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