Financial pressures on institutional health care in Canada in recent years have led to substantial pressures on institutional psychological services. These pressures have resulted in the elimination or substantial diminution of psychological services in some of these institutions, including the discontinuation of many longstanding psychology internship programs. It is therefore important for psychologists to demonstrate their cost-efficiency in delivering services. However, evidence for this efficiency in the current Canadian context is lacking. This investigation examines the costs and clinical activities of the interns and staff at a major Canadian teaching hospital in order to determine the degree to which the internship is a cost-efficient method of delivering services. The results indicate that there is a small increased cost to having the services delivered through an internship program. The results are viewed as part of a balanced scorecard approach to the evaluation of an internship program. From such a perspective, other factors can be seen as balancing out the slightly increased cost. Also, a number of strategies are outlined for increasing internship cost-efficiency.
With the advent of managed care health systems in the United States came increased concerns regarding quality assurance. These concerns spread across the health care industry and now play a large role in the manner in which health services, including psychological services, are provided to the public. In Canada, this need for greater accountability has led to numerous organizational changes, such as product-line management in hospitals (e.g., clinical service lines, program management; Leatt, Lemieux-Charles, & Aird, 1994). While these changes have had negative impacts on the staff of the organizations (Lees & Sleeves, 2003; Woodward et al., 1999), they nonetheless continue as greater pressures for financial accountability are placed on health care systems.
The increasing financial pressures in Canadian health care have led to large-scale reviews of the system to determine methods for the effective allocation of increasingly scarce public funds (Canada 2002a, b, 2003, 2004a). Koch, Lewis, and McCaIl (1998) noted that mental health services are also faced with increasing demands for cost containment, quality improvement, and accountability. Many factors have been found to play a role in the quality of care of these patients, including the values of the patients and the types of interventions that are available (Manderscheid, 1998). However, the bottom line in health care management has become financial efficiency (Stein, 2002).
It is recognized that the professional services offered by psychologists are often unique amongst health care providers and some of these "can play a critical role in improving the quality of the system and ensuring its sustainability into the future" (Romanow & Marchildon, 2003, p. 293). However, while there is considerable valuable evidence supporting psychology's role in cost-effective health care (Hunsley, 2002), governments often do not use this information when making decisions on health care spending (Mikail & Tasca, 2004; Romanow & Marchildon, 2004) and pressures on institutional psychological services in Canada have increased (Nicholson, Velikonja, & Bisnaire, 2004; Service, Mikail, & Nicholson, 2001). Not only have these pressures affected the accessibility of available psychological services in institutions (Canada, 2004b), but they have also resulted in the elimination of several accredited predoctoral clinical psychology internship programs.
Before conferring the doctoral degree in professional psychology, a program accredited by the Canadian Psychological Association (CPA), requires the completion of a CPA-accredited internship or its equivalent (CPA, 2002). The internship program is "the final but essential step in preparation for professional practice in psychology at the doctoral level" (CPA, p. …