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