PN: What about the people who are in private practice today? As I talk to therapists around the country, it seems that most of the experienced clinicians I know are able to be quite successful in private practice. Will this trend toward integrated care affect their livelihood?
Cummings: Back in 1996, I predicted that as the managed care companies continued to fail in delivering adequate and quality mental health services, consumers would be willing to pay out of pocket for private care that wasn't covered by insurance. But I also predicted that this "boutique market" would only last for a few years. It was a transient thing, a bubble, that was going to be very much subject to economic times--boutiques don't do well in recessions--and could never grow above five to eight percent of the market. I based that percentage on the fact that in every country that has universal health care, whether you're talking about Sweden or the United Kingdom, no more than five to eight percent of the population is willing to pay out of pocket for services that are insured. So the boutique market can be seductive, but it's a transient thing.
The success of the boutique market is inversely proportional to the number of people in it. The people who got into it first are doing very well. But if 30 or 40 or 50 percent of practitioners out there decide to go after the out-of-pocket, fee-for-service clientele, they're going to find that there's a very, very small clientele out there--too small to keep a large number of practitioners in practice.
Advice for Therapists
PN: Okay. If that is the big picture, what do you say to the individual practitioner who's trying to prepare for the contingencies of the future? As a therapist, how can I best shape my own destiny, rather than having the marketplace shape it for me?