A STEADY PROGRESSION TOWARDS INTEGRATED CARE

With the 2012 Presidential election finally over and the upholding of the constitutionality of President Obama's landmark Patient Protection and Affordable Care Act (ACA) [P.L. 111-148] by the U.S. Supreme Court, our nation's health policy leaders have begun focusing upon the all important implementation process.  The underlying philosophy behind ACA is to ensure timely access to patient-centeredprimary care for all Americans.  The target implementation date for the vast majority of the law's provisions is 2014, with the states being granted considerable flexibility to craft approaches that are sensitive to unique local needs and priorities.  As an example of the magnitude of this process, the individual states are now deciding whether to participate or "opt out" of the Medicaid expansion provision of the law.  Currently, 12 states have decided to participate; 7 states have decided to "opt out;" and the remaining states have yet to announce their participation status.  Medicaid finances 17% of all personal health spending.  Under ACA, Medicaid eligibility will expand to reach millions more poor Americans – mostly uninsured adults.  Critical for psychology which, unlike professional nursing, has historically expressed little interest in being statutorily recognized under the federal or individual state Medicaid statutes, the program will become the coverage pathway for most low-income individuals and the foundation of the broader public-private system of health coverage envisioned by ACA.  In 2009, Medicaid covered 31 million children, 16 million nonelderly adults, 6 million seniors, and 9.5 million persons with disabilities (including 4 million children).  Almost all elderly Medicaid enrollees and 39% of disabled Medicaid enrollees are also covered by Medicare (comprising 9.4 million "dual-eligibles").  Expanding the use of clinical preventive services is a key goal of ACA, as is the increasing utilization of Health Information Technology (HIT) including Electronic Health Records (EHRs).  The health care system of tomorrow will be data-based, prevention oriented, and interdisciplinary in nature.

Growing Awareness:  Change is always unsettling; especially change of the magnitude envisioned by ACA.  The Supreme Court subtly acknowledged this in noting: "We do not consider whether the Act embodies sound policies.  That judgment is entrusted to the Nation's elected leaders.  We ask only whether Congress has the power under the Constitution to enact the challenged provisions."  Bob McGrath, director of the Fairleigh Dickinson Clinical Psychopharmacology (RxP) and Integrated Care programs, experienced this diffuse anxiety when he recently addressed a conference of 75+ members of the Vermont Psychological Association.  "At times the anxiety was palpable, as the participants struggled with the uncertainty and risks that are inherent to change of this magnitude.  As the day progressed, I identified several underlying themes to keep in mind when discussing the challenges of health care reform.  Clearly psychologists have reason to be concerned… concerned that the ACA institutionalizes systems in which a conflict of interest can potentially exist where health care providers benefit from restricting care....  About quality metrics, because we're living in a period where oversight is being used by insurers to ration care arbitrarily….  About pressure to offer brief, time-limited, population-based interventions….  And, the realization that this is going to happen whether we like it or not.  We have no choice but to deal with it.  We ask our patients to act despite their anxiety all the time.  We have to do the same."

            From our personal health policy frame of reference, it is important that psychology appreciate that now is the time to affirmatively "make the case" for why our profession in particular is critical to the ultimate success of ACA.  The future will be, and for visionaries such as APA's Cynthia Belar always has been, the clinical contributions of health psychologists within integrated, patient-centered health delivery systems.  There are at least three levels of involvement that are absolutely necessary.  First, as Katherine Nordal has passionately stressed at the past several State Leadership conferences, awareness that critical implementation decisions are going to be made at the state level and that our practitioners must be at the table (or else, as she so graphically states -- "we will be on the menu").  Secondly, psychology must collectively expand its federal and state legislative presence to ensure that the relevant ACA legislative provisions specifically recognize our potential contributions; for example, obtaining federal support for upgrading psychological records onto the EHR systems and requiring reimbursement for our practitioners under the various federal initiatives targeting the nation's obesity epidemic, as President Suzanne Johnson stated during this year's APA Opening Ceremony in Orlando.

Perhaps most importantly, however, our practitioners must affirmatively and effectively demonstrate to those responsible for administering the evolving patient-centered service delivery systems (i.e., Patient-Centered Medical Homes and Accountable Care Organizations) that psychological services are clinically necessary for quality care and they are cost-effective.  Coral Andrews, executive director of the Hawaii Health Connector (ACA's Health Insurance Exchange): "Nurses, psychologists, social workers, etc. are coming into their own with the ACA.  The shapes and sizes of talent won't be the traditional ones that we've long since expected.  Professionals, within and outside of health care, will emerge in leadership positions to support the requirements needed to fully implement ACA.  As a result, a new market will emerge….  Our leaders will need to diversify their thinking and align their strategies differently to insure that they attract and retain talent…..  At the Connector, we are getting ready to go through a process… to help us benchmark our positions in this emerging market and to assist our Board with access to information that helps to clarify/contrast pre-ACA ideology with post-ACA realities.  Diversity in the talent, diversity in the approach to human resources, and diversity in the workforce are all things that will need to evolve alongside the more visible challenges that we are seeing in the models and systems of care."  Unprecedented opportunities exist for those who get involved, and we would suggest especially for those colleagues who obtain advanced training in clinical psychopharmacology (RxP), as our nation increasingly evolves towards integrated and holistic-oriented health care systems in which mental health care will be deemed an integral component of primary care.

The Maturing RxP Agenda:  Bob McGrath estimates that there are 1700 colleagues who have completed their advanced RxP training.  Yosef Geshuri notes that: "Although we are not authorized to prescribe in California, some of us, particularly in rural areas like myself, are serving important roles in consulting with other doctors in psychopharmacology in community hospitals, where psychiatrists are not to be found.  So that our being trained in psychopharm really comes to use in our profession."  Two of the more proactive steps that APA has taken in this area are the development of the national Psychopharmacology Examination for Psychologists (PEP) and the RxP Designation System in order to facilitate educated actions by state licensing boards as RxP authorization statutes are eventually enacted at the state level.  Jan Ciuccio reports that the data on achieving the Recommended Passing Score on the PEP includes both first-time takers and repeat-test takers combined.  As of November 9, 2012, 289 individuals have taken the PEP and 230 have met the Recommended Passing Score.  Thus, approximately 80% of taking the exam have eventually passed.

            "In 2006, APA convened a joint task force to review and update APA's psychopharmacology curriculum and model legislation policy documents.  As part of that task force's work, it included a recommendation that APA develop a designation program for education and training programs in psychopharmacology as a means of assuring minimal standards of program quality.  However, the task force felt that development of such a system was beyond the scope of its charge so a subsequent task force was convened to establish such a system, which was approved by the APA Council of Representatives in 2009.

"The purpose of the APA Designation system is to offer public recognition of education and training programs that meet certain minimum standards (that include both didactic and supervised practice components) and published criteria as set forth in the APADesignation Criteria for Postdoctoral Education and Training Program in Psychopharmacology for Prescriptive Authority.  The process of designation is voluntary, to be initiated by the program seeking to be designated, and shall be governed by the policies and procedures specified in this document.  The APA RxP Designation Committee, which oversees the designation process and reviews programs seeking recognition, met for the first time in November 2010.  At this time there are 3 APA designated psychopharmacology programs – Alliant International University (CSPP), Fairleigh Dickinson University, and New Mexico State University/SIAP. http://www.apa.org/education/grad/psychopharmacology.aspx. (Deborah Baker)."

            The Newest RxP Training Program - Hilo:  "The University of Hawaii at Hilo offers a Master of Science in Clinical Psychopharmacology (MSCP) degree solely within our College of Pharmacy.  The program, approved by the University of Hawaii Board of Regents in August, 2011, will graduate its first students on December 15, 2012.  Now in its third year, the MSCP program offers postdoctoral training in psychopharmacology for clinical psychologists.  The curriculum was designed to provide a strong background in physiology, pharmacology, and therapeutics.  Graduates of the program are required to complete a rigorous one year practicum under the supervision of a licensed prescriber and pass the APA PEP before being eligible to prescribe psychotropic medications within the military and Indian Health Service/U.S. Public Health Service, or in a locale that permits psychologists to prescribe (currently Louisiana, New Mexico, and Guam).  The program provides 90% of the coursework through online technology, enabling students at Tripler Army Medical Center (TAMC) to participate from Oahu.  The MSCP program accepted its first student outside TAMC this year and has received inquires from more than 15 psychologists interested in entering the program.  Consistent with ACA's interdisciplinary focus, Ed Fisher, Associate Dean of Academic Affairs for the College of Pharmacy, serves as the Program Director.  My background is in psychobiology and Danita Henley, PharmD serves as the Clinical Coordinator, collaborating with local nurse practitioners including Alice Davis who is on the faculty at the University of Hawaii at Hilo School of Nursing.  We are in the beginning stages of seeking APA Designation (Judi Steinman)."

            ACA and Wellness:  The Obama Administration's proposed regulations for implementing the Wellness provisions of ACA expect to offer the nation the opportunity to not only improve the health of Americans, but also to help control health care spending.  There is an appreciation that workplace health programs have the potential to promote healthy behaviors; improve employees' health knowledge and skills; help employees get necessary health screenings, immunizations, and follow-up care; and reduce workplace exposure to substances and hazards that can cause diseases and injury.  The proffered regulations would not specify the types of wellness programs employers can/must offer, instead providing considerable flexibility encouraging appropriately designed, consumer-protective wellness programs.  Programs would have to offer a reasonable chance of improving health or preventing disease and not be overly burdensome for individuals.  Those attending David Ballard's inspiring presentations at the Practice Directorate State Leadership conferences will appreciate the unprecedented opportunity that this particular initiative offers psychology.  "Yes, retirement from an academic job can be good.  But keeping a hand in and the brain consequently alive is invaluable.  For example, just got elected to a national board – lots of travel, responsibilities, and networking.  Good for one, all that (Jac Carlson)."  Aloha,

 

Pat DeLeon, former APA President – Division 42 – December, 2012

 

THE ALL IMPORTANT ACA IMPLEMENTATION STAGE

  With the enactment of President Obama's landmark health care reform legislation, the Patient Protection and Affordable Care Act [P.L. 111-148] (ACA), and its subsequent affirmation by the U.S. Supreme Court, psychology is entering into an unprecedented era as a health care profession.  The underlying statute proffers broad federal objectives, delegating to the states the authority to develop the specifics for implementation in order to effectively address local concerns and priorities.  Eventually, all Americans will have access to patient-centered primary care.  Change is always unsettling and unquestionably the "devil is in the details."

            The Alliance for Health Reform has been holding a series of informational briefings on Capitol Hill, recently focusing upon Medicaid Expansion.  Pursuant to the Court's decision, the individual states must now decide whether to participate or "opt out" of the Medicaid expansion provision of the law.  Currently, 12 states have decided to participate, 7 states have decided to "opt out," and the remaining states have yet to announce their participation status.  Unlike professional nursing which has obtained mandatory coverage of nurse-midwives, certified pediatric nurse practitioners, and certified family nurse practitioners (whether or not the practitioner is under the supervision of, or associated with, a physician or other health care provider), organized psychology has been notably lax in seeking Medicaid recognition.  Our practitioners are covered under its very broad provider language.

            The Alliance notes that Medicaid is the largest public health insurance program in the nation, covering over 60 million low-income individuals, or roughly 1 in every 5 Americans.  The program is administered by the states within broad federal rules and financed jointly by the states and the federal government.  Medicaid beneficiaries include children and some parents, people with disabilities, and seniors.  Without Medicaid, most of its beneficiaries would lack coverage for care they need.  It provides essential funding to safety-net providers, including hospitals and health centers serving the underserved.  It is the single largest source of coverage for nursing home and community-based long-term care.  Altogether it finances 17% of all personal health spending.  Under ACA, Medicaid eligibility will expand in 2014 to reach millions more poor Americans – mostly uninsured adults.  The program will become the coverage pathway for most low-income individuals and the foundation of the broader public-private system of health coverage envisioned by ACA.  In 2009, Medicaid covered 31 million children, 16 million nonelderly adults, 6 million seniors, and 9.5 million persons with disabilities (including 4 million children).  Almost all elderly Medicaid enrollees and 39% of disabled Medicaid enrollees are also covered by Medicare (comprising 9.4 million "dual-eligibles").

            A New England Perspective:  This Fall Bob McGrath, director of the Fairleigh Dickinson clinical psychopharmacology and integrated care programs, addressed the Vermont Psychological Association.  "VPA was particularly fortunate to also hear from Anya Rader Wallack, chair of the Green Mountain Care Board, which is the organization responsible for implementing health care reform in Vermont.  All of the speakers during this visionary conference highlighted the importance of collaborating with those implementing health care reform to make sure psychology's voice is ultimately heard.

"At times the anxiety was palpable, as the participants struggled with the uncertainty and risks that are inherent to change of this magnitude.  As the day progressed, I identified several underlying themes to keep in mind when discussing the challenges of health care reform:  1. Psychologists have reason to be concerned that the ACA institutionalizes systems in which a conflict of interest can potentially exist where health care providers benefit from restricting care.  We have to remember that the current system, in which health care providers benefit from offering unnecessary care, threatens to bankrupt the nation without achieving better outcomes.  We must work to ensure that an emphasis on quality of care balances cost containment concerns.  2. Psychologists have reason to be concerned about quality metrics, because we're living in a period where oversight is being used by insurers to ration care arbitrarily.  We have to remember that the intended purpose of the new metrics is to provide that balance between cost containment and quality of care at the level of the population.  We must work to ensure that those metrics are used for their intended purpose rather than to justify eliminating services for the individual.  3. Psychologists have reason to be concerned about pressure to offer brief, time-limited, population-based interventions.  We have to remember that the current system is incapable of meeting the mental health needs of the general population.  We must work to ensure that the entire spectrum of services remains available including long-term individual psychotherapy.  And,  4. This is going to happen whether we like it or not.  We have no choice but to deal with it.  We ask our patients to act despite their anxiety all the time.  We have to do the same."

            The Hawaii Perspective:  Coral Andrews, executive director of the Hawaii Health Connector: "You often speak candidly about the expanded role of advanced practice staff in the 'new' delivery system.  I serve as the Regent for the American College of Healthcare Executives (ACHE) Hawaii-Pacific Region.  The national organization and the Chapter are focused on Diversity at all levels of the health care industry.  It's our flagship issue.  Diversity at all levels: ethnicity, gender, equal access to leadership positions, respecting diverse points of view, etc.  More information about this initiative can be found atwww.ache.org.  As the health care industry evolves into new business models, new professional structures and new models of care, so too will the strategy by which we attract and retain talent.  I am already seeing it as we work to establish the health insurance exchange.  Our workforce is blended and pulls from multi-industry markets, not just health.  As a result, we have to be competitive with these other industries as well.

            "Nurses, psychologists, social workers, etc. are coming into their own with the ACA.  The shapes and sizes of talent won't be the traditional ones that we've long since expected.  Professionals, within and outside of health care, will emerge in leadership positions to support the requirements needed to fully implement ACA.  As a result, a new market will emerge.  Our leaders will need to diversify their thinking and align their strategies differently to insure that they attract and retain talent.

            "At the Connector, we are getting ready to go through a process with the help of Integrated Healthcare Strategies, a national human capital strategy firm, to help us benchmark our positions in this emerging market and to assist our Board with access to information that helps to clarify/contrast pre-ACA ideology with post-ACA realities.  Diversity in the talent, diversity in the approach to human resources, and diversity in the workforce are all things that will need to evolve alongside the more visible challenges that we are seeing in the models and systems of care.  I look forward to supporting ACHE's efforts to advancing Diversity at all levels of the health care industry."  Aloha,

 

Pat DeLeon, former APA President – HPA – December, 2012

 

HEALTH CARE REFORM – INTEGRATED CARE

The enactment of President Obama's landmark health care reform legislation, thePatient Protection and Affordable Care Act (ACA) [P.L. 111-148], provides visionary psychologists and advanced practice nurses (DNP) with an unprecedented opportunity to serve the nation, and in so doing determine their profession's future.  With many of ACA's provisions taking effect by 2014, we are currently in the implementation stage -- the states having been granted considerable flexibility to craft innovative approaches to broad, overarching federal requirements.  The health care system of tomorrow will provide patient-centered, interdisciplinary-oriented integrated care, with priority being given to holistic, wellness, and preventive services; rather than the traditional emphasis upon procedure-reimbursed acute care.  Chronic disease management, encouraging healthy behaviors and lifestyles, integration of mental health into primary care, and the unprecedented utilization of developments occurring within the communications arena (i.e., telehealth and electronic health records (EHRs)) are the future.

            Ever since November, 1984 when U.S. Senator Daniel K. Inouye urged the Hawaii Psychological Association to seek prescriptive authority in order to provide comprehensive care, the RxP legislative agenda has steadily matured.  In 2002 New Mexico became the first state in the nation to enact legislation, soon followed by Louisiana.  Guam andIndiana had previously succeeded; however, their bills have yet to be implemented.  Throughout the federal system psychologists have formally prescribed with Floyd Jenningsobtaining this authority in the Indian Health Service in June, 1988.  Consistently, the quality of their care is outstanding.  Bob McGrath, Director of the Fairleigh Dickinson Clinical Psychopharmacology training program and a participant in your November meeting devoted to health care reform, estimates that there are over 1,700 colleagues who have completed their advanced RxP training.  His program has been expanding in recent years, continuing to attract students from almost every state and from the military.  Details are available atwww.rxpsychology.com and/or chat with your President Rick Barnett, a FDU graduate.

            The Alliance for Health Reform recently conducted a Congressional briefing on the Virtual World of Health Information Technology.  Whereas at the time of enactment of ACA the Administration estimated that only 5% of physicians possessed fully functional EHRs, a 2011 survey found that 55% of physicians had adopted EHRs with a slightly greater proportion of primary care providers vs. specialists.  The vast majority of providers using EHR systems (85%) report being "somewhat" or "very" satisfied.  Rural providers have been particularly engaged in this transformation process and private vendors are proactively responding to the advent of health care technology.

A fundamental element of ACA is encouraging systems of care, as reflected in its Accountable Care Organization (ACO) andPatient-Centered Medical Home provisions (neither formally recognizes psychology).  This is not a new approach, reflecting the strategic thinking of the Nixon Administration HMOs and President Clinton's Managed Care models.  Almost all of the panelists described their systems as having been functioning as an ACO for a number of years.  They stressed the effectiveness of technology in improving quality of care, holding down costs, and allowing cross-patient and cross-diagnostic comparisons.  Engaged consumers (i.e., patients) were a reality.  During the audience discussion, the importance of integrating mental health, substance abuse, domestic issues, etc. into primary care was highlighted.  This is a (r)evolution that the Institute ofMedicine has increasingly emphasized -- "Primary care providers address a broad range of health issues to which mental health concerns are integral."

            For the profession of psychology to thrive within our nation's evolving health care environment it is absolutely essential that we become personally engaged, proactive, and responsive to society's pressing needs.  Psychology is one of the health care professions and our services are increasingly being deemed those of "primary care."  The knowledge and clinical expertise surrounding the appropriate utilization (or lack thereof) of psychotropic medication is definitely needed throughout primary care and in rural America.  Whether the Vermont Psychological Association will rise to this exciting challenge is yours to decide.  As Katherine Nordal so eloquently stated during this year's State Leadership Conference: "If we're not at the table, it's because we're on the menu."  Aloha,

 

Pat DeLeon, former APA President – Vermont Psychological Association – October, 2012

 

THE ADVENT OF NATIONAL HEALTH INSURANCE (NHI)

In our judgment, the 2010 enactment of President Obama's landmark Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) reflects our nation's commitment to finally ensuring that all Americans will have timely access to "gold standard" health care when required. The underlying statute has been crafted to provide for incremental implementation with many of the major provisions taking effect by 2014 and still others by 2019-20. The individual states have been provided with considerable flexibility to shape broad federal mandates in a manner that best reflects local priorities and concerns. Complex and highly controversial, in upholding the constitutionality of the law the Chief Justice of the U.S. Supreme Court opined: "We do not consider whether the Act embodies sound policies. That judgment is entrusted to the Nation's elected leaders. We ask only whether Congress has the power under the Constitution to enact the challenged provisions." Justices Ginsburg and Sotomayor provided a different perspective: "The provision of health care is today a concern of national dimension, just as the provision of old-age and survivors' benefits was in the 1930's…. In enacting [ACA] Congress comprehensively reformed the national market for health-care products and services…. Unlike the market for almost any other product or service, the market for medical care is one in which all individuals inevitably participate…. Not all U.S. residents, however, have health insurance. In 2009, approximately 50 million people were uninsured, either by choice or, more likely, because they could not afford private insurance and did not qualify for government aid."
In developing ACA's underlying regulatory schema, Congress passed several bills, including the American Recovery and Reinvestment Act of 2009 (the Economic Stimulus legislation) which provided significant funding (estimated at $19+ billion) and comprehensive programmatic authority for aggressively moving our nation's health care system into the 21st century world of communications technology (i.e., virtual realities, electronic health records (EHRs), telehealth, and cross-patient and cross-diagnostic comparisons (competitive effectiveness research)). Partisan politics precluded the usual process of technical modifications and as a result, it is difficult to accurately predict ACA's specific impact upon the daily practices of our colleagues. Without question, however, the health care world of tomorrow will be fundamentally different than our practitioners and educators ever imagined. Health care will be patient-centered, integrated, and interdisciplinary in nature. Reimbursement priorities will shift from curative, procedure-driven acute illness care to holistic, wellness-oriented, primary and preventive care. Mental health services will be deemed "primary health care" services; no longer to be considered "specialty care" except under special conditions. As the Institute of Medicine (IOM) has repeatedly noted there is an "inextricable link between mental health and primary care…. Primary care providers address a broad range of health issues to which mental health concerns are integral. Mental, behavioral, and physical health are so closely entwined that they must be considered in conjunction with one another." From a policy frame of reference, the critical importance of the psychosocial-economic-cultural gradient of care will be increasingly recognized. In many ways psychology, nursing, and the behavioral sciences will have an unprecedented opportunity to shape the future of their professions and our nation. These will be exciting times, with unique opportunities and challenges.
I recently had the opportunity to visit the joint clinical-community doctoral psychology program at the University ofAlaska, including flying out to an Indian Health Service (Alaskan Native) clinic in ruralBethel. Students and faculty at the Anchorageand Fairbanks campuses interact seamlessly utilizing modern day video technology. Courses taught on either campus, including faculty and/or student meetings, are fully interactive. It was, for example, admittedly a bit startling to have participants introduce themselves along one side of the table, continue into the virtual space, and then cycle back to where I was sitting. Treatment staff at the Bethel clinic report being readily able to utilize in real-time the medication expertise of psychiatrists located in Washington State andMinnesota, who over time have become intimately familiar with their patients, again in a seamless fashion. From a policy frame of reference, distance learning, telehealth services, simulation labs, health information technology (HIT), and utilization of interactive electronic health records (EHRs) are inseparable – they represent the exciting infusion of communications technology into the health care environment. Interestingly, at the time ACA was enacted the Administration estimated that only 5% of physicians possessed fully functional electronic health records. Their goal was to bring this up to 90% by 2019.
Although electronic devices are pervasive throughout our culture, they are a relatively new phenomenon in the health care world. The Alliance for Health Reform notes that the Economic Stimulus legislation included a provision, the Health Information Technology for Economic and Clinical Health (HITECH) Act, which has already jump started the process, focusing upon "meaningful use." Health care transformation has begun, with HHS announcing that providers' adoption of HIT has doubled in two years. Nevertheless, special challenges exist for solo and small practices. Coordination of care, active patient involvement, and the development of a relevant workforce continue to be high priorities for the Administration. Under HITECH $677 million has already been allocated to support a nationwide system of Regional Exchange Centers to make sure that primary care providers receive the help they need. Change is definitely coming. The American Association of Colleges of Nursing 2012 Fall Semiannual meeting is entitled "Taking Advantage of Technology in Nursing Higher Education." What are we as psychologists doing to address the critical issue of licensure mobility? Why is a senior colleague who was licensed in Alaska, a former State Association President, not able to continue providing clinical services in ruralNew York during her retirement? The underlying policy rationale for licensure is patient protection. Are the residents of these two states so qualitatively different? Accordingly, I commend the National Register for its visionary efforts to effectively address this increasingly important issue as the advent of technology and NHI steadily overcomes traditional geographical barriers.
"Seems you are giving voice to the experiences of colleagues who are retiring from the field. I was in Denver a few weeks ago and attended a CE session on psychiatric disorders in the aging population. Among other things, I took note of the observation by the presenter that oftentimes depression occurs in successful CEO types who retire because no one listens to them anymore because they no longer have any authority. Hard to imagine this happening with the psychologists we know since I am sure most of them have lots of things they want to do when they retire. I sure did. Off to see daughter and husband inVermont with train rides down to NYC, NJ, and PA to see friends" [Jon Esty]. Aloha,

Pat DeLeon, former APA President – National Register – October, 2012

THE ADVENT OF NATIONAL HEALTH INSURANCE (NHI)

In our judgment, the 2010 enactment of President Obama's landmark Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) reflects our nation's commitment to finally ensuring that all Americans will have timely access to "gold standard" health care when required. The underlying statute has been crafted to provide for incremental implementation with many of the major provisions taking effect by 2014 and still others by 2019-20. The individual states have been provided with considerable flexibility to shape broad federal mandates in a manner that best reflects local priorities and concerns. Complex and highly controversial, in upholding the constitutionality of the law the Chief Justice of the U.S. Supreme Court opined: "We do not consider whether the Act embodies sound policies. That judgment is entrusted to the Nation's elected leaders. We ask only whether Congress has the power under the Constitution to enact the challenged provisions." Justices Ginsburg and Sotomayor provided a different perspective: "The provision of health care is today a concern of national dimension, just as the provision of old-age and survivors' benefits was in the 1930's…. In enacting [ACA] Congress comprehensively reformed the national market for health-care products and services…. Unlike the market for almost any other product or service, the market for medical care is one in which all individuals inevitably participate…. Not all U.S. residents, however, have health insurance. In 2009, approximately 50 million people were uninsured, either by choice or, more likely, because they could not afford private insurance and did not qualify for government aid."
In developing ACA's underlying regulatory schema, Congress passed several bills, including the American Recovery and Reinvestment Act of 2009 (the Economic Stimulus legislation) which provided significant funding (estimated at $19+ billion) and comprehensive programmatic authority for aggressively moving our nation's health care system into the 21st century world of communications technology (i.e., virtual realities, electronic health records (EHRs), telehealth, and cross-patient and cross-diagnostic comparisons (competitive effectiveness research)). Partisan politics precluded the usual process of technical modifications and as a result, it is difficult to accurately predict ACA's specific impact upon the daily practices of our colleagues. Without question, however, the health care world of tomorrow will be fundamentally different than our practitioners and educators ever imagined. Health care will be patient-centered, integrated, and interdisciplinary in nature. Reimbursement priorities will shift from curative, procedure-driven acute illness care to holistic, wellness-oriented, primary and preventive care. Mental health services will be deemed "primary health care" services; no longer to be considered "specialty care" except under special conditions. As the Institute of Medicine (IOM) has repeatedly noted there is an "inextricable link between mental health and primary care…. Primary care providers address a broad range of health issues to which mental health concerns are integral. Mental, behavioral, and physical health are so closely entwined that they must be considered in conjunction with one another." From a policy frame of reference, the critical importance of the psychosocial-economic-cultural gradient of care will be increasingly recognized. In many ways psychology, nursing, and the behavioral sciences will have an unprecedented opportunity to shape the future of their professions and our nation. These will be exciting times, with unique opportunities and challenges.
I recently had the opportunity to visit the joint clinical-community doctoral psychology program at the University ofAlaska, including flying out to an Indian Health Service (Alaskan Native) clinic in ruralBethel. Students and faculty at the Anchorageand Fairbanks campuses interact seamlessly utilizing modern day video technology. Courses taught on either campus, including faculty and/or student meetings, are fully interactive. It was, for example, admittedly a bit startling to have participants introduce themselves along one side of the table, continue into the virtual space, and then cycle back to where I was sitting. Treatment staff at the Bethel clinic report being readily able to utilize in real-time the medication expertise of psychiatrists located in Washington State andMinnesota, who over time have become intimately familiar with their patients, again in a seamless fashion. From a policy frame of reference, distance learning, telehealth services, simulation labs, health information technology (HIT), and utilization of interactive electronic health records (EHRs) are inseparable – they represent the exciting infusion of communications technology into the health care environment. Interestingly, at the time ACA was enacted the Administration estimated that only 5% of physicians possessed fully functional electronic health records. Their goal was to bring this up to 90% by 2019.
Although electronic devices are pervasive throughout our culture, they are a relatively new phenomenon in the health care world. The Alliance for Health Reform notes that the Economic Stimulus legislation included a provision, the Health Information Technology for Economic and Clinical Health (HITECH) Act, which has already jump started the process, focusing upon "meaningful use." Health care transformation has begun, with HHS announcing that providers' adoption of HIT has doubled in two years. Nevertheless, special challenges exist for solo and small practices. Coordination of care, active patient involvement, and the development of a relevant workforce continue to be high priorities for the Administration. Under HITECH $677 million has already been allocated to support a nationwide system of Regional Exchange Centers to make sure that primary care providers receive the help they need. Change is definitely coming. The American Association of Colleges of Nursing 2012 Fall Semiannual meeting is entitled "Taking Advantage of Technology in Nursing Higher Education." What are we as psychologists doing to address the critical issue of licensure mobility? Why is a senior colleague who was licensed in Alaska, a former State Association President, not able to continue providing clinical services in ruralNew York during her retirement? The underlying policy rationale for licensure is patient protection. Are the residents of these two states so qualitatively different? Accordingly, I commend the National Register for its visionary efforts to effectively address this increasingly important issue as the advent of technology and NHI steadily overcomes traditional geographical barriers.
"Seems you are giving voice to the experiences of colleagues who are retiring from the field. I was in Denver a few weeks ago and attended a CE session on psychiatric disorders in the aging population. Among other things, I took note of the observation by the presenter that oftentimes depression occurs in successful CEO types who retire because no one listens to them anymore because they no longer have any authority. Hard to imagine this happening with the psychologists we know since I am sure most of them have lots of things they want to do when they retire. I sure did. Off to see daughter and husband inVermont with train rides down to NYC, NJ, and PA to see friends" [Jon Esty]. Aloha,

Pat DeLeon, former APA President – National Register – October, 2012

THE TRAIN KEEPS ON MOVING

The past has been good to psychology.  The number of successful practitioners, as well as our underlying clinical knowledge base, continues to expand nicely.  Colleagues such as Antonette Zeiss have been appointed to impressive leadership positions within such critical agencies as the Department of Veterans Affairs (VA) which has been instrumental in furthering psychology's post-doctoral presence.  Collectively, we have obtained formal recognition under a wide range of federal statutes; for example, the federal criminal code as expert witnesses; eligibility for serving as U.S. Public Health Surgeon General; pay bonuses for obtaining diplomat status; and most recently, the health professions Graduate Psychology Education (GPE) initiative as a result of the persistence and dedication of the APA Education Directorate.  As always, there remain numerous challenges ahead – Medicare's Graduate Medical Education (GME) and the Children's Hospital GME accounts to name but two.  With the enactment of President Obama's landmark Patient Protection and Affordable Care Act (ACA) [P.L. 111-148] our profession is facing unprecedented challenges throughout the healthcare system, which is rapidly changing from its previous emphasis on reimbursing for specific clinical procedures targeted toward curative care, to a more comprehensive, patient-centered, holistic, data-driven health care system with a high priority on prevention, public health, interdisciplinary care, and effectively utilizing technology – especially, the extraordinary advances in communication sciences (i.e., Health Information Technology).

            Without question, there are several critical provisions within ACA where psychology currently is not recognized; i.e., the very important Accountable Care Organization (ACO) and Patient Centered Medical Home (PCMH) initiatives.  AsKatherine Nordal insightfully stresses at her annual State Leadership conferences, the key for psychology is enthusiastic engagement at the local level, in collaboration with similar-minded partners (such as Doctors of Nursing Practice (DNP) and Clinical Pharmacists (PharmD))  For it is at the state level where the real work of implementing health care reform will be taking place.  Conceptually we are in good shape.  Over the past decade, the Practice Directorate has built a robust State Leadership infrastructure.  APA's governance leadership appreciates the importance of embracing integrated care and expanded roles of practice (such as prescriptive authority (RxP)), as well as tele-psychology and the absolute necessity of licensure mobility.  As always, ultimately the key to recognition and support by our nation's elected officials is effectively addressing society's pressing needs.  Accordingly, we must pause and wonder: Why have we not been collectively interested in obtaining recognition under Medicaid?  And, Why do we not have an active presence within federally qualified community health centers?  For these are the true "safety net" envisioned by President Lyndon Johnson's Great Society?

            What must happen next from my public policy perspective is that our profession's training institutions must learn from their colleagues in medicine and nursing about the importance of possessing "homes of their own."  Within ACA there are impressive incentives recognizing the importance of encouraging the educational institutions of both of these professions to address society's pressing needs (i.e., by providing financial assistance).  For example, Nurse-Managed Health Clinics that will provide comprehensive primary health care and wellness services to vulnerable or underserved populations; a new Medicare Graduate Nurse Education Demonstration program for up to five eligible hospitals to receive support for clinical training costs attributed to providing advanced practice nurses with qualified training.  And, a Teaching Health Centers initiative to expand primary care residency programs.  The Senate Appropriations Committee has recommended that not less than $5 million be expended for the nurse-managed health clinic program, within the $231+ million allocated for nursing training.  The Children's Hospital GME initiative will receive $265+ million exclusively targeted for medical schools, notwithstanding the important psychosocial component of childhood and family care following accidents and for those children afflicted with potentially devastating diseases such as childhood cancer.  Historically, psychology's training programs have expressed little, if any, interest in expanding their legislative presence (other than most recently, under the newly authorized GPE program).

            As educated professionals, we should take serious notice of the unfortunate reality of the Institute of Medicine (IOM) finding that: "The lag between the discovery of more efficacious forms of treatment and their incorporation into routine patient care is unnecessarily long, in the range of about 15 to 20 years.  Even then, adherence of clinical practice to the evidence is highly uneven."  This delay in the translation of evidence to practice is unacceptable and must be addressed.  We must come to appreciate that our training institutions are where the next generation of psychology's practitioners will learn their skills and practice patterns for decades to come.  They are also absolutely critical in bringing the most up-do-date clinical knowledge to the attention of today's practitioners.  With the expanding availability and exciting potential inherent in tele-psychology, virtual realities, and data-driven cross-patient comparisons, it must ultimately be our training institutions (and I expect it will be our professional schools) that must now demonstrate proactive leadership in making these connections – in bringing "town and gown" effectively together.

            For those colleagues who argue that we should not consider ourselves "health care providers"; that psychology should not seek to expand its scope of practice (i.e., pursue RxP); and that we need fewer students, rather than more, I can only say that "the train has already left the station."  Hopefully, our next generation of colleagues will appreciate what they might have individually contributed to our future, notwithstanding.  "I hear the train a comin'."  Aloha,

 

Pat DeLeon, former APA President – Division 42 Viewpoint – September, 2012

 

CRITICAL TIMES – AS ALWAYS, EXCITING OPPORTUNITIES

The annual APA Practice Directorate State Leadership conferences (SLC) provide an exciting opportunity for practitioners to personally experience how the public policy process will directly affect their future.  With the enactment of President Obama's landmarkPatient Protection and Affordable Care Act (ACA) [P.L. 111-148], our nation has finally joined the rest of the developed world in guaranteeing access to necessary health care for all of its citizens.  One of the most significant provisions of ACA is the establishment of health insurance exchanges which by 2014 will be available in every state.  These entities will ensure that all plans include the same package of essential health benefits, although they will vary by four different levels of "actuarial value," or percentage of costs that a plan pays on average.  In upholding its constitutionality, the U.S. Supreme Court estimated that by 2019, 24 million Americans will obtain their health insurance through one of the newly authorized exchanges.  Hawai'iwas the first state in the nation to declare its intent to establish a state-certified exchange and today is well underway in implementing its vision, having received a $61.8 million grant from the federal government this summer.

The Hawai'i Health Connector's executive director Coral Andrews (former Navy Nurse Corps): "The establishment of our health insurance exchange in Hawai'i is driving new business models between the private and public sector.  There is a high degree of collaboration with a focus on mutual success.  Our collective priority is to contribute positively to the health and well-being of the residents of Hawai'i.  With this recent supplemental grant award, it signals confidence in the work that we are doing and further supports the goal of developing a state certified health insurance exchange in Hawai'iby 2014."  Dean Mary Beth Kenkel, Florida Institute of Technology, and I long ago came to appreciate that enacted health policies represent the views and underlying value systems of engaged participants.  At this year's SLC, Katherine Nordal: "We are in for a change like probably none we have ever seen in terms of shaping what our practices are going to be like in the next decade or two.  We're facing unchartered territory with proposed new models of care delivery.  We know that the states are in the drivers' seat.  Most of what happens about health care reform is going to happen back home.  You've got to get involved in coalitions.  We're going to have to address health insurance exchanges."

Psychologists must come to appreciate that it is essential to be personally involved in the public policy/political process if we want to maintain our professional identity and independence.  The newly elected President of the American Medical Association (AMA), in response to questions regarding non-physician health care providers, has stated: "It's imperative that we collaborate.  The patients need that.  We think that care must be delivered in a physician-led team.  There are appropriate roles for other health-care providers, like nurse practitioners [NPs] and physician assistants [PAs].  They all have the ability to function to their highest level within a physician-lead team.  [Why 'physician-led team?']  The physician has the potential and capability to manage the unexpected, something that might not go as predicted.  And that's why you need a team.  The physician is the highest trained and the one who has to be in charge of the whole thing."

Perhaps not a surprising orientation.  However, last summer the Centers for Medicare and Medicaid Services (CMS) issued proposed conditions of participation for community mental health centers (CMHCs) which seem to take the AMA's view to another level.  "The comprehensive assessment would build from the initial evaluation and be completed by the physician-led interdisciplinary team in consultation with the patient's primary health care provider, if any….  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."  Interestingly, psychologists will be allowed to conduct psychiatric evaluations, if there is a "physician counter signature."  This summer the Department of Veterans Affairs (VA) requested: "A nationwide blanket tier exception for Psychiatrists… in order to provide a broader and more competitive salary range to potential recruits and provide greater retention to existing staff."  Hardly a vision of effectively utilizing the skills of non-physician providers by the current Administration.

President Obama recently issued an important Executive Order – Improving Access to Mental Health Services for Veterans, Service Members, and Military Families.  He called for the Departments of Veterans Affairs and Defense to jointly develop and implement a national suicide prevention campaign focused on connecting veterans and service members to mental health services.  An Interagency Task Force will be established to be co-chaired by the Secretaries of Defense, Veterans Affairs, and Health and Human Services, or their designees.  The critical question for psychology, as well as for other non-physician health care providers: What will our role be?  We would suggest that it would be extraordinarily naïve to assume that all those involved in establishing and implementing important national (and local) health care policies truly have "the best interest" of the client/patient in mind, rather than their own professional identity or "turf."  As our visionary leader Katherine Nordalproclaimed at this year's SLC: "We have to be ready to claim our place at the table.  We need to get involved at the ground level.  If we're not at the table, it's because we're on the menu."  For those senior colleagues who are wondering whether they should become more involved in the Nebraska Psychological Association's political efforts, these thoughtful words from former APA President Nick Cummings should be carefully considered:  "As one who forever keeps flunking retirement, I strongly recommend flunking…."  Get involved!  Aloha,

 

Pat DeLeon, former APA President – Nebraska Psychological Association – September, 2012

 

 

EMBRACING INTEGRATED HEALTH CARE

   Steady RxP Progress:  During ourOrlando convention, Illinois Psychological Association President-Elect Beth Rom-Rymer predicted an exciting future for those colleagues who embrace integrated care and who appreciate the importance of prescriptive authority (RxP) for the profession's future and quality of care that psychologists can provide within our nation's rapidly changing health care environment.  "There has been extensive movement in the RxP initiative since January 1, 2012.  The movement has been most productive in two states, Illinois and New Jersey, and the Canadian province of Ontario. Hawai'i is re-introducing RxP in 2013.  There has also been a recent announcement that theNew Zealand government has mandated that psychologists become trained to prescribe in that country in 2013, because of the critical shortage of psychiatrists and significant health risks to New Zealand citizens due to the lack of mental health prescribing providers.

            "The Illinois Psychological Association (IPA) is pursuing an aggressive campaign for RxP.  It all began on March 6, 2012, when the IPA RxP bill passed out of the Public Health Committee of our State Senate.  Its champion and sponsor was the President Pro-tem of the Senate, Don Harmon.  The Chair of the Public Health Committee, Senator William Delgado, was also key in this legislative success.  SinceMarch 6^th, IPA has created an extensive grassroots campaign, involving more than 200 psychologists, from around the state, who are meeting with their legislators and speaking to mental health associations, social service organizations, law enforcement associations, hospital groups, prison health care providers, among others.  The psychologists are emphasizing the robust training that prescribing psychologists receive; the critical shortage of mental health prescribing providers; the success of prescribing psychologists in the U.S. military, on Indian reservations, and in the states of New Mexico and Louisiana; and the need to prepare for the entry of hundreds of thousands of new patients into the mental health and primary health care system on January 1, 2014, when President Obama's Patient Protection and Affordable Care Act (ACA) [P.L. 111-148] takes hold in Illinois.  IPA's goal is passage of the RxP authority bill in the legislature in Spring, 2013.

            "The New Jersey Psychological Association (NJPA) and the New Jersey Academy of Medical Psychologists, under the leadership of Sean Evers, President-Elect of NJPA, is pursuing an aggressive campaign for RxP with its legislators.  They have support from Autism New Jersey, the National Association of County Veterans Service Officers, the VFW District 12, the National Association of County Veterans Service Officers, the VFW Post 6063, and the New Jersey Association of Veterans Service Officers, among others.  NJPA hopes for passage of their RxP bill in the General Assembly (the lower house of the state legislature) in the Fall of 2012.  They have received bi-partisan support from leadership in both houses of the legislature with the Senate Majority Leader signing on as a co-sponsor and positive interest from the administration.

            "The Ontario Psychological Association Committee for Prescription Privileges is chaired by Diana Velikonja and Jane Storrie, with Honorary Co-Chair, Marie Greenspan.  Their RxP Committee is working very hard to garner support for RxP.  Internally, the committee is seeking support from the Ontario Psychological Association's (OPA's) Board of Directors, the Canadian Psychological Association, and the College ofPsychologists in Ontario.  They are also seeking support from outside groups, including the Nurse Practitioners Association of Ontario, the Nurses Association of Ontario, the Collegeof Physicians of Ontario, the Pharmacy Association of Ontario, the Bureau of Indian Affairs, the Military, and the Ontario Medical Association.  There will be a motion to the OPA Board in September, 2012 for support of RxP and a submission to the Deb Mathews, Provincial Minister of Health, requesting expansion of practice for psychologists, in October 2012.

            "Darryl Salvador, President-Elect of the Hawai'i Psychological Association (HPA), is leading the continuing movement for RxP inHawaii.  In 2011, HPA added language to their existing RxP bill that would develop a 5-year, multi-phase pilot program that would limit prescriptive authority to psychologists practicing in the largest federally qualified community health center (FQCHC) in Hawai'i for the first two years and then expanding the training and subsequent practice to other FQCHCs in the following years.  HPA has enlisted the help of key Native Hawaiian community leaders and has secured the support of a psychiatrist to assist with supervising psychologists during the practicum phase of their RxP training.  There has been positive changes to the composition of the Hawaii Board of Psychology; a Master's of Science Program in Clinical Psychopharmacology in now housed within the University of Hawai'i at Hilo College of Pharmacy; and there are increased opportunities to work collaboratively with the new state government officials, including the Governor, the Lieutenant Governor, and the Director of the Department of Health.  HPA plans to introduce legislation during the 2013 legislative session.  Because of an election in 2012, the expectation is that there will be changes, favorable to RxP, in the House leadership and Committees."

            The Struggles Surrounding Professional Autonomy Continue:  The newly elected President of the American Medical Association (AMA) recently reaffirmed their support for President Obama's ACA, which is estimated to provide 32 million additional Americans with access to necessary primary health care.  In response to questions regarding non-physician health care providers, she stated: "It's imperative that we collaborate.  The patients need that.  We think that care must be delivered in a physician-led team.  There are appropriate roles for other health-care providers, like nurse practitioners [NPs] and physician assistants [PAs].  They all have the ability to function to their highest level within a physician-lead team.  [Why 'physician-led team?']  The physician has the potential and capability to manage the unexpected, something that might not go as predicted.  And that's why you need a team.  The physician is the highest trained and the one who has to be in charge of the whole thing.  I have worked with physician assistants and have a wonderful relationship.  I've worked with nurse practitioners and we work collaboratively.  But when there was an issue that needed something beyond the scope of the individual, I was the one managing that."

            This is at a time, as Morgan Sammonspoints out, combining NPs and PAs, the numbers of non-physician practitioners are on track to exceed that of primary care physicians in the near future.  There are approximately 250,000 NPs and PAs in the U.S., compared with 306,000 primary care allopathic physicians (medical and osteopathic).  This trend is consistent with projections made a decade ago.  It is also projected that a quarter million more nurses will be needed by 2025 to care for the growing and aging population, especially those with chronic care needs.  Forty-five percent of today's nurses say they plan to make a career change in the next one to three years.  Katherine Nordal's vision at the Spring State Leadership Conference that State Psychological Associations be actively engaged in health care reform deliberations at the local level, and in collaborations with our nursing colleagues, is absolutely critical.  Aloha,

Pat DeLeon, former APA President – HPA – September, 2012

 

THE CRITICAL IMPORTANCE OF INVOLVEMENT

    During this year's exciting State Leadership Conference, Katherine Nordal called upon the membership to become increasingly involved in shaping the future of our profession.  "We're facing unchartered territory with proposed new models of care.  Change is inevitable.  We have to be ready to claim our place at the table.  We need to be involved at the ground level when you get back home.  You've got to get involved in coalitions….  We're going to have to address health insurance exchanges.  These are exchanges that provide health plans for individuals and small businesses that will be set up at the state level."  Without question, President Obama's Patient Protection and Affordable Care Act [P.L. 111-148] is complex and will have an extraordinary impact upon psychology.  In 2014 health insurance exchanges will be available in every state with all plans including the same package of essential health benefits, although they will vary by four different levels of "actuarial value," or percentage of costs that a plan pays on average.  In upholding its constitutionality, the U.S. Supreme Court estimated that by 2019, 24 million Americans will obtain their health insurance through one of the newly authorized exchanges.

 

            The State of Hawai'i was the first in the nation to declare its intent to establish a state-certified exchange and is well underway in implementing its vision, having received $61.8 million from the federal government this summer.  The HHS grant will allow the state to meet several new milestones including multi-cultural community outreach, language access, customer relations management, and information technology training and operations.  Governor Neil Abercrombie: "The successful establishment of the Hawai'i Health Connector is part of our New Day Plan in transforming healthcare in Hawai'i."

 

            The Hawai'i Health Connector is an online health insurance exchange established by the state legislature as a non-profit organization in 2011.  Its aim is provide an online marketplace that is Hawai'i-for-Hawai'i, effectively taking into account the state's unique culture and Prepaid Health Care Act, an employer health mandate in effect since 1974.  The Connector has a 15 member board of directors.  For psychology or any other health profession not to be involved in these policy deliberations would be, to invoke Katherine's inspirational charge: "If we're not at the table, it's because we're on the menu…."  Energetic coalitions with like-minded colleagues, such as advanced practice nurses and clinical pharmacists, are absolutely critical to the future of our profession.  We are making significant progress embracing the 21^stcentury.  In Orlando, Illinois Psychological Association President-elect Beth Rom-Rymer noted that her colleague Michael Ranney reports that the Ohio Psychological Association bill, which will mandate up to 6 prescribing psychologists in the Ohio State Prison System, is expected to pass in the 2013 State Legislature.  Addressing society's pressing needs remains the key.  Aloha,

 

Pat DeLeon, former APA President – Division31 

September, 2012

 

AN EXCITING ORLANDO CONVENTION

   Psychopharmacology & Prescriptive Authority (RxP):  One of the most inspirational symposiums at this year's Orlando convention was that chaired by Kevin McGuinness of the U.S. Public Health Service Regular Corps who is a Prescribing Psychologist and President of Division 55, The American Society for the Advancement of Pharmacotherapy.  "We had a very well attended symposium entitled 'How to Become a Prescribing Psychologist.'  I had the honor of introducing the presentations by Bob McGrath (Fairleigh Dickinson University),Christina Vento (Southwest Institute for the Advancement of Psychotherapy/New Mexico State University, and Virginia Waters, an RxP graduate of the Fairleigh Dickinson program.  I outlined the APA's recommendations regarding postdoctoral education and training programs in psychopharmacology for prescriptive authority and described the requirements for licensure in New Mexico andLouisiana.  We included a discussion of grass roots advocacy, post-doctoral education, RxP licensure, social networking with psychologists, local political activism, affiliate health professions, and the integration of psychologists' roles in healthcare practice settings.  Regarding the integration of psychologist roles, we emphasized faithfulness/consistency to the primary role as 'clinical psychologist'; commitment to collaborative relationships with MDs, PCPs (primary care providers), and other psychologists; education of the public on the quality of comprehensive psychological service ('one-stop-shopping'), and the need for prescribing psychologists and other psychologists to find their niche in primary care, rural medicine, academia, public policy, and the APA governance.

            "Bob McGrath discussed the responsibility of clinical psychologists to understand clinical psychopharmacology in order to serve in consultative roles across the spectrum of health care settings.  He emphasized the role of post-doctoral training in clinical psychopharmacology to prepare such consultants and not only prescribers.  Bob asserted his belief that clinical psychologists with such training have saved many lives.  Virginia Waters discussed the value of her training at Bob's program for preparing her as a consultant in a state that has not yet granted prescriptive authority to psychologists.  She uses her training everyday in this capacity, especially when it comes to educating patients on the medications they are taking.  Christina Vento, on the other hand, utilizes her training as a licensed prescriber.  Both graduates functionally address polypharmacy by 'unprescribing' medications under appropriate circumstances and more fully utilizing psychotherapy as a primary therapeutic intervention.  Our tasty 'free lunch' for those attending was undoubtedly a successful drawing card."  As our nation's health care systems evolve towards integrated, patient-centered holistic care, it was very nice to see the next generation of psychology's practitioners appreciating the inherent challenges and opportunities for their professional future.

            Evolving Journeys:  Having retired from the U.S. Senate staff after 38+ years, I have become quite interested in how our colleagues are approaching this next phase (or journey) of their lives.  Ruth Paige and Steve Ragusea: "All our lives we've been busy achieving and meeting responsibilities and expectations to – do well in school, raise children, earn a living, be socially and culturally engaged – and then, we finally retire.  We haven't been trained for this.  And that makes it so urgent and scary for some….  But not others….  Some of us read the research on retirement long ago and began our preparations by slowing down and snorkeling.  It's not about stopping; it's about slowing down and taking more side roads along the highway of life."  Summing up what seems to be a consistent theme for those who are successful in adapting to their new life, a colleague who recently stepped down from a high level academic position: "Pretty good – miss the people but not some other aspects.  Am currently in North Carolina – was a bridesmaid in a wedding of friends fromHawaii – we were a mature wedding group – lots of fun.  How are you doing?"

            Academia:  "How to terminate tenured professors?  I am sure those of us who have reached or are reaching what has been the traditional age of retirement, age 65, contemplated retiring.  While those of us in defined pension plans may have the incentive of realizing that their pension may be very close to what they are earning, and thus they may be working for close to nothing, those of us in battered 401 plans see continued employment as trying to regain their losses over the past several years.  Moreover, the longer the latter group works the less money they will need because they will live fewer years in retirement; that is the real advantage to delaying retirement.

            "Being tenured does offer a great deal of job security if you are not in a medical center.  Terminating tenure for cause is a time consuming and drawn out procedure that administrators would prefer to avoid.  Voluntary retirement is the preferred strategy.  So how do you terminate a tenured professor?  One cause of voluntary termination is social pressure and local norms.  If the faculty member is in an environment that highly values research grants and publications then a professor who buys into those norms and is not performing might not feel good about continuing to work in such an environment.  I have seen several faculty retire under those conditions who are still effective teachers as evidenced by the willingness of the university to hire them back to teach courses at less than 10% of their previous salary.

            "An alternative to the above approach is to make the environment uncomfortable for the faculty member whose behavior is not governed by such norms.  I have seen this happen to faculty but it is a very difficult strategy.  Moving a faculty member's office to an unpleasant location may have worked in the past but with the Internet it doesn't matter where you work.  Assigning such a faculty member to lots of advisees or large classes is self-defeating for the university if the faculty member does a poor job.  Moreover, anything that increases the alienation of the faculty member will result in even poorer performance and weaken the ability to influence the faculty member through norms or peer pressure.

            "I have had a good life at VanderbiltUniversity.  I have been here 31 years (not an expectation my family or I had when we came) and actively participated in the governance of the College and University as associate dean for research, chair of the IRB, and chair of the most powerful committee on campus – traffic and parking.  I have also served two consecutive terms as chair of the faculty council.  On the other hand I have been housed outside the department most of my time, first at a policy research center and then in the administration building.  I have been director of a center since I came to Vanderbilt that has afforded me a great deal of autonomy.  I would characterize myself more a cosmopolitan rather than a parochial professor in the classic Jencks and Riesman's (1968) terms and thus local norms are less influential.  Although I only taught two classes a year, after 40 years of teaching I wanted to focus on other things in my life.

            "My wife partially retired several years ago but still serves as managing editor of a journal I edit.  We have three children and four grandchildren, who we would like to see more often but teaching classes requires, at a minimum, that you show up in class.  Some may see this as a minor inconvenience but with the traveling we wanted to do it is a significant barrier.  Second, in the last decade we have developed a web-based measurement and feedback system that the university is commercializing, from which I will receive some income if it is successful.  The system is based on several social psychological theories and has been shown to improve outcomes for youth receiving mental health services.  But becoming an entrepreneur/businessperson is a new challenge for me (and for the university since we are the first to do this inside the university structure) and takes a great deal of time and effort.  Given these interests, I was ready to tradeoff my teaching for other activities but the university had to make it attractive to give up my lifetime guarantee of employment.

            "At the end of June the university sent emails to all faculty members offering a new 'Retirement Assistance Program' for all tenured faculty in University Central that does not include the medical center.  I opted for the 'Transition Plan' the university has offered.  It was described as 'a one-time window of opportunity will be provided to full-time tenured faculty members who have at least 15 years of continuous full-time service to Vanderbilt University and will be at least 63 years of age as of July 1, 2012.'  In addition, the faculty member will receive one year of limited health care coverage for each five years of service.

            "I have been married 48 years and I always discuss decisions with my wife.  However, I saw my dean about 15 minutes after I received the email and I told her that I would probably take the offer.  She told me I was the second person to tell her that.  I considered it a no-brainer.  I was ready to give up my tenure, for a price, but not to retire.  The dean and I agreed that I could stay on as an untenured research professor as long as I could support my staff and myself.  With three or more years left on several grants, I thought this would work out just fine.  This year I teach my last graduate and undergraduate class.  The answer to the question posed in the title is simple – pay tenured professors to give up their tenure.  I don't know how the university came up with this plan but I would not be surprised if there were consulting companies that provided advice.  I am curious to see which other professors take the offer and if it works out best for the university and the professors [Len Bickman]."  Aloha,

Pat DeLeon, former APA President – Division 18 – September, 2012