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Behavioral technology and hospital psychiatry: Considerations from the private sector
Analysisand Interventionin DevelopmentalDisabilities,Vol. 3, pp. 205-214, 1983 Printed in the USA. All rights reserved.
0270-4684/83 $3.00 + .00 Copyright© 1983 PergamonPress Ltd
Behavioral Technology and Hospital Psychiatry: Considerations from the Private Sector Gene Richard Moss Behavioral Medical Croup and University of Southern California
Contingencies operating in the health care industry can have direct effects upon applications of behavioral technology to the hospital treatment of psychiatric patients. Although to date behavioral technology has made little impact upon the general practice of psychiatry, shifting economic and political contingencies may favor the specificity, objectivity, and accountability of behavioral paradigms. Those qualified in program design and implementation may find an increasingly receptive audience among directors of private hospitals, both proprietary and non-profit.
Despite a history spanning two decades, clinical applications of behavioral technology largely have been ignored by psychiatrists. Even basic terms such as "behavioral technology," "behavior therapy," or "behavior modification" often are misunderstood by psychiatrists and other physicians alike. The majority of psychiatrists continue to practice predominantly from psychodynamic and pharmacological models. Perhaps a relative lack of training in behavioral technology during residency may have contributed to this indifference (Brady, 1973; Brady and Wienckowski, 1978). Ironically, recent advances in behavioral technology hold out promise as effective components of psychiatric treatment. By meeting explicit, operational criteria in utilizing biological and behavioral treatment procedures, psychiatrists can acquire scientific respectability by providing the kind of specificity, objectivity, and accountability increasingly demanded by their critics (Moss and Boren, 1971). Address reprint requests to Gene Richard Moss, M.D., 400 Newport Center Drive, Newport Beach, California 92660.
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CONTINGENCIES IN THE PRIVATE SECTOR Economic
The health care industry is a big business, accounting for almost ten percent of the gross national product of the United States. All businesses must show a profit to survive, and the health care industry is no exception. In the public sector, losses sustained through inadequate revenues are offset by governmental subsidy. In the private sector, profits are generated typically by fees for direct, patient care. Such fees may come from patients themselves or from third party payors such as insurance companies. Accordingly, a foremost consideration in the future utilization of behavioral technology in private facilities will be its economic impact. To promote the financial appeal of behavioral technology, behaviorists have proclaimed its relative cost-effectiveness (Foreyt, 1975). Such proclamations may have a paradoxical, adverse effect upon private, fee-for-service, health care facilities while favorably appealing to pre-paid, health care facilities. General hospitals, for example, generate revenues from a variety of sources, including daily room charge, facilities utilized (e.g., operating room), pharmacy, central supply, and ancillary services (e.g., laboratory, radiology, physical therapy, etc.). Psychiatric units generate revenues primarily from daily room charge. For medical/surgical units, the greatest revenues are generated within the first, several days of the hospital stay. Given a high level of utilization, medical/ surgical units generate a maximum profit from high turnover of patient census with relatively brief lengths-of-stay. For psychiatric units, revenues generated may co-vary directly with the average length-of-stay. Profit per patient/day actually may increase the longer a patient remains in the hospital. Thus, psychiatric programs that are particularly cost-effective may lead to decreased revenues and lower profits through briefer hospital stays. Increased utilization promoted through behavioral programs may be a far more effective inducement for psychiatric units in the fee-for-service, private sector than cost-effectiveness. Currently, there exists a surplus of hospital beds in many areas of the United States. This surplus results in under-utlization of some hospital facilites. A decreased, average length-of-stay through enhanced cost-effectiveness hardly is likely to exert strong, sales appeal to a hospital that already has too many empty beds. The possibility of increased utilization through program design, on the other hand, is far more likely to occasion a receptive response. If hospital programs based upon behavioral technology are more clinically effective than programs that are not, the layman as well as the professional must be made aware of this difference. Acceptance of behavioral technology by the private sector will come as a result of public and professional demand for effective methods, which then lead to increased utlization and profit. As long as the public
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and the psychiatric profession remain uninformed about the therapeutic benefits of behavioral technology, demand will remain low and acceptance within the private sector marginal.
Political Political contingencies in the private sector fall into several categories, including legal statutes, inter-disciplinary competition, and intra-disciplinary competiton. These political contingencies directly affect the type and quality of services delivered.
Legal statutes. Every hospital contends with a plethora of legal statutes and agency regulations on a federal, state and local level. The impact of these laws and regulations should not be underestimated. Clinical applications of behavioral technology have generated exceptional legal controversy and have come under special scrutiny (Goldiamond, 1975). Yet, laws and regulations vary from locality to locality in a manner that can be considered almost whimsical. Regulations regarding "clients' rights" are an example. Application of regulations to the psychiatric care of adolescents in private hospitals located in the County of Los Angeles versus those located in the adjacent County of Orange, for example, differs substantially. Hospitals located on one side of the county line may implement policies and procedures that would be considered illegal on the other. No hospital program politically or economically can afford to violate for long applicable laws and regulations. Designers of hospital programs based upon behavioral technology must take special care to ensure conformity with laws and regulations as interpreted by the local authorities. Interdisciplinary competition. Competition among "mental health professionals" seems to be assuming increasing intensity in the struggle for political power and an economic share of the market. Clinical psychologists have waged a rather successful battle not only for equal coverage with psychiatrists by third party payors but for equal voting and admitting privileges in hospitals. Some hospitals and many psychiatrists have opposed these efforts; other hospitals and a few psychiatrists have offered support. The political and economic consequences of giving psychologists equal status in hospitals could be destructive for physicians and especially for psychiatrists. Yet, it is well known that many psychologists but few psychiatrists are trained in applications of behavioral technology. Accordingly, the design and implementation of hospital programs based upon principles of behavioral technology may depend of necessity upon the services of clinical psychologists who occupy administrative and clinical positions of some authority. To allow them to do so may be perceived by psychiatrists as a direct threat to their own political and
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clinical authority. As long as clinical applications of behavioral technology are viewed as the domain of psychologists, psychiatrists may oppose establishment of behavioral programs on inter-disciplinary, political grounds alone.
Intradisciplinary competition. Competition among members of the same profession exists in every professional system as individuals vie for political and economic advantage. Among psychologists, for example, "behaviorism" versus "humanism" has been a raging battle for more than a generation and has been used as a political issue by both sides. To psychiatrists, on the other hand, this particular issue has had little, political relevance. More pertinent for psychiatrists is the fact that most have little background or training in behavioral technology. Consequently, behavioral technology has not represented much of a political issue among them. It becomes a political issue, however, when a behaviorally oriented psychiatrist attempts to establish a behavioral program on a psychiatric unit that has an open medical staff. Since most psychiatrists find themselves at a real disadvantage due to a lack of appropriate training, they may oppose behavioral innovations as vigorously as if a psychologist were making the attempt. If and when the day arrives that psychiatrists in substantial numbers have become trained in behavioral technology, establishment of behavioral programs on psychiatric units with open medical staff may be greeted with greater, clinical enthusiasm and less, political opposition. Quality of Care For the consumer, quality of care is the primary concern, but the consumer is at a disadvantage in determining the quality of care purchased. Having little in the way of scientific or medical background as a basis to compare services offered, the consumer is in a weak position to judge. To complicate matters, the forces of the open marketplace do not operate upon the health care industry as they do upon other industries. In the context of diluted, market forces, consumer ignorance can have a powerful and negative impact. Because the delivery of health care services does not take place in a free and open market, the economic forces affecting the health care industry become distorted. Due to governmental regulation and third party payment, economic forces typical of other industries are almost completely undone. Less qualified professionals and poorly managed hospitals are reimbursed as generously as their more competent competition. The patients who utilize these sub-standard services generally are unable to judge the quality of those services while insurance companies who pay for them are not in a position to do so. In the private sector especially, there can arise a real and dangerous conflict between quality of care delivered versus profit realized. Psychiatrists and other "mental health professionals" generally are paid for their time rather than for
Behavioral Technology and Hospital Psychiatry
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specific procedures. Consequently, there arises a tendency to seek ways to increase revenues generated per unit of time; for example, by resorting to group therapies and rendering service through lesser trained personnel. These alternative means of delivering service are not necessarily undesirable in that properly implemented and supervised they may provide an increase in affordable services for more of the population. On the other hand, these more profitable modalities may lead to inappropriate services provided by poorly trained and unqualified personnel. Clinical applications of behavioral technology may be especially prone to this kind of abuse. Procedures such as biofeedback, desensitization, and social skills training can be provided by unqualified personnel without the consumer suspecting the service is inappropriate or inadequate. With claim forms to third party payors signed by a licensed professional, the third party payor has no way of ascertaining whether the quality of care paid for was actually what was claimed. On the other hand, properly designed and implemented behavioral programs can provide a level of accountability not generally available otherwise. BEHAVIORAL TECHNOLOGY AND HOSPITAL PROGRAMS
Categories of Hospitals and the "HMO" Hospitals can be classified into one of the following four categories: private/ proprietary; private/non-profit; university; and public. Combinations occur, such as a university hospital funded by the public sector. Whatever the category, most hospitals strive for maximum utilization, even public hospitals. The only exception to this rule are hospitals in the private sector operated by pre-paid health maintenance organizations. Since these "HMO" facilities are funded through a pre-payment plan, the less service rendered, the greater the profit for the hospital. HMO facilities thus actively attempt to minimize utilization and to keep patients out of the hospital. Psychiatric hospitalization probably represents one of the greatest terrors in the life of an HMO administrator. The lengths-of-stay are exceptionally long compared to general medical and surgical admissions, and the cost per day is almost as high. Pre-paid health plans are one of the few areas of the health care industry where the contingencies directly favor cost-effectiveness. If behaviorists can demonstrate that their programs, in fact, are more cost-effective, they may find a warm reception among HMO's on that basis alone.
Behavioral Programs in the Private Sector Despite the highly competitive private psychiatric sector in Southern California, the author and his colleagues have been able to develop and market a
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variety of behavioral programs suited to the needs of private psychiatric and general hospitals during the past 10 years. These programs will be briefly outlined. Adult psychiatry. Half a generation ago, Ayllon and Azrin (1968) published a
series of reports that revolutionized clinical applications of behavioral technology in the hospital setting by systematically applying principles of operant technology through a token economy to a population of chronically schizophrenic patients. Their pioneering efforts led to the rapid application of the token economy to a wide variety of populations inside and outside hospital settings. Currently, the token economy has become the backbone of behavioral programs in hospital and residential settings for children, adolescents, the retarded, and the chronically mentally ill. For chronically ill adults, it has been demonstrated in a public sector setting to be more effective than equally intensive milieu therapy (Paul and Lentz, 1977). The token economy, however, does not serve well the hospital treatment of adults in acute, private settings. Accordingly, alternate behavioral vehicles have been developed. We, for example, have developed a comprehensive treatment package utilizing programmed, patient/staff interaction; prompts; social reinforcement; and on-going, quantitative behavioral measurement systems (Moss and Brown, 1981 a). Specific treatment goals are targeted, and specific behavioral and biological treatments are instituted to achieve these previously specified goals. A measurement system is implemented that may be based upon external monitoring of the patient's behavior by hospital staff or upon self-monitoring by the patient himself under the supervision of hospital staff (Brown amd Moss, 1982). The choice of which kind to use depends upon the characteristics of the patient population. Higher functioning patients can use self-monitoring, which offers the advantage of teaching the patient a skill usable outside the hospital. Lower functioning patients require external monitoring, although as they improve they may be able to make the transition to a self-monitoring program. The specific design of any given program depends, in part, upon the characteristics of the patient population. Child and adolescent psychiatry. Our applications of behavioral technology to the private hospital treatment of children and adolescents lie within a multi-axial framework, encompassing developmental and educational as well as behavioral parameters (Moss and Mann, 1978; Moss and Levine, 1980; Moss and Rick, 1981). Developmental assessment is used as the basis for design of a comprehensive, individual treatment plan, including an individual educational plan and parent training. Educational services, including school consultations, are offered based upon the individual educational plan. The behavioral component consists
Behavioral Technology and Hospital Psychiatry
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of a standardized, token economy with development of a home contract for patients to promote generalization after discharge from the hospital. In the context of the token ecnomy, individualized behavioral goals are targeted for each patient, and the staff teaches adaptive, social behavior based upon the child's assessed developmental level of functioning. Alcoholism and substance abuse. In contrast to single strategies aimed only at the abusive drinking behavior itself, we employ a more comprehensive approach, applying behavioral technology to the total life situation of the patient, initially in the hospital context (Moss and Brown, 198 lb). After detoxification, the patient participates in a life survey with emphasis based upon differential reinforcement of behaviors other than those associated with alcohol or drugs. Analysis of social skills, leisure time skills, and vocational and avocational interests is made. A specific treatment program including discrimination training, relaxation training, social skills training, biofeedback, and leisure skills training is tailored to the individual needs of the patient. Concomitantly, nutritional and physical conditioning programs are implemented in a fashion designed to generalize outside the hospital setting. Generalization of treatment effects is the pivotal aspect of any program. Accordingly, family members, employers, and outside agencies may become involved in the treatment. A specific treatment contract is developed, often utilizing disulfram (Antabuse) for alcoholics. Abstinence remains a treatment goal. Patients are encouraged to sample Alcoholics Anonymous (or Narcotics Anonymous), which offers social and recreational reinforcement in an alcoholfree context. Pharmacotherapy is offered in those cases where a clearcut, psychiatric condition exists for which a specific medication offers documented benefit. Following discharge, aftercare is offered through individual, family, and group therapies. Behavioral medicine. Behavioral medicine is a recently emerging discipline that applies principles of behavioral technology to the study and treatment of medical disorders (Ferguson and Taylor, 1980; McNamara, 1979; and Williams and Gentry, 1977). The extent to which behavioral medicine is related to its predecessor, psychosomatic medicine, represents something of a point of controversy. Whereas behavioral medicine is based upon principles of behavioral technology, psychosomatic medicine is based upon principles of psychoanalytic theory. In this context, the term, "bio-behavioral," has been offered as a substitute for "psychosomatic." We have developed a comprehensive hospital program for pain management, stress reduction, medication reduction, and eating disorders (Moss and Brown, 1981c). These programs can be located in general hospitals, or they can be modified for implementation in free-standing, psychiatric hospitals.
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M A R K E T I N G AND I M P L E M E N T A T I O N In the business of program design and consultation, marketing and sales are the lifeblood of the organization. The consultant and his firm must sell their products and services in order to survive. Professional knowledge, training, and experience does not necessarily prepare one for the competitive vigor of the business side of the health care industry. And business it is as hospital ownership, control, and management increasingly are taken away from physicians by businessmen, lawyers, and finance officers. For the most part, these people cannot judge the quality of medical/ surgical programs, let alone psychiatric or behavioral ones. They must be educated about the benefits of behaviorally-oriented hospital programs. Conversely, program consultants must educate themselves about the business aspects of the health care industry. A finance officer may not be able to judge the quality of a clinical program, but he certainly can judge its profitability from a pro forma. Accordingly, clinical programs in the private sector must be designed to make economic sense. Clinical data and empirical validations are important to hospital ownership, but feasibility and profits are even more impressive. Who does the marketing? Who makes the sales? Hospital administrators traditionally are accustomed to talking to physicians about clinical matters. In the business of program consultation, it is helpful to have a behaviorally trained psychiatrist or other physician on the marketing team; however, marketing and sales generally will be a coordinated effort among public relations and advertising people, psychiatrists, psychologists, lawyers, and accountants. Whether we like it or not as clinicians, a new era has been thrust upon us. Once a program has been sold, program design becomes the next task. A consultant must bring his design behavior under the control of the hospital in which the program will be implemented. Each program should be tailored individually to the needs of the particular institution. These needs are not limited to clinical parameters but include economic and political parameters as well. The program designed must meet the clinical needs of the patient population to be served, must gain the acceptance of the local community, must appeal to the medical staff of the hospital, and must generate sufficient revenues to produce a profit. After program design comes program implementation. To implement a program, an appropriate nursing and ancillary staff must be assembled. The task may not be an easy one. Most nurses and ancillary staff are as unfamiliar with behavioral technology as are most psychiatrists. Among those nurses and ancillary staff who are familiar with behavioral technology, there may exist a considerable amount of pre-conceived, negative attitudes. Here again, education is the key. Through effective, in-service training, the program consultant develops an effective staff to implement the program. Taking advantage of the high level of specificity of behavioral programs, the consultant can design examinations for staff to measure their readiness to implement the program. Mon-
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itoring procedures can be designed and implemented to assess staff effectiveness on a continuing basis. Depending upon the level of labor union activity, in the private sector employment and advancement can be made contingent upon knowledge and performance. The final phase is program evaluation and modification. Behavioral technology is a dynamic, evolving body of knowledge and procedures. Every clinical program should be under continual evaluation with modifications made as necessary. The function and effectiveness of the program design should be monitored as carefully as the treatment behavior of the staff and the clinical progress of the patients. DISCUSSION AND FUTURE CONSIDERATIONS
Unquestionably, there will continue to occur major changes in the funding patterns for the delivery of health care services in the United States. The byword for the 1980s appears to be "pro-competition." At the behest of the federal government, competition will increase among every sector of the health care industry--hospital vs. hospital; practioner vs. practitioner; hospital vs. practitioner; fee-for-service vs. HMO, etc. As these changes in funding patterns lead to increasing competition, they will have an impact upon clinical applications of behavioral technology. Behavioral technology can be competitive in that it offers a high degree of specificity, objectivity and accountability. Heretofore, such attributes have been lacking in the hospital practice of psychiatry. A high degree of specificity, objectivity, and accountability appeals to government regulators and third party payors. Although improving cost-effectiveness and quality of care may not be sufficient to convince boards of directors, facilitating reimbursement, avoiding regulatory harassment, and beating the competition may. As hospital services become controlled increasingly by businessmen and finance officers rather than physicians, the attributes of behavioral technology may find new admirers. Practitioners interested in clinical applications of behavioral technology will have the opportunity to seize upon this new era of competition in order to promote their products and services. Hospital owners and directors will be looking for new ways to increase their competitive advantage, by improving levels of care and offering new and different services. If those qualified to design and develop behavioral programs can capture the moment, they can make an impact previously undreamed of upon hospital psychiatry and the entire health care industry. REFERENCES Ayllon, T. and Azrin, N. H.: The Token Economy: a motivational system for therapy and rehabilitation. New York: Appleton-Century-Crofts, 1968.
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Brady, J. P.: The place of behavior therapy in medical student and psychiatric resident training. Journal of Nervous and Mental Disease, 1973, 157, 21-26. Brady, J. P. and Wienckowski, L. A.: Update on teaching of behavior therapy in medical student and psychiatric resident training. Journal of Behavior Therapy and Experimental Psychiatry, 1978, 9, 125-127. Brown, R. A. and Moss, G. R.: Reliability and validation of a psychiatric assessment instrument for the hospital treatment of adults. Psychological Reports, 1982, 51, 142. Ferguson, J. M. and Taylor, C. B.: The comprehensive Handbook of Behavioral Medicine. New York: Spectrum Publications, 1980. Foreyt, J. P. et al" Benefit-cost analysis of a token economy. Professional Psychology, 1975, 6, 26-33. Goldiamond, I.: Singling out behavior modification for legal regulation. Arizona Law Review, 1975, 17, 105-120. McNamara, J. R.: Behavioral Approaches to Medicine. New York: Plenum Press, 1979. Moss, G. R. and Boren, J. J.: Specifying criteria for completion of psychiatric treatment. Archives of General Psychiatry, 1971, 24, 441-447. Moss, G. R. and Brown, R. A.:AdultPsychiatry: a manualfor programmed patient/staff interaction. Newport Beach, California: Behavioral Medicine Associates, 1981a. Moss, G. R. and Brown, R. A.: Alcoholism and Substance Abuse: a manualfor programmed patient! staff interaction. Newport Beach, California: Behavioral Medicine Associates, 1981 b. Moss, G. R. and Brown, R. A.: Behavioral Medicine: a manual for programmed patient~staff interaction. Newport Beach, California: Behavioral Medicine Associates, 1981c. Moss, G. R. and Levine, M. J.: A developmental, educational, and behavioral approach to the hospital treatment of children. Psychiatric Clinics of North America, 1980, 3, 501-511. Moss, G. R. and Mann, R. A.: A behavioral approach to the hospital treatment of adolescents. Psychiatric Clinics of North America, 1978, 1,263-275. Moss, G. R. and Rick, G. R.: Applications of operant technology to behavioral disorders of adolescents. American Journal of Psychiatry, 1981, 138, 1161-1169. Paul, G. L. and Lentz, R. J.: Psychosocial Treatment of Chronic Mental Patients: milieu versus social-learning programs. Cambridge: Harvard University Press, 1977. Williams, R. B. and Gentry, W. D.: Behavioral Approaches to Medical Treatment. Cambridge: Ballinger, 1977.
0270-4684/83 $3.00 + .00 Copyright© 1983 PergamonPress Ltd
Behavioral Technology and Hospital Psychiatry: Considerations from the Private Sector Gene Richard Moss Behavioral Medical Croup and University of Southern California
Contingencies operating in the health care industry can have direct effects upon applications of behavioral technology to the hospital treatment of psychiatric patients. Although to date behavioral technology has made little impact upon the general practice of psychiatry, shifting economic and political contingencies may favor the specificity, objectivity, and accountability of behavioral paradigms. Those qualified in program design and implementation may find an increasingly receptive audience among directors of private hospitals, both proprietary and non-profit.
Despite a history spanning two decades, clinical applications of behavioral technology largely have been ignored by psychiatrists. Even basic terms such as "behavioral technology," "behavior therapy," or "behavior modification" often are misunderstood by psychiatrists and other physicians alike. The majority of psychiatrists continue to practice predominantly from psychodynamic and pharmacological models. Perhaps a relative lack of training in behavioral technology during residency may have contributed to this indifference (Brady, 1973; Brady and Wienckowski, 1978). Ironically, recent advances in behavioral technology hold out promise as effective components of psychiatric treatment. By meeting explicit, operational criteria in utilizing biological and behavioral treatment procedures, psychiatrists can acquire scientific respectability by providing the kind of specificity, objectivity, and accountability increasingly demanded by their critics (Moss and Boren, 1971). Address reprint requests to Gene Richard Moss, M.D., 400 Newport Center Drive, Newport Beach, California 92660.
205
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Gene Richard Moss
CONTINGENCIES IN THE PRIVATE SECTOR Economic
The health care industry is a big business, accounting for almost ten percent of the gross national product of the United States. All businesses must show a profit to survive, and the health care industry is no exception. In the public sector, losses sustained through inadequate revenues are offset by governmental subsidy. In the private sector, profits are generated typically by fees for direct, patient care. Such fees may come from patients themselves or from third party payors such as insurance companies. Accordingly, a foremost consideration in the future utilization of behavioral technology in private facilities will be its economic impact. To promote the financial appeal of behavioral technology, behaviorists have proclaimed its relative cost-effectiveness (Foreyt, 1975). Such proclamations may have a paradoxical, adverse effect upon private, fee-for-service, health care facilities while favorably appealing to pre-paid, health care facilities. General hospitals, for example, generate revenues from a variety of sources, including daily room charge, facilities utilized (e.g., operating room), pharmacy, central supply, and ancillary services (e.g., laboratory, radiology, physical therapy, etc.). Psychiatric units generate revenues primarily from daily room charge. For medical/surgical units, the greatest revenues are generated within the first, several days of the hospital stay. Given a high level of utilization, medical/ surgical units generate a maximum profit from high turnover of patient census with relatively brief lengths-of-stay. For psychiatric units, revenues generated may co-vary directly with the average length-of-stay. Profit per patient/day actually may increase the longer a patient remains in the hospital. Thus, psychiatric programs that are particularly cost-effective may lead to decreased revenues and lower profits through briefer hospital stays. Increased utilization promoted through behavioral programs may be a far more effective inducement for psychiatric units in the fee-for-service, private sector than cost-effectiveness. Currently, there exists a surplus of hospital beds in many areas of the United States. This surplus results in under-utlization of some hospital facilites. A decreased, average length-of-stay through enhanced cost-effectiveness hardly is likely to exert strong, sales appeal to a hospital that already has too many empty beds. The possibility of increased utilization through program design, on the other hand, is far more likely to occasion a receptive response. If hospital programs based upon behavioral technology are more clinically effective than programs that are not, the layman as well as the professional must be made aware of this difference. Acceptance of behavioral technology by the private sector will come as a result of public and professional demand for effective methods, which then lead to increased utlization and profit. As long as the public
Behavioral Technology and Hospital Psychiatry
207
and the psychiatric profession remain uninformed about the therapeutic benefits of behavioral technology, demand will remain low and acceptance within the private sector marginal.
Political Political contingencies in the private sector fall into several categories, including legal statutes, inter-disciplinary competition, and intra-disciplinary competiton. These political contingencies directly affect the type and quality of services delivered.
Legal statutes. Every hospital contends with a plethora of legal statutes and agency regulations on a federal, state and local level. The impact of these laws and regulations should not be underestimated. Clinical applications of behavioral technology have generated exceptional legal controversy and have come under special scrutiny (Goldiamond, 1975). Yet, laws and regulations vary from locality to locality in a manner that can be considered almost whimsical. Regulations regarding "clients' rights" are an example. Application of regulations to the psychiatric care of adolescents in private hospitals located in the County of Los Angeles versus those located in the adjacent County of Orange, for example, differs substantially. Hospitals located on one side of the county line may implement policies and procedures that would be considered illegal on the other. No hospital program politically or economically can afford to violate for long applicable laws and regulations. Designers of hospital programs based upon behavioral technology must take special care to ensure conformity with laws and regulations as interpreted by the local authorities. Interdisciplinary competition. Competition among "mental health professionals" seems to be assuming increasing intensity in the struggle for political power and an economic share of the market. Clinical psychologists have waged a rather successful battle not only for equal coverage with psychiatrists by third party payors but for equal voting and admitting privileges in hospitals. Some hospitals and many psychiatrists have opposed these efforts; other hospitals and a few psychiatrists have offered support. The political and economic consequences of giving psychologists equal status in hospitals could be destructive for physicians and especially for psychiatrists. Yet, it is well known that many psychologists but few psychiatrists are trained in applications of behavioral technology. Accordingly, the design and implementation of hospital programs based upon principles of behavioral technology may depend of necessity upon the services of clinical psychologists who occupy administrative and clinical positions of some authority. To allow them to do so may be perceived by psychiatrists as a direct threat to their own political and
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clinical authority. As long as clinical applications of behavioral technology are viewed as the domain of psychologists, psychiatrists may oppose establishment of behavioral programs on inter-disciplinary, political grounds alone.
Intradisciplinary competition. Competition among members of the same profession exists in every professional system as individuals vie for political and economic advantage. Among psychologists, for example, "behaviorism" versus "humanism" has been a raging battle for more than a generation and has been used as a political issue by both sides. To psychiatrists, on the other hand, this particular issue has had little, political relevance. More pertinent for psychiatrists is the fact that most have little background or training in behavioral technology. Consequently, behavioral technology has not represented much of a political issue among them. It becomes a political issue, however, when a behaviorally oriented psychiatrist attempts to establish a behavioral program on a psychiatric unit that has an open medical staff. Since most psychiatrists find themselves at a real disadvantage due to a lack of appropriate training, they may oppose behavioral innovations as vigorously as if a psychologist were making the attempt. If and when the day arrives that psychiatrists in substantial numbers have become trained in behavioral technology, establishment of behavioral programs on psychiatric units with open medical staff may be greeted with greater, clinical enthusiasm and less, political opposition. Quality of Care For the consumer, quality of care is the primary concern, but the consumer is at a disadvantage in determining the quality of care purchased. Having little in the way of scientific or medical background as a basis to compare services offered, the consumer is in a weak position to judge. To complicate matters, the forces of the open marketplace do not operate upon the health care industry as they do upon other industries. In the context of diluted, market forces, consumer ignorance can have a powerful and negative impact. Because the delivery of health care services does not take place in a free and open market, the economic forces affecting the health care industry become distorted. Due to governmental regulation and third party payment, economic forces typical of other industries are almost completely undone. Less qualified professionals and poorly managed hospitals are reimbursed as generously as their more competent competition. The patients who utilize these sub-standard services generally are unable to judge the quality of those services while insurance companies who pay for them are not in a position to do so. In the private sector especially, there can arise a real and dangerous conflict between quality of care delivered versus profit realized. Psychiatrists and other "mental health professionals" generally are paid for their time rather than for
Behavioral Technology and Hospital Psychiatry
209
specific procedures. Consequently, there arises a tendency to seek ways to increase revenues generated per unit of time; for example, by resorting to group therapies and rendering service through lesser trained personnel. These alternative means of delivering service are not necessarily undesirable in that properly implemented and supervised they may provide an increase in affordable services for more of the population. On the other hand, these more profitable modalities may lead to inappropriate services provided by poorly trained and unqualified personnel. Clinical applications of behavioral technology may be especially prone to this kind of abuse. Procedures such as biofeedback, desensitization, and social skills training can be provided by unqualified personnel without the consumer suspecting the service is inappropriate or inadequate. With claim forms to third party payors signed by a licensed professional, the third party payor has no way of ascertaining whether the quality of care paid for was actually what was claimed. On the other hand, properly designed and implemented behavioral programs can provide a level of accountability not generally available otherwise. BEHAVIORAL TECHNOLOGY AND HOSPITAL PROGRAMS
Categories of Hospitals and the "HMO" Hospitals can be classified into one of the following four categories: private/ proprietary; private/non-profit; university; and public. Combinations occur, such as a university hospital funded by the public sector. Whatever the category, most hospitals strive for maximum utilization, even public hospitals. The only exception to this rule are hospitals in the private sector operated by pre-paid health maintenance organizations. Since these "HMO" facilities are funded through a pre-payment plan, the less service rendered, the greater the profit for the hospital. HMO facilities thus actively attempt to minimize utilization and to keep patients out of the hospital. Psychiatric hospitalization probably represents one of the greatest terrors in the life of an HMO administrator. The lengths-of-stay are exceptionally long compared to general medical and surgical admissions, and the cost per day is almost as high. Pre-paid health plans are one of the few areas of the health care industry where the contingencies directly favor cost-effectiveness. If behaviorists can demonstrate that their programs, in fact, are more cost-effective, they may find a warm reception among HMO's on that basis alone.
Behavioral Programs in the Private Sector Despite the highly competitive private psychiatric sector in Southern California, the author and his colleagues have been able to develop and market a
210
Gene Richard Moss
variety of behavioral programs suited to the needs of private psychiatric and general hospitals during the past 10 years. These programs will be briefly outlined. Adult psychiatry. Half a generation ago, Ayllon and Azrin (1968) published a
series of reports that revolutionized clinical applications of behavioral technology in the hospital setting by systematically applying principles of operant technology through a token economy to a population of chronically schizophrenic patients. Their pioneering efforts led to the rapid application of the token economy to a wide variety of populations inside and outside hospital settings. Currently, the token economy has become the backbone of behavioral programs in hospital and residential settings for children, adolescents, the retarded, and the chronically mentally ill. For chronically ill adults, it has been demonstrated in a public sector setting to be more effective than equally intensive milieu therapy (Paul and Lentz, 1977). The token economy, however, does not serve well the hospital treatment of adults in acute, private settings. Accordingly, alternate behavioral vehicles have been developed. We, for example, have developed a comprehensive treatment package utilizing programmed, patient/staff interaction; prompts; social reinforcement; and on-going, quantitative behavioral measurement systems (Moss and Brown, 1981 a). Specific treatment goals are targeted, and specific behavioral and biological treatments are instituted to achieve these previously specified goals. A measurement system is implemented that may be based upon external monitoring of the patient's behavior by hospital staff or upon self-monitoring by the patient himself under the supervision of hospital staff (Brown amd Moss, 1982). The choice of which kind to use depends upon the characteristics of the patient population. Higher functioning patients can use self-monitoring, which offers the advantage of teaching the patient a skill usable outside the hospital. Lower functioning patients require external monitoring, although as they improve they may be able to make the transition to a self-monitoring program. The specific design of any given program depends, in part, upon the characteristics of the patient population. Child and adolescent psychiatry. Our applications of behavioral technology to the private hospital treatment of children and adolescents lie within a multi-axial framework, encompassing developmental and educational as well as behavioral parameters (Moss and Mann, 1978; Moss and Levine, 1980; Moss and Rick, 1981). Developmental assessment is used as the basis for design of a comprehensive, individual treatment plan, including an individual educational plan and parent training. Educational services, including school consultations, are offered based upon the individual educational plan. The behavioral component consists
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of a standardized, token economy with development of a home contract for patients to promote generalization after discharge from the hospital. In the context of the token ecnomy, individualized behavioral goals are targeted for each patient, and the staff teaches adaptive, social behavior based upon the child's assessed developmental level of functioning. Alcoholism and substance abuse. In contrast to single strategies aimed only at the abusive drinking behavior itself, we employ a more comprehensive approach, applying behavioral technology to the total life situation of the patient, initially in the hospital context (Moss and Brown, 198 lb). After detoxification, the patient participates in a life survey with emphasis based upon differential reinforcement of behaviors other than those associated with alcohol or drugs. Analysis of social skills, leisure time skills, and vocational and avocational interests is made. A specific treatment program including discrimination training, relaxation training, social skills training, biofeedback, and leisure skills training is tailored to the individual needs of the patient. Concomitantly, nutritional and physical conditioning programs are implemented in a fashion designed to generalize outside the hospital setting. Generalization of treatment effects is the pivotal aspect of any program. Accordingly, family members, employers, and outside agencies may become involved in the treatment. A specific treatment contract is developed, often utilizing disulfram (Antabuse) for alcoholics. Abstinence remains a treatment goal. Patients are encouraged to sample Alcoholics Anonymous (or Narcotics Anonymous), which offers social and recreational reinforcement in an alcoholfree context. Pharmacotherapy is offered in those cases where a clearcut, psychiatric condition exists for which a specific medication offers documented benefit. Following discharge, aftercare is offered through individual, family, and group therapies. Behavioral medicine. Behavioral medicine is a recently emerging discipline that applies principles of behavioral technology to the study and treatment of medical disorders (Ferguson and Taylor, 1980; McNamara, 1979; and Williams and Gentry, 1977). The extent to which behavioral medicine is related to its predecessor, psychosomatic medicine, represents something of a point of controversy. Whereas behavioral medicine is based upon principles of behavioral technology, psychosomatic medicine is based upon principles of psychoanalytic theory. In this context, the term, "bio-behavioral," has been offered as a substitute for "psychosomatic." We have developed a comprehensive hospital program for pain management, stress reduction, medication reduction, and eating disorders (Moss and Brown, 1981c). These programs can be located in general hospitals, or they can be modified for implementation in free-standing, psychiatric hospitals.
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M A R K E T I N G AND I M P L E M E N T A T I O N In the business of program design and consultation, marketing and sales are the lifeblood of the organization. The consultant and his firm must sell their products and services in order to survive. Professional knowledge, training, and experience does not necessarily prepare one for the competitive vigor of the business side of the health care industry. And business it is as hospital ownership, control, and management increasingly are taken away from physicians by businessmen, lawyers, and finance officers. For the most part, these people cannot judge the quality of medical/ surgical programs, let alone psychiatric or behavioral ones. They must be educated about the benefits of behaviorally-oriented hospital programs. Conversely, program consultants must educate themselves about the business aspects of the health care industry. A finance officer may not be able to judge the quality of a clinical program, but he certainly can judge its profitability from a pro forma. Accordingly, clinical programs in the private sector must be designed to make economic sense. Clinical data and empirical validations are important to hospital ownership, but feasibility and profits are even more impressive. Who does the marketing? Who makes the sales? Hospital administrators traditionally are accustomed to talking to physicians about clinical matters. In the business of program consultation, it is helpful to have a behaviorally trained psychiatrist or other physician on the marketing team; however, marketing and sales generally will be a coordinated effort among public relations and advertising people, psychiatrists, psychologists, lawyers, and accountants. Whether we like it or not as clinicians, a new era has been thrust upon us. Once a program has been sold, program design becomes the next task. A consultant must bring his design behavior under the control of the hospital in which the program will be implemented. Each program should be tailored individually to the needs of the particular institution. These needs are not limited to clinical parameters but include economic and political parameters as well. The program designed must meet the clinical needs of the patient population to be served, must gain the acceptance of the local community, must appeal to the medical staff of the hospital, and must generate sufficient revenues to produce a profit. After program design comes program implementation. To implement a program, an appropriate nursing and ancillary staff must be assembled. The task may not be an easy one. Most nurses and ancillary staff are as unfamiliar with behavioral technology as are most psychiatrists. Among those nurses and ancillary staff who are familiar with behavioral technology, there may exist a considerable amount of pre-conceived, negative attitudes. Here again, education is the key. Through effective, in-service training, the program consultant develops an effective staff to implement the program. Taking advantage of the high level of specificity of behavioral programs, the consultant can design examinations for staff to measure their readiness to implement the program. Mon-
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itoring procedures can be designed and implemented to assess staff effectiveness on a continuing basis. Depending upon the level of labor union activity, in the private sector employment and advancement can be made contingent upon knowledge and performance. The final phase is program evaluation and modification. Behavioral technology is a dynamic, evolving body of knowledge and procedures. Every clinical program should be under continual evaluation with modifications made as necessary. The function and effectiveness of the program design should be monitored as carefully as the treatment behavior of the staff and the clinical progress of the patients. DISCUSSION AND FUTURE CONSIDERATIONS
Unquestionably, there will continue to occur major changes in the funding patterns for the delivery of health care services in the United States. The byword for the 1980s appears to be "pro-competition." At the behest of the federal government, competition will increase among every sector of the health care industry--hospital vs. hospital; practioner vs. practitioner; hospital vs. practitioner; fee-for-service vs. HMO, etc. As these changes in funding patterns lead to increasing competition, they will have an impact upon clinical applications of behavioral technology. Behavioral technology can be competitive in that it offers a high degree of specificity, objectivity and accountability. Heretofore, such attributes have been lacking in the hospital practice of psychiatry. A high degree of specificity, objectivity, and accountability appeals to government regulators and third party payors. Although improving cost-effectiveness and quality of care may not be sufficient to convince boards of directors, facilitating reimbursement, avoiding regulatory harassment, and beating the competition may. As hospital services become controlled increasingly by businessmen and finance officers rather than physicians, the attributes of behavioral technology may find new admirers. Practitioners interested in clinical applications of behavioral technology will have the opportunity to seize upon this new era of competition in order to promote their products and services. Hospital owners and directors will be looking for new ways to increase their competitive advantage, by improving levels of care and offering new and different services. If those qualified to design and develop behavioral programs can capture the moment, they can make an impact previously undreamed of upon hospital psychiatry and the entire health care industry. REFERENCES Ayllon, T. and Azrin, N. H.: The Token Economy: a motivational system for therapy and rehabilitation. New York: Appleton-Century-Crofts, 1968.
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Brady, J. P.: The place of behavior therapy in medical student and psychiatric resident training. Journal of Nervous and Mental Disease, 1973, 157, 21-26. Brady, J. P. and Wienckowski, L. A.: Update on teaching of behavior therapy in medical student and psychiatric resident training. Journal of Behavior Therapy and Experimental Psychiatry, 1978, 9, 125-127. Brown, R. A. and Moss, G. R.: Reliability and validation of a psychiatric assessment instrument for the hospital treatment of adults. Psychological Reports, 1982, 51, 142. Ferguson, J. M. and Taylor, C. B.: The comprehensive Handbook of Behavioral Medicine. New York: Spectrum Publications, 1980. Foreyt, J. P. et al" Benefit-cost analysis of a token economy. Professional Psychology, 1975, 6, 26-33. Goldiamond, I.: Singling out behavior modification for legal regulation. Arizona Law Review, 1975, 17, 105-120. McNamara, J. R.: Behavioral Approaches to Medicine. New York: Plenum Press, 1979. Moss, G. R. and Boren, J. J.: Specifying criteria for completion of psychiatric treatment. Archives of General Psychiatry, 1971, 24, 441-447. Moss, G. R. and Brown, R. A.:AdultPsychiatry: a manualfor programmed patient/staff interaction. Newport Beach, California: Behavioral Medicine Associates, 1981a. Moss, G. R. and Brown, R. A.: Alcoholism and Substance Abuse: a manualfor programmed patient! staff interaction. Newport Beach, California: Behavioral Medicine Associates, 1981 b. Moss, G. R. and Brown, R. A.: Behavioral Medicine: a manual for programmed patient~staff interaction. Newport Beach, California: Behavioral Medicine Associates, 1981c. Moss, G. R. and Levine, M. J.: A developmental, educational, and behavioral approach to the hospital treatment of children. Psychiatric Clinics of North America, 1980, 3, 501-511. Moss, G. R. and Mann, R. A.: A behavioral approach to the hospital treatment of adolescents. Psychiatric Clinics of North America, 1978, 1,263-275. Moss, G. R. and Rick, G. R.: Applications of operant technology to behavioral disorders of adolescents. American Journal of Psychiatry, 1981, 138, 1161-1169. Paul, G. L. and Lentz, R. J.: Psychosocial Treatment of Chronic Mental Patients: milieu versus social-learning programs. Cambridge: Harvard University Press, 1977. Williams, R. B. and Gentry, W. D.: Behavioral Approaches to Medical Treatment. Cambridge: Ballinger, 1977.