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