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 

LEAVING ON A JET PLANE

            Over the next five to ten years, President Obama's landmark Health Care Reform legislation (the Patient Protection and Affordable Care Act [PPACA]) will be systematically implemented.  Psychology should appreciate that the law is fundamentally patient-oriented and not provider-centric.  The States and Administration have considerable flexibility to address overarching national objectives.  Increasing access to quality primary health care and making scientifically-based clinical decisions are central to its vision.  The 21^stcentury will be an era of educated consumers, interdisciplinary and integrated health service delivery systems, and an unprecedented utilization of communications technology (e.g., telehealth and electronic health records).

            Telehealth – Service Delivery Of The Future:  The HHS Budget notes that the Office of Telehealth is an integral component of its Improve Rural Healthcare Initiative, with the goal of expanding the use of telecommunications technologies to increase access to, and the quality of, healthcare provided to rural populations.  A major goal is to strengthen partnerships among rural health care providers, recruit and retain rural health care professionals, and modernize the health care infrastructure in rural (and urban) areas.  These technologies are not viewed as products or ends in themselves, but as the means to provide services at a distance and to overcome geographic, economic, and other social barriers to obtaining health care.  A related objective is to increase the number of states adopting a common licensure application and participating in mutual recognition of each other's licenses.  Evaluation activities will focus upon telehealth's economic impact, particularly on the implications for coverage by government and third party payers which are critical for its viability.

The APA Council of Representatives recently established a ten person Task Force on the Development of Telepsychology Guidelines, co-chaired by Linda Campbelland Fred Millan (ASPPB), in conjunction with the APA Insurance Trust.  The goal is to provide direction to psychologists as they navigate the numerous ethical, regulatory, legal, and practice issues in their increasing utilization of this exciting technology for the delivery of psychological care.  Nevada is the home of the U.S. Senate Majority Leader.  His colleague, Senator Sheldon Whitehouse has introduced legislation (S. 539), the Behavioral Health Information Technology Act, which would extend eligibility for psychologists and other behavioral health care providers to obtain federal assistance in moving into the rapidly evolving technological era.  APA'sMarilyn Richmond would appreciate your active support of this legislation.  "I'm leaving on a jet plane.  I don't know when I'll be back again.  Oh babe, I hate to go."  Aloha,

 

Pat DeLeon, former APA President – Nevada Psychological Association – April, 2011

STEADILY FORWARD IN UNCHARTED WATERS

            Over the next five to ten years psychology will experience the steady implementation of President Obama's landmark health care reform legislation, thePatient Protection and Affordable Care Act [PPACA].  The President's vision is fundamentally patient-centered, rather than provider-centric, and provides the Department of Health and Human Services (HHS) and the States with considerable flexibility to meet overarching national goals.  From a public policy frame of reference, we will see the revitalization of the states as "living laboratories" of social reform.  It is estimated that at least 32+ million currently uninsured Americans will obtain primary care coverage by 2014, although some experts predict a significantly higher number of nearly 50 million.  With an aging provider workforce and concerted efforts in the newly elected House of Representatives to repeal ObamaCare at all costs, Who will be available to provide these necessary services? And, What role will psychology ultimately play?

            Accountable Care Organizations: What Are They?  The Accountable Care Organizations (ACOs) concept is among the most visible health care payment and delivery system models provided for in the now one-year old health reform law [P.L. 111-148].  ACOs have the dual purpose of realigning the provider payment system and retooling performance measurement approaches to ensure accountability; thereby, shifting health care practice from a volume and intensity-based system to one that supports coordinated, high quality, and cost-effective care.  Specifically, this section of the federal statute focuses upon promoting accountability for Medicare beneficiaries through voluntary participation in the Medicare Shared Savings Program (which will be created before January 1, 2012), via ACOs.  The law defines ACOs as provider-led organizations, which may include hospitals, that share with payers accountability for care quality and cost containment and address the continuum of care and specialty needs for a patient population (of at least 5,000).  Accountability is fostered primarily through cost and quality transparency and economic rewards shared by providers and payers when costs are reduced.  The initiative will be implemented in January, 2012 and the Centers for Medicare and Medicaid Services (CMS) regulations are scheduled to come out in the near future.  Providers, executives, and even health insurance companies are scrambling to design and establish ACOs, but structural details are still forthcoming.

            ACOs have been characterized as "the elusive unicorn – everyone seems to know what it looks like, but nobody's actually seen one."  Ultimately, the shape of ACOs will likely depend on a variety of factors including proposed CMS regulations and the related financing environment, relevant statutory definitions; and, in some cases, state practice acts.  High stakeholder demands for flexibility and regulation nimbleness – until we learn what works – indicate that the debate around which entities will qualify will likely be ongoing.  Leading experts do agree that four general models capture the essential elements of potential ACOs: an integrated delivery system, multi-specialty group practice, physician-hospital organization, and independent practice association.  Historically, whenever any complex legislation, such as PPACA, has been enacted, over the next couple of years the committees with jurisdiction will recommend bipartisan "technical fixes" in order to smooth the implementation process, based upon practical experiences.  Unfortunately, in the current Congressional climate such necessary legislative oversight seems unlikely.

            Exciting Opportunities For Psychology:  As the exact nature of ACOs is still evolving, it is important for organized psychology to affirmatively enter into the policy debate, at both the local and federal level, especially in determining the fate of non-physician providers and non-physician led practices.  Will the ACOs be broadly defined and horizontally-organized including behavioral health providers as equal partners (or leaders)?  Or, Will they take on a physician-dominated hierarchical structure?  As the four models above indicate, ACOs are not necessarily physician focused.  They address all facets of a patient's condition and foster shared accountability for overall quality and costs encompassing a larger range of providers.

            With respect to the quality and integration side of the equation, the opportunities for psychology are clear.  First, the role of the behavioral health provider will only become more essential.  Mental health and substance-use problems are the leading cause of combined disability and death of women and second highest in men in theUnited States.  Currently, only 7% of health care expenditures go to mental health treatment.  This, despite the fact that over 70% of people dually eligible for Medicare and Medicaid have mental illness.  Further, we know that 67% of adults and more than 92% of people with serious mental illness do not receive effective mental health and substance-use treatment.  This is due to multiple variables that affect success and acceptability of care, but these statistics highlight the type of patient who will be served in ACOs.  As with health homes (or "medical homes"), the ACO concept emphasizes prevention, early identification and intervention, chronic disease management, person-centered approaches, and implies adoption of evidence-based practice.  There are now several compelling examples of high value integrated care interventions targeting mental health and substance-use in elderly adults that include psychological interventions/supervision.  Two examples of cost-effective models with good outcomes include the Improving Mood Promoting Access to Collaborative Treatment (IMPACT) and the Primary Care Research in Substance Abuse and Mental Health for Elderly (PRISM-E) programs.

            Second, quality care depends upon access to the well-implemented, cost-effective best practices.  Psychologists can fill a knowledge and skill void here, in a number of ways.  They include: a.) recruiting, training, and retraining a competent behavioral health workforce; b.) developing and studying effective implementation and service delivery models including: c.) screening and assessment technology: instrument selection and construction, administration and interpretation, training, supervision, and research; d.) bridging science and service and facilitating the dynamic, iterative learning process resulting from their interplay; e.) client- and family-centered shared decision making: intervention design, training and supervision, and basic and applied research; f.) competency in developmental psychology across the lifespan; specifically in older adults and adults with psychiatric disabilities: training and supervision, development of selection tools and interventions, and conducting and translating research; g.) developing decisional algorithms for referral to specialty services; and, h.) implementing outcome-driven, culturally-informed, evidence-based intervention strategies.  In addition, high quality, multidisciplinary care and cross-training is rife with interest for psychologists in both practice and research fronts.  Some examples include: standardized screening, outcome measures, data collection, analysis and interpretation in the context of multiple literatures, training of staff on behavioral health evidence-based practices and process, patient engagement, and, of course, conducting research and translating findings into practice top the list of examples.  Finally, coordinating communication and treatment planning across a multidisciplinary team requires appreciation for the overlapping and unique knowledge bases and skill sets of each participating discipline and managing group dynamics in the context of delivering quality-based care.  Regardless of the fate (or face) of ACOs, it is clear that psychologists can and must play a critical role in their development and successful implementation.  ACOs are being developed within the policy context of reports by the Institute of Medicine (IOM) that excessive costs stemming from waste and inefficiency within the nation's health care system currently total between $750-$785 billion annually.

            Visionary Leadership:  Susan McDaniel of the University of Rochester Medical Center has long been in the forefront of psychology's evolution into integrated 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).  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.  Psychology has much to learn from our sister discipline of nursing, whether through interdisciplinary courses or collaborative research or advocacy."  Aloha,

Sandra Wilkniss, APA/AAAS Congressional Fellow & Pat DeLeon, former APA President.  National Register – March, 2011

 

AN EXCITING OPPORTUNITY

            As President Obama's landmarkPatient Protection and Affordable Care Act [PPACA] [P.L. 111-148] is systematically implemented over the next 5-10 years, it is important that our State Associations appreciate that the law is fundamentally patient-centered, and not provider-centric, andfurther that the States have considerable flexibility to develop local approaches which address broad, often non-specific, national objectives.  Psychology is one of the nation's health care professions and as such, must increase its efforts to work collaboratively with other disciplines, engage patients in taking responsibility for their own health care, and begin utilizing the unprecedented advances occurring within the communications and technology fields (i.e., telehealth and virtual realities) to ensure data-based, high quality care.  Geographical boundaries (for example, in rural America) no longer are acceptable excuses for denying care.  State Associations must work with their legislatures and licensing boards to achieve licensure portability.

            The Robert Wood Johnson Foundation (RWJF) recently announced a new grant program Public Health Law Research: Making the Case for Laws That Improve Health.  RWJF seeks to build the evidence for, and strengthen the use of, regulatory, legal, and policy solutions to improve public health and help individuals lead healthier lives.  It is equally interested in identifying and ameliorating laws and legal practices that unintentionally harm health.  Critical questions: How does law influence health and health behavior?  Which laws have the greatest impact?  Can current laws be made more effective through better enforcement, or do they require amendment?  Preference will be given to applicants that are public entities or nonprofit tax-exempt (501(c)(3)) organizations.  Short-term study grants up to 18 months ($150,000 each); complex and comprehensive study grants up to 30 months ($450,000 each).  A total of $2.85 million will be available for this round of grants.

            The Call for Proposals focuses upon three topics: 1.) Effects of laws and legal practices on population health outcomes.  2.) Using innovative regulatory tools to promote health.  And, 3.) Effects of law, regulation, and policy on the performance of public health systems and the delivery of public health services.  Examples include: studies that will investigate the design and implementation of a new legal intervention or assess effects of an existing law or enforcement strategy on physical or mental health; exploring the impact of the criminal justice system on the health of communities; studies of the unintended effects of law on the incidence or prevention of chronic diseases; and, studies of the organization, financing, and delivery of public health services, including public mental and behavioral health services, and the effects of those services on public health.  One selection criterion is effective collaboration between public health, legal researchers, and practitioners.  We would suggest that this RWJF initiative provides an exciting opportunity for state psychological, nursing, and bar associations to collaboratively address some of society's most pressing needs.  Law and business remain the most common professional backgrounds of elected officials.  Early career exposure goes a long way towards encouraging professional respect for other disciplines.  This Spring, Hawaii Psychological Association was successful in having their prescriptive authority (RxP) legislation pass the State Senate on an 18-3-4vote.  With mutual respect comes legislative success.  Aloha,

 

Pat DeLeon, former APA President – Division 31 – March, 2011