"Lived by the Sea…." At the end of the fiscal year, I retired from the U.S. Senate staff after 38+ years, having served from the first day of the infamous Watergate hearings. Already the types of information readily available to me have shifted, not to mention the "demands of the moment." I have finally had time to have a leisurely lunch with several of my favorite professional colleagues. They say, "Puff frolicked in the Autumn mist in a land called Honah Lee." Looking perhaps now from afar, it remains increasingly clear that the health care environment of the next decade will be dramatically impacted by the advances occurring within the communications and technology fields, and further that psychology must strive for licensure mobility and a meaningful presence within integrated health care (i.e., obtaining prescriptive authority (RxP)).
This Fall the State of Hawaii received significant funding from the Department of Health and Human Services (HHS) to help establish and implement the Hawaii Health Connector, an on-line health insurance exchange designed to help Hawaii's consumers find affordable health care plans. This is viewed as a critical step towards ensuring that all residents of Hawaii will ultimately have access to high quality, affordable health care, pursuant to President Obama's Patient Protection and Affordable Health Care (PPACA) legislation.
"Globalization – It's relevance toHawaii's Health Care Delivery System Vision. When we were offered the opportunity to share our thoughts with the readership, we contemplated our approach. Our curiosities led to broader questions: How do the efforts to transform Hawaii's health care delivery system affect social change? Does our vision of health care transformation have the opportunity to have a broader impact on social systems and our state's economic foundation? How can key initiatives contained within the Affordable Care Act (ACA), currently being implemented in Hawaii, accomplish parallel outcomes to globalization ideologies? What can the transformation yield so that it ties to the broader vision for the State of Hawaii… to be the conduit between U.S. and Asian markets?
"Let's start with globalization: Globalization, as defined by the Rockefeller Foundation, is the technological, social, and economic process by which people around the world have grown inextricably interdependent. In 1998 the University of Hawaii's School ofSocial Sciences presented a seminar on Globalization in which Fred Riggs presented dimensions of globalization that included economics, political science, sociology, psychology, anthropology, communications, and geography. Concepts of globalization can be similarly applied to a state level as the focus is on benefits being shared widely such that economic and social challenges can be overcome. Collaboration among individual communities and across the state can lead to positive outcomes across boundaries, whether socioeconomic, political, etc. A shared goal of globalization is to promote the well-being of humanity. In order to achieve this, systems are integrated. Information is transported more readily which also contributes to health promotion, social advancement, and improved economic viability.
"The Patient Protection and Affordable Care Act (ACA), a transformational initiative in health care, was passed in March 2010. Its goals are to increase access to care, to expand health care coverage, and to increase the focus on prevention. Like globalization, it is intending to promote well-being. The health of communities is directly linked to individuals' abilities to contribute positively to the economic viability of their communities as well.
"Hawaii is demonstrating progress in implementing federal health reform through several initiatives underway statewide. They include: the Hawaii Island Beacon Community, the Hawaii Health Information Exchange/Regional Extension Center, and the Hawaii Health Connector (insurance exchange). Each is described below. Hawaii Island Beacon Community: Established in May 2010, this federally funded collaborative project ($16.1 million grant) is administered through the College of Pharmacy at theUniversity of Hawaii, Hilo. Its goals include: improving access to health care, chronic disease prevention, focused reductions in health disparities of Native Hawaiians and other at-risk populations, and increased use of electronic health records to support information sharing between primary care providers. Hawaii Health Information Exchange (HHIE) and Regional ExtensionCenter (REC): Established in 2009, the HHIE is focused on the implementation of a statewide health information exchange that will ultimately feed into the national health information network. Its goals are to transform the current state of health care into one that coordinates care, reduces costs (for patients and providers), addresses the needs of the aging population, and provides incentives to engage patients in a proactive approach to their health care. The REC, also established in 2009, provides technical support to health care providers who are striving to meet the meaningful use requirements (electronic health records use) as described in the ACA. HawaiiHealth Insurance Exchange: Act 205, signed into law in 2011, established the Hawaii Health Connector (the state's health insurance exchange). HHS has awarded the State a total of $15.4 million to plan for and establish the exchange. States are operating under a very short timeline to implement their exchanges (by January 2014). Its goal is to create a marketplace for individuals and small businesses to purchase health care insurance.
"Each of these initiatives has a role in transforming Hawaii's healthcare delivery system but will only affect social change in the broader framework of health and healthcare transformation. Hawaii's Governor Neil Abercrombie also wants to transform the healthcare delivery system. His vision includes creating a patient-centered system that relies on comprehensive primary care, empowering a team of care-givers that expertly deliver medical, behavioral health, pharmaceutical, nutritional, and care coordination. The Governor's vision also includes developing and deploying a robust system of timely feedback and information to improve provider performance and transparency in reporting to guide consumer choices.
"These changes in healthcare will be reflected in Hawaii's economy as the cost for public and private insurance is stabilized but it also represents new career opportunities for our residents who might never aspire to be clinicians but can contribute meaningfully as care coordinators. This model of healthcare also offers hope for sustainability for rural and isolated communities that can't attract a physician or specialist in this era of shortages.
"Our ultimate vision for health is one where no group suffers disparities and the effects of poverty, lack of education, and other social determinates are erased. Improving the economy, creating new jobs that value community and cultural competence, and prioritizing patient experience and engagement all contribute to that vision. Healthcare transformation must be an on-going community-wide effort and we believe Hawaiiis ready for the challenge" [Coral Andrews, Hawaii Health Connector; Beth Giesting, Hawaii Healthcare Transformation.]
The Past Is Prologue For The Future: The future for our nation's health care delivery systems will embrace integrated, interdisciplinary, and patient-centered cross-disciplinary care. No longer will the individual professions be encouraged to practice in isolated, silo-oriented environments. Bringing science directly to the clinician will become an increasing policy priority. At the final Senate Labor-HHS-Education appropriations subcommittee hearing which I attended, the Director of the National Institutes of Health (NIH) and several of his colleagues testified on the NIH's Investments in Innovation strategy: accelerating discovery through technology; applying science to prevention; enhancing theU.S. economy and global competitiveness; and, advancing translational science. When asked what the single most important clinical intervention was, in their professional judgment, each of the NIH directors quickly spoke to the value of regular exercise. Finally, the psychosocial-cultural-economic gradient of quality care is being formally recognized at the highest policy levels. No one discipline can possibly know (or reasonably consider itself to be) the totality of health care – collaboration is absolutely critical.
In the early stages of psychology's prescriptive authority quest, visionary Linda Campbell worked closely with her Georgiapharmacy colleagues to develop a psychology-friendly training program. Recently, theCollege of Pharmacy at the University ofHawaii, Hilo (UHH) has been similarly engaged in collaborating with psychology. "On August 25, 2011, I attended the Board of Regents meeting to answer any questions posed by Board members concerning the MS in Clinical Psychopharmacology program we were developing. This program had already progressed through the entire University ofHawaii at Hilo review process. This last step would officially allow the UHH College ofPharmacy to offer the program. After a brief introduction, and overview of the program presented by the Vice Chancellor for Academic Affairs, UHH, the floor was opened for questions. The question and answer session lasted approximately 30 minutes. Some areas of concern voiced were: the sustainability of the program, the Continuing Education process of program graduates, and the current situation regarding the graduate's ability to prescribe. I believe that I was able to adequately answer all of their questions. The University President showed her support of the program by interjecting her opinion on administrative maters raised by the Board. She stated that this is provisional approval, and that all provisional programs must come back to the Board again, before they officially becomeUniversity of Hawaii programs. The vote was overwhelmingly in favor of the program with one negative vote [Ed Fisher, Associate Dean for Academic Affairs, UHH].
As we indicated earlier, Licensure Mobility is a critical issue for all clinicians. Reciprocity of pharmacy licensure is currently possible across all the States, Puerto Rico, and the District of Columbia and is facilitated by a national licensure transfer process and a national jurisprudence exam. There is no multi-state compact, however, as in nursing. The National Association of Boards of Pharmacy (NABP) provides these national mobility resources as a service to member state boards of pharmacy and to licensees. NABP also provides the Model Pharmacy Practice Act and updates it regularly. The Model Act addresses key issues, including the regulatory framework for collaborative drug therapy management (CDTM), agreements between pharmacists and physicians, nurse practitioners, and other prescribers. It facilitates pharmacists' patient management activities which include the initiation, modification, and cessation of medications. Psychology could learn much from pharmacy's experiences.
Over the years, I have been particularly impressed by the heroic efforts of Bill Howelland Vicki Vandaveer in struggling with the underlying applicability of licensure (and APA accreditation) for our Industrial-Organizational (IO) colleagues. There are clearly several areas in which the legitimate interests of health care providers and non-health care providers essentially clash. For example, Must all doctoral programs be APA accredited? Are pre- and post-supervision requirements relevant? The considerable mobility needs of national/international IO psychologists may be more pressing that those presently experienced by most clinicians. And, Do not most state licensure exams focus more on clinically-oriented content than IO colleagues would find relevant to their work? How do other professions address similar concerns? Collectively, we must elevate our consideration of addressing the underlying issues of competence, timeliness, and consumer protection. "Puff, the magic dragon lived by the sea. And frolicked in the Autumn mist in a land called Honah Lee." Aloha,
Pat DeLeon, former APA President -- Division 55 -- January, 2012
