IF YOU MISS THE TRAIN I’M ON….

Women's Preventive Health Care:  As our nation experiences the steady implementation of President Obama's landmark health care reform legislation, thePatient Protection and Affordable Care Act [PPACA], over the next 5 to 10 years, it is important for psychology to appreciate the significance of Katherine Nordal's State Leadership charge to "get personally involved."  The underlying legislation is broadly written, endorsing important long-range objectives, while providing the States and the Administration with considerable flexibility to craft the implementing details.  This Summer, the Institute of Medicine (IOM) released its recommendations to the Department of Health and Human Services (HHS) Clinical Preventive Services for Women: Closing the Gaps.  The Committee chairperson and former Director of the National Institute for Occupational Safety and Health:  "The Patient Protection and Affordable Care Act of 2010 has afforded us an historic occasion.  For the first time, prevention plays a central role within the scope of new health insurance plans in theUnited States.  Also, an ongoing focus on women's preventive services is expected to be included in these efforts.  Given the history of inadequate attention to women's health research and preventive services noted by many, (including previous IOM committees), I am truly optimistic that gains in women's health and well-being will ensue.  With the multiple roles that women play in society, to invest in the health and well-being of women is to invest in progress for all."  Exciting opportunities….

The preventive services and screenings specified in PPACA, and ultimately expanded by HHS, will be fully covered without patient copayment.  The three sets of guidelines currently being utilized to define "preventive services" include recommendations made by the U.S. Preventive Services Task Force, the Bright Futures for Adolescents of the American Academy of Pediatrics, and the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices.  The charge to the IOM: "Convene an expert committee to review what preventive services are necessary for women's health and well-being and should be considered in the development of comprehensive guidelines for preventive services for women.  The committee will also provide guidance on a process for regularly updating the preventive screenings and services to be considered."  Issues to be explored included: What is the scope of preventive services not included?  What additional screening and preventive services have been shown to be effective for women?  What services and screenings are needed to fill gaps in recommended preventive services for women?  And, What models could HHS and its agencies use to coordinate regular updates of the comprehensive guidelines for preventive services and screenings for women and adolescent girls?

In fulfilling its mission, the IOM sought to identify preventive measures that were aimed at filling the gaps that it had identified.  In most cases these measures had already been proposed in the guidelines of other professional organizations.  Those preventive measures that were clearly not developed, tested, or known well enough to have a measurable impact were eliminated from consideration.  Fundamentally, the IOM asked: Are high-quality systematic evidence reviews available which indicate that the service is effective in women?  Are quality peer-reviewed studies available demonstrating effectiveness of the service in women?  Has the measure been identified as a federal priority to address in women's preventive services?  And, Are there existing federal, state, or international practices, professional guidelines, or federal reimbursement policies that support the use of the measure available?

The IOM noted that prevention is a well-recognized, effective tool in improving health and well-being and has been shown to be cost-effective in addressing many conditions early.  Prevention goes well beyond the use of disease prevention measures.  Historically, the many disparate components of our health care system have relied more on responding to acute problems and the urgent needs of patients than on prevention.  The provision of preventive health care services is inherently different from the treatment of acute problems, but our nation's health care system has fallen short in the provision of such services.  Compared with a system that prevents avoidable conditions early, a system that responds to the acute health care needs of patients can be inefficient and costly, and a focus on response instead of prevention is a major barrier to the enactment of optimal health and well-being by Americans.  Our nation's current orientation is in spite of the fact that for nearly two decades we have collectively known that nearly half of all deaths in the U.S. are caused by modifiable health behaviors.  And, research indicates that an increase in the use of clinical preventive services in the U.S. could result in the saving of more than 2 million life-years annually.  On average, women tend to use more preventive care than men, owing to reproductive and gender-specific conditions, causing significant out-of-pocket expenditures.  This creates a particular challenge to women, who typically earn less than men and who disproportionately have low incomes.  Before PPACA, there was little standardization of the preventive services offered by both private and public payers.  Medicaid, for which the benefits are essentially crafted at the State level, offers coverage for many preventive services for its approximately 66 million beneficiaries, including 30 million children.  In our judgment, it is unfortunate that psychology did not have the foresight to seek express recognition under the federal Medicaid statute prior to the enactment of PPACA.

Although none of the IOM committee members were psychologists, one of the important "Identified Gaps" addressed by the IOM was mental health care.  Depression is a widespread mental disorder that affects approximately 121 million people worldwide and has been identified to be 1 of the top 10 leading causes of disease burden.  Depression may lead to suicidal ideation and actions.  Postpartum depression is a condition specific to new mothers.  Depression can occur throughout the life cycle, from childhood to late in life.  Suicide rates in women are highest within the age range of 45 to 54 years.  Across the life course, women may develop depression more often or more prominently around the time of certain reproductive events, such as menstruation, pregnancy, loss of a baby, birth of a baby, infertility, and menopause.  Women are consistently rated as a high-risk group for depression as depression is significantly more prevalent in women than in men at almost twice the rate.  Between 10% and 20% of mothers experience postpartum depression within the first year after giving birth, which has significant consequences for both the child's development and the mother's well-being.  Depression is a condition commonly encountered in primary care because those with major depression utilize health care at higher rates and mental health issues are increasingly becoming a part of primary care, in part because of increased physician education.  The primary gap in prevention services recognized by the IOM is that the current recommendation for depression screening and follow-up does not address suicide and postpartum depression as related conditions to be evaluated.  We would postulate that if psychology had been more actively engaged in this important IOM study a significantly broader recommendation would have evolved.  As Katherine Nordalemphatically stressed, our nation's health care system is undergoing unprecedented change and would significantly benefit from psychology's concerted presence.

            MACPAC:  One of the most satisfying aspects of serving in the public policy arena is the opportunity of working closely with our nation's next generation of public servants.  Coming from varying backgrounds, these leaders of tomorrow are extraordinary bright, enthusiastic, and dedicated.  Hopefully, as they mature into seasoned professionals, they will retain these defining traits.  "Only a year out of my undergraduate studies and interning inWashington, DC for the first time, I have found myself diving head first into a veritable sea of complex issues I had never had to look more closely at than the articles in my local newspaper.  I have been fortunate enough to have the opportunity to work closely on many different health related issues during my short tenure here and am struck by the inseparable bond existing between the health issues I study and the debt talks going on all around me.  As the struggle to reform healthcare and balance the Federal budget continues, the U.S. is increasingly looking at patient-centered and team-based approaches as a more effective way to not only treat patients, but also to manage their long-term care.  With so much change being implemented on the system as a whole, the role of the psychologist within the new healthcare system is also evolving.  On the one hand, recent studies show the tremendous psychological effect of expanded Medicaid or access to medical insurance.  Evidence from the first year of the Oregon Health Insurance Experiment indicates that 'when poor people are given medical insurance, they not only find regular doctors and see doctors more often but they also feel better, are less depressed and are better able to maintain financial stability.'  On the other hand is the problem of finding adequate funding to support these initiatives.

            "Persons requiring mental health services, while representing a comparatively small portion of the Medicaid recipient population, also incur a disproportionately high level of associated cost.  The APA reports that most Medicaid beneficiaries are not entitled to psychological services.  With the exception of children under the age of 21, who are covered by Medicaid as part of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefits for psychological services, access for low-income families and disabled persons varies from state to state.  Because it is considered an 'optional benefit,' only 50% of the states offer psychological services through independent practices while the other half may cover services in certain situations only, such as through a hospital, according to the APA.  However, in those circumstances, psychologists are not able to bill Medicaid directly.  States' policies on psychological treatment as an 'optional benefit' vary considerably and are at risk for cuts as states facing budget shortfalls must make tough choices.

            "In an effort to confront the national goal of cutting spending while improving the care management necessary for this population's complex needs, states have been increasingly trending away from fee-for-service and towards managed care in Medicaid, a movement that is likely to continue, according to the Medicaid and CHIP Payment and Access Commission's (MACPAC's) recent Report to Congress: The Evolution of Managed Care in Medicaid.  Managed care can be used to define many different arrangements for delivering and financing health care services, though the main three arrangements are comprehensive risk-based plans, primary care case management programs, and limited benefit plans.  While each state takes a slightly different approach, 48 states and the District of Columbia now use some combination of managed care, incorporating 71% of all Medicaid enrollees.

            "This being said, another paradox exists regarding Medicaid and behavioral health patients.  Medicaid enrollees generally tend to have a higher prevalence of behavioral health issues than the greater population; and further, mental health conditions can exacerbate other existing medical conditions.  Conversely, behavioral health services are often the most 'carved out' services in Medicaid programs, causing enrollees to have to struggle with a complex system and coordinating services.  These problems are further compounded when, in some states, the behavioral health services are 'carved out' of the plan benefit package but the pharmaceutical costs associated with them are included.  Other states have taken a more limited-benefit approach to their plans and have contracts to manage the subset of benefits and services required for particular subpopulations, such as individuals in need of inpatient mental health services.

            "The particular and increasing relevance of managed care in Medicaid comes not from its apparent discrepancies or from the challenges it has had in securing provider participation, but rather from PPACA, which is expected to be fully implemented by 2014.  Notably, this Act will require the states to establish coverage for nonelderly parents, childless adults, and adults with disabilities with incomes up to 138% of poverty.  It also calls for the creation of Accountable Care Organizations (ACOs), which are networks of hospitals, doctors, and other health professionals that agree to share responsibility for the care received by patients.  Falling under the broader category of 'other professionals,' psychologists and other behavioral health specialists will undoubtedly play an integral role as part of these health teams.  Perhaps as we look to the future of healthcare reform in this country, the need for psychologists to be more than just 'other professionals' legislatively will become more apparent and both the government and the psychological community will be called upon to provide both the funding and the necessary professionals to meet the needs of the American people" (Anna Borris, Intern for U.S. Senator Daniel K. Inouye).

            Conditions of Participation for Community Mental Health Centers:  This Summer HHS proposed regulations for community mental health centers which would require comprehensive patient assessments by a "physician-led interdisciplinary team in consultation with the client's primary health care provider, if any.  The interdisciplinary team would be composed of a doctor of medicine, osteopathy or psychiatry, a psychiatric registered nurse, clinical psychologist, a clinical social worker, an occupational therapist, and other licensed mental health counselors, as necessary."  The required psychiatric evaluation must be "completed by a psychiatrist or psychologist with physician counter signature, that includes the medical history and severity of symptoms."  "The CMHC must designate a physician-led interdisciplinary treatment team that is responsible, with the client, for directing, coordinating, and managing the care and services furnished for each client.  The interdisciplinary treatment team is composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and therapeutic needs of CMHC clients."  We would suggest that Katherine's message is extraordinary important if psychology is to remain an independent health care profession under PPACA.  I will soon be retiring from the U.S. Senate staff after 38+ years of a fascinating journey.  "If you miss the train I'm on, you will know that I am gone.  You can hear the whistle blow a hundred miles."  Aloha,

Pat DeLeon, former APA President – Division 29 – August, 2011

 

LICENSURE MOBILITY

            Over the years, psychology's elected leadership has increasingly called for focused attention upon the importance of facilitating licensure mobility.  Stan Moldawsky obtained the endorsement of the APA Council of Representatives slightly over a decade ago and mobility was a significant topic at James Bray's 2009 Presidential Summit on the Future of Psychology.  James notes: "Australia implemented national licensure in 2010 – it was a challenge to get it started, but initial reports indicate that it has helped psychologists practice across the vast country and better serve the broadly dispersed population from the cities to the outback.  The Australia Psychological Society was the key mover of this legislative change."  This Spring, HRSA submitted its report to Congress on licensure portability, assessing the level of cooperation among the various licensing boards and evolving models.  "Licensure portability is seen as one element in the panoply of strategies needed to improve access to quality health care services through the deployment of telehealth and other electronic practice services (e-care or e-health services) in this country….  Overcoming unnecessary licensure barriers to cross-state practice is seen as part of a general strategy to expedite the mobility of health professionals in order to address workforce needs and improve access…."

            Steve DeMers, Association of State and Provincial Psychology Boards (ASPPB): "In addition to our Credentials Bank, Disciplinary Data System and Certificate of Professional Qualification programs that promote mobility, we are also pilot testing in two jurisdictions a Uniform Application for Psychology Licensure system.  In these two jurisdictions, applicants for licensure will actually apply through ASPPB and we will both primary source verify and store the applicant's licensure related information before transmitting it to the jurisdiction for a licensure decision.  We are largely following the Federation of State Medical Boards (FSMB) model of expedited licensure rather than the Nursing Compact approach.  ASPPB is planning on seeking a federal (HRSA) grant to support model programs to expedite licensure as a means of promoting telepractice."

Examples of the magnitude of change just over the horizon: HHS has proposed regulations to assist rural patients, under which practitioners credentialed at one hospital would be allowed to utilize telemedicine – interacting with a patient over interactive video devices – even if they are not credentialed at the hospital where the patient is receiving care.  The House of Representatives Department of Defense (DoD) authorization act includes a provision expanding the state licensure exception to include qualified and credentialed contractor and civilian health care professionals, in order to allow the National Guard, reserves, veterans, and retirees quicker and more efficient access to care.  "This amendment will allow for new technologies in telephone and Internet communications to expand into the [DoD], which will greatly expand access, especially in rural America.  It will also allow more specialists to be involved in providing care….  (Quoting the Vice Chief of Staff of the Army): 'The Army, like the larger American society, is suffering from a shortage of behavioral health specialists, and that is, in fact, a national crisis.  Efforts in tele-behavioral health – allowing specialists to meet with patients through teleconferencing technology, for instance – could increase the effectiveness and reach of a limited number of providers….  There are challenges regarding the credentialing and licensing of specialists to work across State lines.'"

We would rhetorically ask: Have our State Association members engaged in discussions with their own licensure board in order to ensure that licensure mobility becomes a significant priority?  Currently, 24 States have adopted the Nursing Compact approach; 37 States are in some phase of implementation of the FSMB Uniform Licensure Application approach.  Where are your State Association and Licensing Board in this important discussion?  Aloha,

 

Pat DeLeon, former APA President – Division31 – June, 2011

 

 

AN EXCITING VISION FOR THE FUTURE

The Department of Veterans Affairs:  I recently had the opportunity to attend the 14^th annual VA Psychology Leadership Conference, "Innovation through Leadership, Research, Service, and Advocacy."  This was the largest gathering in their history with over 200 excited colleagues attending, many for the first time.  Maui'sKathy McNamara and Kathleen Piercerepresented Hawaii.  APA President Melba Vasquez gave a truly inspiration report on the Association's efforts on behalf of our nation's veterans, as well as her Presidential initiatives; for example, carefully addressing the needs of our increasing immigrant population. Katherine Nordal and Randy Phelps from the Practice Directorate highlighted the importance of psychology seeing itself as a bona fide health care profession and working hard to ensure that our nation's health policy experts (including those in the White House) appreciate all that we can bring to their vision.  VA Central Office was well represented.  I was very pleased with the extent to which Bob Zeiss has been systematically expanding our post-doctoral presence; this year funding 267 positions at 58 sites in 31 states and the District of Columbiaand Puerto Rico.

Over half of our profession's clinicians have had some VA training experience.  Many of us grew up in families in which loved ones served in the military.  VA is working hard to transform itself into a veteran-centric, highly responsive integrated health care system utilizing the most up-to-date technology to provide state-of-the-art care.  Historically practitioner-comfortable "silos" must give way to interdisciplinary, coordinated care.  VA will attract retiring DoD colleagues with their unique veteran's perspective.  And, with the military already authorizing prescriptive authority, VA will eventually follow suit.  The federal sector has a unique opportunity, with its considerable resources and national presence, to bring the rest of the health care world into the 21^st century capitalizing upon the unprecedented developments occurring within the health information technology (HIT) environment.  Is there, for example, any meaningful difference between on-site supervision and that conducted via telehealth?  At the highest level, VA and DoD are committed to integrating their electronic health records.  This will allow seamless care from active duty to retirement, and across-patient and family comparisons of effectiveness and need.  VA visionaries Toni Zeiss and Lisa Kearney truly did an outstanding job.

            "Telepsychology is knocking:  The key to responsible use in our clinical work is the training of psychologists regarding the existing legal, ethical, and clinical issues involved with not only e-mail but video-chat such as Skype, Facebook, text messaging, iPhone apps, as well as a number of other technologies.  Handling the barrage of new electronic services promising to make practice 'easier' is fraught with nuances that are difficult for the average clinician to detect.  Privacy and confidentiality; licensure and other regulatory issues; patient and practitioner authentication; HIPPA requirements; appropriate online professionalism, including boundaries in social media sites; treatment ramifications of searching for patient information online; reputation management and reacting to negative reviews in online rating websites; mandated reporting of abuse or suicide and homicide intent; what to include in the informed consent discussion and document; what to include in the patient record; how online technology is likely to evolve, including the electronic health records and what they mean for psychologists – all these issues are at our doorstep.  When the patient floats from one to another technology and asks that the psychologist accommodate him or her, what is the responsible psychologist to do?" (Marlene Maheu, a visionary leader in telehealth).

            An Interdisciplinary Perspective:  Sandy Harding, MSW, with the AmericanAcademy of Physician Assistants: "The physician assistant (PA) profession was created over 40 years ago in response to a shortage of primary care physicians.  In 1970, there were approximately 250 PAs.  Today, over 75,000 PAs provide high quality, cost effective care in virtually all health care settings and in every medical and surgical specialty.  PAs are one of three health care professionals providing primary medical care in the U.S.  By design, PAs always practice in teams with physicians, extending the reach of medicine and the promise of health care to the most remote and in need-communities.  PAs often provide autonomous medical care, have their own patient panels, and are granted prescribing authority in all 50 states.  In 2009, nearly 300 million patient visits were made to PAs.  By all accounts, the primary health care workforce must grow in order to provide care to the individuals and families who will receive access to covered medical care as a result of the implementations of President Obama's Patient Protection and Affordable Care Act.  PAs are a key part of the solution to today's and tomorrow's health care workforce shortage.  However, to fully utilize PAs in the nation's primary care workforce, Congress must: * Eliminate unnecessary federal barriers to the quality medical care provided by PAs; and, * Integrate PAs into all federal programs designed to promote growth in the primary care workforce.  Currently, for example, Medicare imposes a barrier to hospice care and the Federal Employees' Compensation Act will not honor a clinic-based claim where the PA is the only health care worker on site, but will provide for reimbursement in a hospital emergency room."

            A Historical Perspective:  Jerry Michael, former Dean of the University of Hawaii School of Public Health and Assistant Surgeon General of the U.S. Public Health Service, prophetically observed in 1968: "For broad planning purposes, we can project long-range trends in health manpower supply and demand.  In contrast to our scientific and economic successes and people's expectations based upon them, we see gross inadequacies in trained manpower.  I cannot emphasize too strongly that the value of any auxiliary health worker is directly proportional to the quality of his training and the quality of his supervision.  Quality training and quality supervision are essential.  It is also essential to determine just what jobs the workers are to do – and where – and to train them for the specific jobs.  These precepts are so elementary that it is almost redundant to state them, yet we see all too many instances in which these obvious first steps have been forgotten or overlooked.  The keystone in better utilization of health care facilities is improved planning, training, and education.  Thus it would follow that these elements are equally crucial in the utilization of health personnel.  In addition, planning aimed at the most effective use of health manpower must also be responsive to changing knowledge and social changes and to the increasing expectations of health service consumers.  The scarcity of health manpower must be viewed as both a national and a local problem, and the approach to its solution must be systematic, based on sound knowledge of the makeup of the health system and with the needs of the patient identified and kept paramount."  VA, DoD, and increasinglyHawaii's political leadership appreciate this vision.  Above all else, our system must be patient-centered and no longer concerned with being highly provider comfortable.  Aloha,

Pat DeLeon, former APA President – HPA – June, 2011

 

THE ADVENT OF TECHNOLOGY

Technology's Contribution To Health Care Reform:  As President Obama's landmark health care reform legislation, thePatient Protection and Affordable Care Act (PPACA) [P.L. 111-148], is being steadily implemented, the concerns raised from a number of vantage points can be seen as a testament to his vision, as well as to the magnitude of change involved.  Change is always unsettling, especially for those comfortable with the status quo.  One of the underlying objectives of PPACA is to focus the unprecedented advances occurring within the communications and technology fields directly upon the health care environment, as they are already impacting every other segment of our economy.  This can be seen with the significant resources provided for Comparative Clinical Effectiveness Research (i.e., determining objectively what services work, for what symptoms, and under what conditions); ensuring that all providers have ready access to electronic health records, thus providing the capacity to compare outcomes across patients and diagnoses (Health Information Technology (HIT)); and increasing the applicability of telehealth care, so that one's geographical location will no longer be a barrier to receiving quality care.  There can be no question that central to effectively utilizing this technology are critical and complex licensure issues.  Perhaps the underlying question is: Whether our nation looks at providing necessary health care as representing a societal responsibility or an individual patient/provider decision?

            Organized psychology appreciates the importance of being proactive.  In February, the APA Council of Representatives approved the creation of a Telepsychology Task Force, co-chaired by Linda Campbell and Fred Millan, that will be comprised of four APA representatives, four ASPPB representatives, and two APAIT representatives.  One of the issues that the task force will face is inter-jurisdictional practice/licensure mobility.  Their first meeting is scheduled for mid-July. Judy Hall, National Register Executive Officer: "The National Register of Health Service Providers in Psychology (NR) is uniquely positioned to serve as the primary licensure mobility credential for psychologists in the United States, Canada, and beyond.  We are by far the largest credentialing organization for psychologists, with 11,000 members; have standards and credentialing procedures that are well established and are widely approved by licensing boards to expedite licensure mobility.  To date, we have verified credentials to licensure boards for more than 1,300 Registrants.  The NR is ranked by both early career and more senior psychologists as one of the most valuable benefits, both for the here-and-now value and as an insurance policy for those who may apply for additional licenses later in their careers.  For a list of jurisdictions approving the National Register, seewww.nationalregister.org."

            Health Resources and Services Administration (HRSA):  APA's Debra Baker shared with us the report released this Spring by HRSA: "Health Licensing Board Report To Congress."  Requested by the FY'2010 Senate Appropriations bill, the report updated efforts being made on licensure portability and the level of cooperation between health licensing boards, the best models for such cooperation, and the barriers to cross-state licensing arrangements.  HRSA focused on physicians and nurses since in its view these are: "the two professional groups for which there is the most information on alternative approaches to overcoming licensing barriers to cross-state practice."  Utilizing funding from FY' 2006, HRSA created its licensure portability grant program which has subsequently funded projects submitted by the Federation of State Medical Boards (FSMB) and the National Council of State Boards of Nursing (NCSBN), as well as the State of Wisconsin Department of Regulation and Licensing.

            "Licensure portability is seen as one element in the panoply of strategies needed to improve access to quality health care services through the deployment of telehealth and other electronic practice services (e-care or e-health services) in this country.  But licensure portability goes beyond improving the efficiency and effectiveness of electronic practice services.  Overcoming unnecessary licensure barriers to cross-state practice is seen as part of a general strategy to expedite the mobility of health professionals in order to address workforce needs and improve access to health care services, particularly in light of increasing shortages of healthcare professionals.  It is also seen as a way of improving the efficiency of the licensing system in this country so that scarce resources can be better used in the disciplinary and enforcement activities of state boards, rather than in duplicative licensing processes."

            Those involved in the licensing process of both medicine and nursing are seeking ways to simplify the licensing process for those members of their professions who are interested in obtaining licenses in more than one state, although they have taken different strategic approaches to date.  Nursing has developed a far reaching mutual recognition model under which practice across state lines would be allowed, whether physical or electronic, unless the individual practitioner is under discipline or a monitoring agreement that restricts practice across state lines.  This approach requires each state to enter into an interstate compact, called the Nurse Licensure Compact.  This was first implemented on January 1, 2000 by Maryland, Texas, Utah, and Wisconsin.  Currently 24 states participate.

            Medicine has been encouraging states to adopt the model of expedited endorsement.  This is a method of setting criteria to approve the valid license of another state.  The process accepts a license issued in one state that was verified and sets requirements for endorsing a license granted in another state.  Idaho, Iowa,Michigan, Nevada, New Mexico, North Carolina, Oregon, and Rhode Island currently have adopted the expedited endorsement process.

Some state authorities are clearly uncomfortable with accepting the licensing process of another state.  Concerns expressed include: not every state board requires criminal background checks and state boards are ultimately responsible for maintaining public protection within the state.  Control/lack of authority; lack of uniform standards; cost/loss of revenue; fear among unions and state professional associations that this could facilitate strike breaking; a general misunderstanding about the process among practitioners; and the lack of independent evaluations have all been noted as potential barriers.  A number of these concerns can be satisfactorily addressed, especially as the broader provider community becomes more clinically comfortable with the use of advanced technology (HIT) in their daily practices.  To place this evolution in perspective, at the time the Obama Administration began its successful quest for health care reform, their goal was to bring physician HIT utilization up from five percent to 90 percent by 2019 and hospital utilization to 70 percent during the same time frame, with their estimate being that only 1.5 percent of hospitals had a comprehensive electronic system available in all units.

For over a century, health care in theUnited States has primarily been regulated by the states.  Such regulation includes the establishment of licensure requirements and enforcement of standards of practice for health providers.  The licensure authority is administered with the goal of ensuring that health care professionals are academically qualified, competent, and mentally and physically fit to provide the activities covered by the license.  "As the U.S. health system evolves to meet the changing needs of consumers, traditional methods of healthcare delivery are being transformed.  No longer do the patient and the provider need to be in the same location to receive quality health services.  Telehealth (telecommunications and information) technologies are being used to provide healthcare services in a more efficient and effective manner to address the shortages and maldistribution of healthcare professionals that result in lack of access to quality healthcare services, whether due to geographic, economic, or other social factors.  Telehealth services are increasingly becoming part of the mainstream of healthcare.  For these reasons, the number of physicians and the number of other health providers practicing across state boundaries have increased in recent years.  This trend is expected to continue in the foreseeable future."

The purpose of licensing health care professionals is to protect the public from incompetent or impaired practitioners.  A licensure system must be able to administer and enforce its standards.  The basic standards for medical and nursing licensure have become largely uniform across all states.  Physicians and nurses must graduate from nationally approved educational programs and pass national licensure examination.  However, there are significant differences in administrative and filing requirements among the states.

The American Bar Association Health Law Section in its 2008 report proposed a model for allowing the cross-state licensure of physicians, which was approved by the ABA House of Delegates.  The Federal Communications Commission (FCC) released its National Broadband Plan in 2010 urging states to revise licensure requirements to enable "e-care."  Noting that current licensure requirements limited practitioners' ability to treat patients across state lines, which hindered access to care, the FCC urged increased collaboration.  And, if the states failed to develop reasonable licensing policies to facilitate electronic practice over the next 18 months, it recommended that Congress ensure that Medicare and Medicaid beneficiaries are not denied the benefits of "e-care."  Some have already called for the federal government to enact national licensure.  In our view, the states still have time to demonstrate vision.  "You know I feel all right."  Aloha,

Pat DeLeon, former APA President – Division 18 column – June, 2011

 

WHERE HAVE ALL THE FLOWERS GONE?

 The Robert Wood Johnson Foundation (RWJ) is the nation's largest philanthropy devoted solely to the public's health.  Their efforts focus upon improving both the health of everyone in America, and their health care – how it's delivered, how it's paid for, and how well it does for patients and their families.  By investing in improving systems through which individuals receive health care and in fostering environments that promote health and prevent disease and injury, RWJ expects to achieve comprehensive, meaningful, and timely change.  Creating leverage for change is RWJ's greatest asset.  Annually RWJ issues its Anthology, which this year focused upon Improving the Health and Health Care of Vulnerable Populations.  For those colleagues interested in learning about the gradual evolution of our nation's health policy, these publications provide a fascinating glimpse into the vision of the foundation world, where only a few psychologists have ever been involved.  Ruby Takanishi, President of the Foundation for Child Development; Judith Rodin, President of the Rockefeller Foundation; and Anne Peterson, formally of the W.K. Kellogg Foundation, being notable exceptions.

            The Vulnerable Populations portfolio was created in 2003 and has developed a special niche by identifying and supporting innovative programs at the intersection of health and the social factors that influence health – factors such as education, housing, race, class, and income.  As such, it provides a unique opportunity to dramatically change how services are delivered, while at the same time helping individuals, families, and communities make progress towards better health and a healthier society.  Helping real people and moving towards a healthier society are laudable goals which are "possible, but not always easy."

            A concerted effort has been made by RWJ to go beyond supporting creative individual efforts which address national needs, by also nurturing the most promising among them with the hope and expectation that they can become strong enough to "enter the mainstream" of society's expectations.  One example would be RWJ's commitment since the 1970s to fund a range of projects advancing Nurse Practitioners.  The Nurse-Family Partnership program, in which public health nurses visit young, low-income, first-time mothers in their homes, is a RWJ-funded initiative that may be ready to enter the mainstream.  Starting in 1979, support was provided for a new approach to improving the health of babies and their mothers.  In the 31 years since its first grant, RWJ has provided nearly $27 million to build evidence about the effectiveness of this approach and to support its replication.  In 2002, the Edna McConnell Clark Foundation, along with other foundations and corporate funders, supported a major expansion of the program.  President Obama's Patient Protection and Affordable Care Act (PPACA) authorized $1.5 billion for states that adopt home-visitation programs that serve young, low-income mothers.

RWJ's initial nurse practitioner efforts focused upon increasing the access of people living in rural areas and inner cities to non-hospital based care.  These became the forefront of a movement that lead to the widespread acceptance of nurse practitioners as recognized health care professionals.  One might say that the Foundation supported a "disruptive innovations" approach by sponsoring a less costly group of health professionals who could carry out many of the functions performed by a more costly, and often inaccessible group, namely physicians.  The underlying philosophical question remains, however: Why do some initiatives evolve into mainstream concepts while others do not?  Perhaps it is because they are picked up initially by change agents who influence the rest of society until a critical mass of individuals find it is in their best interest to adopt an innovation.  Are there "take-off points" when the accretion of small advances reach the point where change becomes unstoppable?  Or, as APA convention speaker Malcolm Gladwell proposed, by taking one step at a time, does an innovation affect enough people to reach a "tipping point," from which it then naturally races through the population?

            Four elements were highlighted in theAnthology which are seen as necessary to move foundation-funded ideas into the mainstream.  1.) The idea is seen by a substantial portion – or at least an influential portion – of the population as a potential solution to a pressing problem.  2.) The political system is receptive to the adoption of new ideas – especially when legislation is the means of spreading them.  3.) The evidence is strong that an idea is workable and perhaps cost-effective.  And, 4.) Committed advocates keep the idea in the forefront and fight for its widespread adoption.  The RWJ President enumerated five key tools available to philanthropy: Communicating, Convening, Coordinating, Connecting, and Counting (plus a sixth, Cash) – her "Five Cs."  From our experience within the public policy arena over the years, we would especially agree with the view that those who wish to implement significant change must: "Stick with good ideas for a long time.  An inhospitable political climate can suddenly become inviting, as the passage of health care reform in 2010 demonstrates."

            Each of the Vulnerable Population projects has direct application to psychology and the behavioral sciences.  Caring Across Communities explored the need for mental health services among probably the most vulnerable population in our nation, children with mental health problems born to refugees or immigrants.  Generally, this population is not welcome in the medical care system.  If undocumented, they are pretty much precluded from getting care except in public hospitals, free clinics, and community health centers.  They are more likely to live in poverty, be poorly educated, and lack health insurance coverage.  "Despite laws and regulations requiring parity in coverage of mental and physical health services under employer-sponsored health plans, such parity does not in fact exist.  Not to mention the stigma associated with mental illness, which would discourage many people from seeking services for themselves and their children.  Moreover there are all of the cultural barriers, of which language is the most obvious and perhaps the easiest to resolve."

Studies show that one out of every five school children in America is now either the child of an immigrant or an immigrant him or her self.  Problems such as post traumatic stress disorder (PTSD) appear to be particularly prevalent in this population, close to 20% for those immigrants who experienced violence before arriving.  School officials begin to see the effects of PTSD in problems that range from rising individual disciplinary cases to a 25% high school dropout rate for foreign-born pupils nationwide.  North Carolina officials reported 59% of their immigrant children are suffering from symptoms of anxiety, about one-third are dealing with PTSD, and 9% have had thoughts of suicide – while the rates of treatment are appallingly low.  Many refugees and their children have witnessed horrors unimaginable to most Americans.  The parents resettled in the U.S. primarily for their children and yet they face a school system with little understanding of what they or their children have gone through.

            Another impressive initiative, the Alaskan Native Dental Health Aide and Therapist program, is, in our judgment, highly analogous to psychology's prescriptive authority (RxP) quest.  "How to deliver health care services to individuals residing in extremely remote areas?" has long been a challenge for health policy experts.  Professional (and at times social) isolation remains a major challenge for rural America. Alaska is a huge and highly isolated region with what can be considered extraordinary inhospitable weather.  The model proposed by RWJ and others (most notably the Rasmuson and Kellogg Foundations) to address the pressing dental needs of rural Alaska was to provide a limited amount of training to members of the local communities who then could provide basic necessary services to their neighbors (akin to China's barefoot doctors).  The oral health crisis in Alaska has sparked numerous comparisons with the TB epidemic of the 1950s.  Nationwide, tooth decay is the most common chronic childhood disease, interfering with daily activities for an estimated 4 to 5 million children and adolescents annually.  The Indian Health Service (IHS) estimates that untreated lesions exist in 68% of American Indian and Alaskan Native adolescents, compared with 24% of other children in the nation.  One-third of Alaskan Native children report missing some days of school each year due to dental pain.

In 2001 the Alaska Native Tribal Health Corporation, the nation's largest tribal health organization, proposed it's Dental Health Aide Program, based upon the principles underlying community health aides.  At the time there was no appropriate training program in the U.S. since every attempt to introduce such a program had been steadfastly resisted for nearly a century by organized American dentistry.  The World Health Organization (WHO) 2003 report indicated that by that time 42 countries around the world – including Canada, Great Britain, Australia, and New Zealand – had relied for years on such midlevel providers to educate patients, apply sealants, and perform basic dental procedures, from fillings to extractions, and even root canals.  The training for the Alaskan Native providers was conducted in New Zealand.  As the graduates began providing services, the ADA and the Alaska Dental Society filed a joint lawsuit in the state court, accusing the dental therapists of practicing dentistry without a license and mounted a major public relations campaign proclaiming "second class dental care."  In June, 2007 the Alaska Superior Court ruled that the dental health therapists were legal under a federal statue, although we understand that even today there are strict limitations on where they can, in fact, practice.  Organized dentistry's opposition to alternative providers has continued, notwithstanding the dental extender provisions contained in PPACA, as well as increasing financial support from the foundation world.  The underlying policy arguments are: Whether these providers represent an alleged public health hazard?  Or, Are they providing access to quality care?  Not surprisingly, all of the objective evidence supports their continued contribution to the health and well being of the Alaskan Native population and as a result, their probable expansion into the federally qualified community health center network which also continues to report significant difficulty in accessing dental care for their patients.

Throughout the RWJ's impressive history of "making a real difference" there have been at least four reoccurring themes: 1.) Supporting independent quality research to provide an evidence-base that will be widely accepted.  2.) Communications are a key to making research relevant to policy makers and the public.  3.) Answering issues of concern to policy makers.  And, 4.) Policy impact definitely requires a long-term vision.

            This Spring, AARP and RWJ facilitated an impressive Congressional briefing by the House and Senate Nursing Caucuses following up on the Institute of Medicine (IOM) report The Future of Nursing: Leading Change, Advancing Health.  A campaign for action was described with the goal of having Regional Action Coalitions functioning in all 50 states by 2012.  RWJ has already committed $10 million for the campaign which will systematically focus upon building a 21^st century nursing workforce with the skills and knowledge Americans need; increasing the influence of nurses in high levels of health care, policy, business, and community decision making; and removing artificial barriers to nursing being allowed to clinically function to the fullest extent of its training.  Former HHS Secretary Donna Shalala has been actively involved.  Perhaps the most interesting development at the briefing was the public recognition by the President and CEO of the Association of American Medical Colleagues that the time for such change has arrived.  Subsequently, Major General Patricia Horoho was nominated by DoD Secretary Robert Gates to serve as the Surgeon General of the U.S. Army.  When confirmed, she will be the first nurse and first female to serve in that position since the establishment of the Army Medical Corps in 1775.  Times are a-changing.  "When will we ever learn?  When will we ever learn?"  Aloha,

Pat DeLeon, former APA President – Division 42 – June, 2011

 

VISION FOR THE FUTURE – THE IMPORTANCE OF INVOLVEMENT

The Department of Health and Human Services:  In presenting her Fiscal Year 2012 budget, Secretary Sebelius (HHS) expressed her enthusiasm for effectively implementing President Obama's landmarkPatient Protection and Affordable Care Act (PPACA) in a timely fashion.  "In President Obama's State of the Union address he outlined his vision for how the United Statescan win the future by out-educating, out-building and out-innovating the world so that we give every family and business the chance to thrive.  His 2012 budget is the blueprint for putting that vision into action and making the investments that will grow our economy and create jobs.  At the Department of Health and Human Services [HHS] this means giving families and business owners better access to health care and more freedom from rising health costs and insurance abuses.  It means keeping America at the cutting edge of new cures, treatments and health information technology.  It means helping our children get a healthy start in life and preparing them for academic success.  It means promoting prevention and wellness to make it easier for families to make healthy choices.  It means building a health care workforce that is ready for the 21^st century health needs of our country.  And it means attacking waste and fraud throughout our department to increase efficiency, transparency and accountability.  Our 2010 budget does all of this."

            Visionary health psychologist Susan McDaniel and APA Executive Officer Norm Anderson have long been urging our colleagues to become more personally involved in educating society's leaders and the public regarding the importance of the psychosocial-economic-cultural gradient of quality health care, as well as the increasingly emerging scientific and clinical evidence supporting the critical nature of the social determinants of health.  The Secretary clearly has a similar vision.  Her budget redirects and increases funding within the Centers for Disease Control and Prevention (CDC) targeted towards reducing chronic disease.  Rather than splitting funding and making separate grants for heart disease, diabetes, and other chronic diseases, she has proposed one comprehensive grant that will allow States to address chronic disease more effectively.  Similarly, the prevention resources within SAMHSA would be redirected to fund evidence-based interventions and better respond to evolving needs.  States and local communities would benefit from the additional flexibility while funds would still be competed and directed toward proven interventions.

We would rhetorically ask: How many of our colleagues who are primarily in private practice share Division President Glenn Ally's vision and have developed collaborative relationships with their local state or county health authorities?  Glenn, along with two other medical psychologists, works closely with his local Community Mental HealthCenter; other Louisiana medical psychologists in private practice work with their Children's and State Psychiatric Hospitals, not to mention serving on numerous State Boards and Committees/Commissions.  It is only by becoming active community participants and visionary leaders that psychology will ultimately be well positioned to effectively engage in the policy discussions that determine local plans for implementation of PPACA on a collegial and equal basis with other health care disciplines, interested stakeholders, and government and business community leaders.  The President's vision provides the Administration and States with considerable flexibility to develop local strategies for successfully meeting broad-reaching national objectives.  As Jim Quillin keeps reminding us, "All politics are local."

            The HHS Secretary further pointed out that PPACA expands access to affordable coverage to millions of Americans and strengthens consumer protections to ensure individuals have coverage when they most need it.  Focusing upon ensuring access to quality, culturally competent care for vulnerable populations: "The budget includes $3.3 billion for the Health Centers Program, including $1.2 billion in mandatory funding provided through the Affordable Care Act Community Health Center Fund, to expand the capacity of existing health center services and create new access points….  (This) will enable health centers to serve 900,000 new patients and increase access to medical, oral, and behavioral health services to a total of 24 million patients."  Her Innovation Center, in coordination with private sector partners wherever possible, will pursue new approaches that not only will improve quality of care, but also lead to cost savings for Medicare, Medicaid, and CHIP.  We suspect that very few of our colleagues truly appreciate the long term implications for their daily practices of the PPACA established Patient-Centered Outcomes Research Institute which will be funding research and getting relevant, high quality information to patients, clinicians, and policy-makers, so that they can make informed health care decisions.  The Institute of Medicine (IOM) estimates that almost 40% of Americans possess only "basic" or "below-basic" health literacy skills.  Thus, their ability to make informed decisions without concerted assistance will become increasingly difficult as the volume and complexity of data available to them increases.  The Patient-Centered Outcomes Research Trust Fund will fund this independent Institute and related HHS activities.  Approximately $620 million will be allocated during the coming year as investments in core patient-centered health research activities and to disseminate research findings, train the next generation of patient-centered outcome researchers, and improve data capacity.

            The HHS budget also includes $78 million for the Office of the National Coordinator for Health Information Technology to accelerate health information technology (HIT) adoption and promote electronic health records (EHRs) as tools to improve the health of individuals and transform the health care system.  One focus will be assisting health care providers in becoming meaningful users of health information technology.  One of the Secretary's priorities should be of particular interest to APA.  Her budget provides HRSA with $163 million for Health Workforce Diversity programs to improve the diversity of the nation's health workforce and improve care to vulnerable populations.  These funds will support training programs and scholarship opportunities for students from disadvantaged backgrounds who are enrolled in health professions and nursing programs.

            The Department of Defense:  "As this year's Military Nurse Fellow, I was thrilled to attend the Senate Committee on Appropriations defense subcommittee hearing on the DoD Fiscal Year 2012 Health Programs.  During this hearing, Senators heard testimony from the Nurse Corps Chiefs and the Surgeons General from the Army, Air Force, and the Navy.  Not at all surprising was a universal concern voiced by the Senators regarding the behavioral health of our troops and their families.  The Surgeons General and the Nurse Corps Chiefs all mentioned during their testimony that preserving the psychological health of service members and their families is one of the greatest challenges the services face today.  The military is not immune to mental health issues or concerns; behavioral health issues affect military members and their families just as they affect the civilian community, perhaps even more so.

            "Tragically, the wars in Iraq andAfghanistan have produced a group of combat veterans who face a lifelong struggle to cope with the severe physical and psychological traumas of war.  The invisible scars of war cut deep and transcend through military members to their families who are desperately trying to assist their loved ones to cope.  The military health system as a whole strives to provide the very best ongoing healthcare for military members and their families including mental health services and support.  It is clear that early identification of mental health risks through surveillance, education, and training is a key component in helping to mitigate behavioral health and stress related issues.  The Army has developed an approach to strengthen their soldiers' and families' behavioral health and emotional resiliency through a campaign to align various behavioral health programs.  The long term goals of this Comprehensive Behavioral Health System of Care is to protect and restore the psychological health of soldiers and their families and prevent adverse psychological and social outcomes like family violence, DUIs, drug and alcohol addiction, and suicide.

            "Citing that no one is immune to the stresses and strains of life, the Air Force testimony identified that one important aspect of patient-centered preventive care includes preserving the mental health and well-being of service members and improving their resilience.  Initiatives have been developed to support and train front line supervisors to recognize when an individual may be having difficulties.  Counseling services have also been expanded beyond traditional avenues.  Other initiatives aimed at addressing behavioral health and resiliency included utilizing a targeted approach that recognizes different risk groups.  An overarching theme identified was the utilization of 'best practice' programs to help service members become more resilient.  An example of this is teaching the afflicted to realize that seeking help is a sign of strength, not a sign of weakness.

            "The Navy keyed in on the fact that service members and their families are usually mentally and emotionally strong at baseline, but the long conflict (war) and other related deployment challenge this resilience.  Thus, the Navy implemented programs for early detection of stress injuries, which includes focusing on leadership's role in monitoring the health of their people.  Additionally, the programs include providing leaders with tools they may employ when service members are experiencing mild to moderate symptoms and the utilization of multidisciplinary expertise for members more seriously affected.

            "It is evident from the testimony that psychological health issues cut across all walks of life.  Programs that support, prevent, diagnose, mitigate, and treat behavioral health issues are paramount to ensuring the optimal health of our communities, whether civilian or military.  The services are working hard to change the 'culture' and are striving to ensure military members are a healthy, fit and resilient force!" (Lt. Col. Maureen Charles, USAF).

            The Department of Agriculture:  The U.S. Department of Agriculture recently announced a $25 million grant to the Collegeof Agriculture at the University of Hawaii in order to develop obesity prevention strategies among native populations in the Pacific Region, thereby continuing its commitment to meet the rising challenge of obesity in our nation.  The Secretary: "We know that in order to win the future, we have to win the race to educate our children.  That means that our kids must be healthy so they can learn and thrive.  Improving childhood nutrition remains a key priority of the Obama Administration as we work to ensure our kids are ready to out-compete in an increasingly globalized world."  This five year initiative will use a community-based participatory research approach that engages communities to prioritize obesity prevention strategies.  Researchers will work with the communities to develop community needs assessments and establish sustainable nutrition and health-promoting programs.  Specifically, the team will identify specific environmental factors leading to childhood obesity in selected schools and daycare facilities.  Intervention strategies will be attuned to culturally-specific needs and goals, and focus on physical activity, nutritional intake, and the amount of sleep children get each night.  This is a health psychologist's dream.

            The implications of the similar visions expressed by the leadership of these three federal Departments should be quite exciting for psychology, as long as our practitioners, scientists, and educators are actively engaged in shaping the specifics of the implementation strategies as they gradually unfold.  The behavioral sciences have much to contribute to these important national agendas and our visionaries have provided a solid scientifically-based foundation for their success.  Involved we must be.  Aloha,

Pat DeLeon, former APA President – Division 55 – May, 2011

 

INTEGRATED CARE -- MICHAEL, ROW YOUR BOAT ASHORE

            From a national public policy perspective, it is becoming increasingly evident that our nation is steadily evolving towards embracing an integrated, primary care-oriented health care delivery system.  The enactment of President Obama's landmarkPatient Protection and Affordable Care Act [PPACA] is unquestionably the most dramatic indication.  This law provides the various States and the Administration with considerable flexibility to reach national objectives, as it is systematically implemented over the next five to ten years.  The legislation is fundamentally patient-centered and not provider-centric.  Psychology must appreciate that the clinical services our practitioners provide are, in today's political and policy world, deemed to be health care services.  Accordingly, how the nation addresses the complexities of that environment will have a direct and profound impact upon the profession's future (i.e., practice, education, and research).  Substantive change evolves over time and is almost always based upon foundations established by visionaries from the past.  We would urge that psychology pay careful attention to the views expressed by those Institute of Medicine (IOM) participants who have, and frequently still are serving as health policy appointees within the Bush and Obama Administrations.  Their focused attention upon curtailing the ever-escalating cost of health care and bringing data-based, scientific knowledge to the daily delivery of care is unprecedented.  The advances occurring within computer sciences and related communications fields make their vision achievable.

            Movement Towards Integrated Care:  Five years ago the State ofMassachusetts joined Hawaii in enacting legislation which took a significant step towards guaranteeing that all of its citizens would have access to necessary health care.  Recently, due primarily to ever-escalating costs, it is considering replacing its fee-for-service system with an increasingly capitated approach that is very similar to President Obama's Accountable Care Organization (ACO) initiative (which many have suggested is founded upon President Nixon's HMO vision).  The underlying concept is to provide pre-set payments to organized teams of health care providers which would be responsible for all of the care required by a group of patients, with the possibility of bonuses for keeping people healthy.  Currently 98% of Mass.residents are insured with the Senate President acknowledging: "We did access first.  Now we have to figure out how we afford that."  The Governor's proposal builds upon a consensus among leaders from the state's insurance and hospital industries, medical society, and legislature who served on a special state commission.  Fee-for-service "is a primary contributor to escalating costs and pervasive problems of uneven quality" the commission unanimously concluded.

            The Healthcare Imperative: Lowering Costs and Improving Outcomes:  The IOM has proposed lowering the nation's health care expenditures by 10% in 10 years, while improving patient health and the quality of care provided.  The Congressional Budget Office (CBO) estimates that federal spending on health care will double in the next decade, consuming 27% of the budget by 2020.  The overarching IOM vision is to have 90% of clinical decisions being supported by accurate, timely, and up-to-date clinical information by 2020.  To accomplish this, it will be necessary to develop a learning health system that is designed to generate and apply the best evidence for the collaborative health care choices of each patient and provider and to drive the process of discovery to become a natural outgrowth of patient care, while ensuring innovation, quality, safety, and value in health care.  Evidence development must not be merely an occasional byproduct of health care, but instead evidence capture and analysis, as well as its application, must be systematically structured as an integral and natural component of the care process.

            An IOM workshop identified six domains of excess costs in health care: unnecessary services (volume), services delivered inefficiently, prices that are too high, excessive administrative costs, missed prevention opportunities, and fraud.  The participants concluded that each is an important contributor to excessive health care costs and the amount of excessive costs incurred from each is tremendous.  Excess costs stemming from waste and inefficiency in the nation's health care system was estimated by IOM to total between $750 billion and $785 billion in 2009.

Health care cost increases continue to outpace the price and spending growth rates for the rest of the economy by a considerable margin.  At $2.5 trillion and 17% of the GDP in 2009, health spending in our nation commanded twice the per capita expenditures of the average for other developed countries.  "Moreover, there are compelling signals that much of health spending does little to improve health, and, in certain circumstances, may be associated with poorer health outcomes."  Interestingly, the Peter G. Peterson Foundation which supported this workshop is primarily dedicated to the mission of increasing public awareness of the nature and urgency of key economic challenges threatening the nation's fiscal future, and accelerating action by identifying sensible, sustainable solutions.  It has committed significant resources and attention to the area of health care costs and solutions given health care's direct impact upon the economy.

            Without significant action, by 2050 Medicare and Medicaid expenditures will account for nearly a quarter of the entire U.S.economy.  In 2008, Medicaid spending accounted for approximately 21% of total state spending and represented the single largest component of state spending.  Similarly, in the private sector health care costs have contributed to slowing the growth in wages and jobs.  "While the United States has the highest per capita spending on health care of any industrialized nation – 50 percent greater than the second highest and twice as high as the average for Europe, it continually lags behind other nations on many healthcare outcomes, including life expectancy and infant mortality."

            A number of common themes surfaced.  The Cost and Outcome Challenges. * Health Cost Excesses with Personal, Institutional, and National Consequences.  * Health Outcomes Far Short of Expectations.  Racial disparities in access lead to poorer outcomes, lost productivity, and lower quality of life.  * Fragmented Decision Points, Inconsistent Principles, Political Distortions. The Drivers of the Shortfalls.  * Scientific Uncertainty.  The gap between practice needs and available guidance is growing.  * Perverse Economic and Practice Incentives. * System Fragmentation. * Opacity as to Cost, Quality, and Outcomes. * Changes in the Population's Health Status.  Since 48% of Medicare beneficiaries have at least three chronic conditions and 21% have five or more conditions, it has been estimated that approximately 60 million Americans have multiple morbidities, a number that is expected to increase to 81 million by 2020.  * Lack ofPatient Engagement in Decisions.  Almost 40% of Americans possess only "basic" or "below-basic" health literacy skills.  Thus, their ability to make informed decisions becomes increasingly difficult as the volume and complexity of data available to them increases.  * Under-Investment in Population Health.  Only about 6% of national health expenditures are spent on public and population health.  Levers to Address the Drivers.  * Streamlined and Harmonized Health Insurance Regulation.  * Administrative Simplification and Consistency.  * Payment Redesign to Focus Incentives on Results and Value.  There is a need to better target resources on those patients at highest risk of poor outcomes.  * Quality and Consistency in Treatment, with a Focus on the Medically Complex.  There are already more than 3,000 guidelines from more than 280 organizations registered with the National Guideline Clearinghouse, thus consistency in guideline recommendations is a concern.  * Evidence That Is Timely, Independent, and Understandable.  * Transparency Requirements as to Cost, Quality, and Outcomes.  * Clinical Records That Are Reliable, Sharable, and Secure.  * Data That Are Protected But Accessible for Continuous Learning.  * Culture and Activities Framed by Patient Perspective.  With 25% of Medicare expenditures attributed to unwanted variation in preference-sensitive care, it was noted by many of the participants that much of health care delivery has been shaped over the past generation with the primary convenience and interests of the clinician, not the patient, in mind.  * Medical Liability Reform.  And, * Prevention at the Personal and Population Levels.

As one should expect, there was considerable discussion surrounding the potential benefits of Comparative Effectiveness Research and Health Information Technology (i.e., electronic records and telehealth services).  One of the participants asserted that: "(E)nhancing the effectiveness and efficiency of the U.S.healthcare system was dependent upon maximizing the contributions of healthcare professionals who are not physicians.  She identified a number of current barriers which limit appropriate use of such providers, including federal and state laws and regulations; opposition from healthcare systems, professional medical groups, and managed care organizations; reimbursement and other payment policies; and exclusion from demonstrations proposed as part of health reform."

Psychology's Visionaries – Interdisciplinary Care:  "I have had the privilege of serving on the Board of Advisors of the Duke University School of Nursing for the last four years at the request of the Dean who is the current President of the Association for the Advancement of Nursing.  While I have always been a strong advocate of collaborative care, this experience is an education for me in the roles that nurses play in our emerging healthcare systems.  I have learned about the roles nurses play in Global Health, such as the Duke nurses who develop and staff clinics in rural Tanzania with others leading distance education programs in the British West Indies.  I have learned about the new professional degree for nurses, the Doctor of Nursing Practice (DNP).  At Duke, DNPs are being prepared to innovate and provide leadership in clinical service delivery, and to translate evidence into practice at the point of care.  I have learned about the innovative on-line educational programs now available to nurses.  I was able to attend a course for Nurse Informatacists on the Second Life platform.  I have learned about the science of nursing, and the role Ph.D. faculty play in advancing healthcare science and education.  Some nurses ARE psychologists, having earned their Ph.D. in psychology after attending nursing school; for example our immediate APA Past-President Carol Goodheart.  Carol truly appreciates the emerging data on the social determinants of health as well as the importance of the primary healthcare providers in our country: family (as defined by the patient) caregivers, for acute and chronic conditions, which was one of her impressive Presidential initiatives.  I have learned about how effective nursing organizations and their leadership are in their advocacy efforts, supporting their discipline and focused on better patient care.  There is a profound research-practice gap in all disciplines.  Researchers must come to understand the values and beliefs of particular clinicians in order to achieve wide dissemination.  Psychology has much to learn from our sister discipline of nursing, whether through interdisciplinary courses or collaborative research or advocacy" [Susan McDaniel, University of Rochester Medical Center].

Ensuring Culturally Sensitive Care:  "I Ola Lahui Rural Hawai'i Behavioral Health Program opened its doors in August of 2007 with the specific intention of developing an APA accredited internship program to helpHawai'i 'grow its own.'  With only four APA accredited internships in the state, many of the best and brightest have been forced to leaveHawai'i during their crucial training years.  On November 9^th, 2010 the I Ola Lahui Internship Program was approved as an APA accredited program beginning in December, 2009.  Since 2007, we have trained 10 psychologists with eight of them living and working in medically underserved areas.  We currently have five more in training.

"Native Hawaiians continue to have major health and socioeconomic concerns that are disproportionately greater than other ethnic groups in Hawai'i.  Native Hawaiians have the highest rate of untreated medical and psychological concerns, and those who do seek services rely primarily on state and federally sponsored programs for their health care.  Greater medical and psychological concerns coupled with disparities in income and education and the cultural distress experienced by Native Hawaiians have created an unprecedented demand for health and mental health services.  Further exacerbating the dire need for mental health treatment in underserved areas is the reluctance of patients to seek treatment due to the stigma of mental health problems.  Increased access to quality health care for Native Hawaiians and other medically underserved populations in Hawai'iis desperately needed to combat these health disparities.

"The idea of creating I Ola Lahui arose from the growing behavioral and mental health care needs of the medically underserved and people who reside in the rural communities of Hawai'i.  As with many medically underserved and rural communities across the U.S., those in Hawai'i face challenges in receiving quality medical and psychological services.  Often people do not access care, are offered limited care, or are referred to specialty health care services in urban areas miles away or even on another island in our state.  I Ola Lahui provides a sustainable source of behavioral health care that is tailored to the unique needs of this group.

"I Ola Lahui expresses our intent to improve the health and well being of our people.  It means, 'So that the people will live and thrive.'  The I Ola Lahui mission is to provide culturally-minded, evidence-based behavioral health care that is responsive to the needs of medically underserved and predominately Native Hawaiian rural communities.  In recognition of Hawai'i's urgent need for more quality mental health care, I Ola Lahui is committed not only to providing services, but also to investigating the effectiveness of the services we provide and to training future providers with the hope of increasing the number of doctoral level behavioral health providers and services available in the medically underserved and rural areas of Hawai'i.

"I Ola Lahui is designed to serve Native Hawaiians and other medically underserved groups through specialized training exclusively in Hawai'i's Native Hawaiian Health Care System (NHHCS) clinics, Federally Qualified Community Health Centers (FQCHCs), and related programs.  Although we, as an organization, aspire to have a significant impact upon the health and well being of all Native Hawaiians and other medically underserved groups living in rural areas, our mission is simple and based soundly in a real desire to improve the lives of the people in our islands.  We are honored that this year we had 70 applicants for the two internship slots we can offer" [Robin Miyamoto, former HPA President].  "Chills the body but not the soul, hallelujah…. Michael row the boat ashore, hallelujah."  Aloha,

Pat DeLeon, former APA President