of Representatives

30. 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.

31. 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

32. 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 outcomes…data 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 workforce…state 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

33. 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

34. 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.

35. 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.

36. A positive anything is better than a negative nothing!! Jerry McGuire Gets the Last Word…… Presented at the 2009 APPIC Membership Meeting and Conference Portland, OR, April 18, 2008