Earlier this year HHS Secretary Kathleen Sebelius highlighted the ability of President Obama's Patient Protection and Affordable Care Act (ACA) to significantly curtail the ever escalating costs of health care. "The rising cost of health insurance coverage has imposed a heavy burden on our nation…. If health-care costs continue to rise unchecked, they will threaten America's ability to compete and will become unaffordable for most families. One of the major reasons we passed [ACA] was to bring down costs… tackling the underlying cost of medical care…. [ACA] gives us tools to reduce costs by promoting better health and providing better care, especially in Medicare and Medicaid, which can be tremendous forces for positive change across the entire health-care system. The law emphasizes prevention because we know it is far less expensive to prevent disease than to treat it…. The health-care law gives us dozens of tools to improve chronic-disease management, coordinate care among multiple providers and foster innovation. Experts who have studied the law, from the Medicare trustees to the independent Congressional Budget Office, agree that it will put the brakes on skyrocketing Medicare costs. And last January, 272 of America's top economists wrote to the House Budget Committee that the ACA 'contains essentially every cost-containment provision policy analysts have considered effective in reducing the rate of medical spending.' It won't be easy and it won't happen overnight. But at a time when some claim that our only options are to allow health-care costs to continue to skyrocket or to make some of the most dramatic cuts to our health-care programs ever proposed, the Affordable Care Act provides a better way forward."
It is important for all of the health care professions to appreciate the magnitude of change that our nation's health care environment will soon be experiencing. Watching the President's State of the Union Address every practitioner should understand that unprecedented change is coming. "I will not go back to the days when health insurance companies had unchecked power to cancel your policy, deny you coverage, or charge women differently from men. And I will not go back to the days when Wall Street was allowed to play by its own set of rules…." From our perspective, significant policy decisions will evolve at both the local and national level. Are we sufficiently engaged?
ACA is fundamentally patient-centered, heralding a major commitment, over time, to data-based decision making. "What objectively works and under what conditions?" might be seen as its underlying orientation. And yet, given the intensity of efforts being made by various health interest groups (including professional associations), one must expect that active engagement in the public policy/political process will become a major element of decision making. Will, for example, the conceptualized "medical home" require physician direction under an historical "captain of the ship" philosophy or will it embrace true interdisciplinary care, facilitating each discipline practicing to the fullest extent of its training? One factor will undoubtedly be the extent to which the various non-physician professions are successful in modifying federal statutes (e.g., Medicare and Medicaid) to ensure that their training institutions and practitioners have ready access to the same resources that medicine has historically possessed (e.g., financial support for implementing electronic medical record systems and telehealth/telepsychology reimbursement). In the abstract, moving from historically isolated silos of practice and training to interdisciplinary care makes sense, especially under ACA. How to accomplish this monumental change in orientation will be the evolving question.
A Renewed Focus: I recently accepted the exciting opportunity to join the faculty of the Uniform Services University of the Health Sciences (USUHS) of the Department of Defense. I will be located within the School ofNursing and the Department of Psychology, the latter having been on the forefront of the Health Psychology movement thanks to the vision of former APA President Joe Matarazzo, as a member of the Board of Regents. The chair of the Department is David Krantz, another of the original visionaries. I will have the opportunity to become increasingly familiar with the culture and literature of our health profession colleagues. For example, how do they (and perhaps psychology) address the needs of the growing number of individuals with chronic diseases? The Centers for Disease Control and Prevention (CDC) estimates that 7 of 10 deaths among Americans each year are from chronic diseases with obesity becoming a major public health concern (almost 1 in every 3 adults being obese; as is almost 1 in every 5 youth, between the ages of 6 and 19). Seventy-six percent of Medicare spending is currently on patients with 5 or more chronic diseases. By 2020, our nation is projected to spend $685 billion a year in direct medical costs for individuals with chronic diseases.
David and I visited the USUHS Centerfor Deployment Psychology (CDP) which was established 5 years ago, after considerable involvement by the APA Education Directorate (Cynthia Belar and Nina Levitt). Since 2007, the Center has trained more than 20,000 mental health providers working throughout the deployment cycle. The Deputy Director, Bill Brim, is a health psychologist with over a decade of service within the USAF. Former APA Congressional Fellow Paula Domenici is the Director of Training Programs, overseeing several initiatives educating mental health providers about the unique needs of service members, veterans, and their families; and the best strategies to assist them. Since many veterans seek help from community-based clinicians, both immediately and years after their deployment, CDP trains military and non-military providers who care for the warriors and their loved ones. One of CDP's hallmark offerings isAddressing the Psychological Health of Warriors and Their Families, a 1-week course that has been presented in 27 cities, includingHonolulu, San Diego, Albuquerque,Minneapolis, Austin, Nashville, andPittsburgh, to reach civilian audiences across the country. Through this program, over 2,300 psychologists, social workers and other professionals have learned about military culture, the deployment experience, and evidence-based psychotherapies to treat PTSD. Congressman Tim Murphy, a clinical psychologist, emphasized the value of CDP's mission after completing this course: "Although PTSD is treatable, we simply do not have enough trained military and civilian clinicians to meet the needs…. These (CDP) courses provide solid foundations in that critically important training." [www.DeploymentPsych.org].
Clinical Pharmacy: The USPHS Report to the Surgeon General from the Office of the Chief Pharmacist is entitled: ImprovingPatient and Health System Outcomes through Advanced Pharmacy Practice. "The 2011 Report provides rationale and compelling discussion to support health reform through pharmacists delivering expanded patient care services. In collaboration with other providers, this is an existing, accepted, and additional model of improved health care delivery that meets growing health care demands in theUnited States. Health care delivery (including preventive or supportive care) in the United States is challenged by demands of access, safety, quality, and cost. These challenges are amplified by provider workforce shortages and dramatic increases in primary and chronic care visits. Projections suggest worsening of this situation. New or additional paradigms of care must be implemented to reduce these burdens. Current health care demands provide an opportunity for health leadership to recognize and adopt additional and significant health care delivery models….
"The federal sector has already implemented and embraced such a health care delivery model through physician-pharmacist collaboration. This collaboration, through extensive performance data, has demonstrated that patient care services delivered by pharmacists can improve patient outcomes, promote patient involvement, increase cost-efficiency, and reduce demands affecting the health care system. For over forty years, federal pharmacists have collaboratively managed disease through medication use, and other cognitive and clinical pharmacy services. Although these models are accepted in the non-federal sector, utilization is often impeded due to policy, legislation, and compensation barriers…."
Once a diagnosis is made by the primary care provider, pharmacists do manage disease and provide primary care. Pharmacists -- Perform patient assessment (subjective and objective data including physical assessment). Have prescriptive authority (initiate, adjust, or discontinue treatment) to manage disease through medication use and deliver collaborative drug therapy or medication management. Order, interpret and monitor laboratory tests. Formulate clinical assessments and develop therapeutic plans. Provide care coordination and other health services for wellness and prevention of disease. And, Develop partnerships with patients for ongoing (follow-up) care. Under ACA, HHS has considerable flexibility in defining "preventive services" and "essential health benefits" as broadly as desired. Those following psychology's prescriptive authority (RxP) quest will not be surprised to learn that in 1996, the then Director of the Indian Health Service (IHS) issued a Special General Memorandum (SGM 96-2) recognizing Clinical Pharmacy Specialists (CPSs) as primary care providers with prescribing authority. The Dean of one of the nation's leading schools of pharmacy emphasized that clinical pharmacists must complete a four-year postgraduate program focusing on managing complex medications and are extraordinarily cost-effective. At Kaiser PermanenteColorado, pharmacists worked with physician-approved protocols targeting patients with coronary artery disease and hit their blood pressure and cholesterol targets. They achieved an 89% reduction in their patients' overall mortality and nearly $22,000 annual savings in health care costs per patient. Similarly, targeting city employees with diabetes, pharmacists were successful in reducing the annual direct medical costs per worker, on average, by $1,200 to $1,872 – an estimated savings of $4 for every $1 invested. Not surprisingly, the city has since expanded this program to cover other chronic diseases, including hypertension and asthma.
Looking Forward: Having retired from the U.S. Senate staff after 38+ years, I have become quite interested in the experiences of senior colleagues. Reflections from Ed Sheridan, a pioneer in Health Psychology and now Professor/Senior Vice President & Provost Emeritus, University ofHouston: "You certainly are correct that most of us do not think much about retirement until we decide to do it. One reason seems to be that we are among the first generations to be free to work or retire while previous generations had mandatory retirement at age 65 (if you lived that long!). I have only a few suggestions to offer that may be important. If there is a prominent mistake couples seem to make, it is they do not spend enough time in discussing what each person wants from retirement before deciding to retire. Since couples likely will spend much more time together, especially if they retire at the same time, it is essential they share what they desire and what each hopes the partner will want to do. These discussions need to include each partner's strongest wishes for a quality life, whether each finds the other's desires compatible, what to do with potential challenges (e.g., caring for a very ill parent), and what household duties each will agree to accept. Additionally, couples especially need to discuss what they want as a life style in the next few years. There are lots of choices. One consideration is to downsize one's home and use that money for other initiatives (e.g., seeing more of the grandkids, traveling, developing new interests or improving on former ones -- bridge, tennis, dancing, etc. -- teaching part time, consulting). In my case, I find teaching undergraduates (something I did very little of in my first 35 postdoctoral years) is real fun. It is like having an unlimited number of eager grandchildren. Even with such discussions, couples need to realize that retirement requires that each person be willing to be very flexible since no one anticipates all the challenges that eventually will come with this new lifestyle.
"Speaking of homes, I find many couples decide to own two homes, one in a warm environment for the winter and one near the grandchildren. Most eventually realize this was a mistake. As the grandchildren get older, they only desire a limited amount of time with the grandparents and the grandparents find they are spending a lot of money on the upkeep of two homes and this limits travel and other opportunities for stimulation. Most people wonder what they will do with 'all their free time.' Actually, I find there still is not enough time to accomplish what I wish to do. I suspect our colleagues will find the same. The one big change is that you have more control over your time but it still is not enough.
"Having read some literature on financing retirement from organizations like AARP, I did not find their predictions were helpful to us. One common proposal was a couple needs about 80% of their preretirement income. In our case, we spend as much in retirement as we previously spent. One reason may be that as a Dean and Provost, I had almost every lunch and most dinners paid for. I also had a free car. In addition, we received free tickets to most sports events, plays, musicals, etc. and now we pay for these items. One item that does cost less is clothing. In terms of finances, I do think it is important to talk with a financial planner who has no stake in how you invest and get good direction on how you can achieve your income goals. We were fortunate in that we anticipated the Bush fiasco and we were not hurt. However, we have numerous friends who lost 20%-35% of their retirement income by not anticipating the downturn. It also is hard to anticipate what your needs will be if you live 30 or more additional years.
"Healthcare opportunities also is an important topic for consideration. Kathy and I always intended to retire to Kauai (we already had land there to build a home). Then, having spent decades working closely with the leadership of the various health professions, we realized that we would not want to rely on obtaining care at Wilcox Hospital with its considerable rural challenges, while the closest medical center was on Oahu. We understand that subsequently the leadership of MauiMemorial Medical Center has been seeking to fulfill this historical neighbor island gap. Nevertheless, making the decision to be near good health care has paid important dividends for us and we are very appreciative that we recognized this need. Aloha."
PatDeLeon – Division 29 – February, 2012
