Clinicians as advocates: an exploratory study of responses to managed care by mental health professionals

The impact of management on medical professionalism: a review

In the last three decades, medical doctors have increasingly been exposed to management control measures. This phenomenon has been reflected in a number of studies in various disciplines, including sociology, organisation studies, management, and health service research. This article seeks to provide a comprehensive overview of the studies dealing with the impact of management on professional control. In particular, it seeks to bridge the diversity of assumptions, theoretical perspectives and conceptual underpinnings at play, by exploring synergies between them and opening up new horizons for research. The review shows how the relationship between clinicians and management has been analysed at an organisational level using two interconnected analytical frameworks focusing on the sociocultural and task-related dimensions of professionalism. In the final discussion, we argue that comparative, longitudinal and cross-sectional research is necessary, and there is a need to overcome the hegemony/resistance framework in current analyses of the impact of management on professionalism. Such an approach would contribute to the revision of macro theories of professionalism and stimulate emerging research by examining different perspectives towards management in medical specialisations. This approach might also stimulate a discussion of medical professionals' relationships with members of other professional groups, including nurses and healthcare managers.

Workforce professionalism in drug treatment services: impact of California's Proposition 36

This article investigates whether California's Proposition 36 has promoted the workforce professionalism of drug treatment services during its first 5 years of implementation. Program surveys inquiring about organizational information, Proposition 36 implementation, and staffing were conducted in 2003 and 2005 among all treatment providers serving Proposition 36 clients in five selected California counties (San Diego, Riverside, Kern, Sacramento, and San Francisco). A 1-hour self-administered questionnaire was completed by 118 treatment providers representing 102 programs. This article examines five topics that are relevant to drug treatment workforce professionalism: resources and capability, standardized intake assessment and outcome evaluation, staff qualification, program accreditation, and information technology. Results suggest that Proposition 36 had a positive influence on the drug treatment workforce's professionalism. Improvements have been observed in program resources, client intake assessment and outcome evaluation databases, staff professionalization, program accreditation, and information technology system. However, some areas remain problematic, including, for example, the consistent lack of adequate resources serving women with children.

Health professionals' enactment of their accountability obligations: doing the best they can

In the current context of health care, health professionals' accountability obligations may be more extensive than the degree of autonomy that they are permitted to exercise. To date, how professionals fulfil their obligations with regard to this potential for dissonance has not been investigated. The purpose of this Grounded Theory study was to examine how one professional group, occupational therapists, enacted their accountability obligations within their current practice context. Interviews with 21 therapists across three practice sectors in one Canadian province elicited a detailed portrait of the contextual elements within which accountability enactment took place, and a view of the dynamic interplay of these elements with the decision-making involved in fulfilling professional accountabilities. Practitioners moved back and forth between conscious juggling of accountability expectations and more automatically applying tacit practice knowledge. Beyond non-negotiable bottom line commitments to their formal ethical obligations and to retaining autonomy for their clinical recommendations, practitioners' decisions reflected the goal of doing their best. However, participants' efforts to find a balance between satisfactorily fulfilling their obligations and acknowledging the frequently unavoidable reality of contextual constraints elicited inconsistent patterns. The study findings raise concerns about ensuring quality of services and the impact on professionals. Although practitioners have an important role to play in addressing these challenges, other stakeholders, for example, the professional regulatory bodies, also must play a role in creating a coherent accountability framework. Further research is needed to obtain greater understanding of professional accountability enactment across health professions, practice sectors and health jurisdictions, and to explore managerial and professional regulatory bodies' perspectives, roles and responsibilities.

Managed care organizations' use of treatment management strategies for outpatient mental health care

A nationally representative sample of managed care organizations was surveyed (response rate=92%) regarding use of treatment management techniques for outpatient mental health care in their commercial products in 1999. Bivariate tests and logistic regression models were used to examine the relationship between product type, behavioral health contracting arrangement and treatment management techniques (prior authorization, standards for time to initial appointment, concurrent review, standards for follow-up after discharge, case management, practice guidelines). Prevalence varied from 43% to 87% depending on the technique. HMO products and products with specialty behavioral health contracts were more likely to use the techniques. Product type and contracting arrangement had independent effects.

Conceptions of authority within contemporary social work practice in managed mental health care organizations

This article examines how social workers may use their authority to create managed mental health care organizations that support the principles and values of professional social work practice. By exploring research and theoretical contributions from a multidisciplinary perspective, the author suggests ways that social workers may incorporate empowerment strategies into their organizational practices to create more socially responsible and humane mental health organizations.