As we begin to focus upon our forthcoming annual APA convention, to be held in Hawaii, we should reflect upon the challenge issued by Practice Directorate Executive Director Katherine Nordal at this year's exciting State Leadership Conference (SLC) to get personally involved in our state association's legislative efforts. "The clock is ticking toward full implementation of the law [President Obama's landmark Patient Protection and Affordable Care Act (ACA)] and January 1, 2014 is coming quickly. ButJanuary 1st is really just a mile marker in this marathon we call health care reform. We're facing uncharted territory with health care reform, and there's no universal roadmap to guide us. The details of ACA implementation vary from state to state, and so do the key players…. I want to highlight an important new development within APA, the Center for Psychology and Health. The Center includes a new Office of Health Care Financing, which will address challenges such as ongoing implementation of new psychotherapy billing codes and seeking new CPT (Current Procedural Terminology) codes that will adequately capture the work of psychologists in integrated care settings. Dr. Randy Phelps is heading up this office…. Yes, the clock is ticking toward January 1, 2014. But remember, we're not running a sprint. Health care reform is a marathon – we're in it for the long haul. New models of care and changes in health care financing won't take shape overnight. We can't hope to finish the marathon called health care reform if we're not at the starting line. Fortunately, many psychology leaders have embraced our call to action." SLC and our annual conventions have always been the highlight of the psychology year for me – such collective energy, vision, and enthusiasm. Katherine has a wonderful gift of vividly capturing the most critical agendas: This year, "Our practitioners increasingly will need to promote the value and quality they can contribute to emerging models of care. No one else is fighting the battles for psychology… and don't expect them to." Last year, "If we're not at the table, it's because we're on the menu. And I quite frankly don't want to be on anybody's plate to be eaten."
Randy's Vision: "APA launched its new Center for Psychology and Health under the direction of CEO Norman Anderson in January. One component of that Center is a new Office of Health Care Financing (OHCF), which we are currently setting up and will be directed by me. First, some background. As Norman has indicated in a number of venues, the purpose of the new APA Center for Psychology and Health is to vigorously pursue Goal Two of APA's Strategic Plan: Expand psychology's role in advancing health. The Center pulls together top leadership, staff, and major initiatives across all of APA to focus the association's efforts on four inter-related challenges outlined by Norman towards achieving this goal. They are: 1) Workforce, education and training challenges; 2) Influencing how we are viewed by policy makers, the scientific community, other disciplines and the public; 3) Addressing how we view and define ourselves; and, 4) What Norman calls the 'getting included, getting paid' challenge. There is, and has been, a tremendous amount of work by APA on each of these challenges, and we will keep the membership informed.
"Specifically regarding the 'getting included, getting paid' challenge, hopefully you're aware of the ongoing advocacy by the APA Practice Organization to legislatively define psychologists as 'physicians' in Medicare, gain inclusion of psychologists in every state's Medicaid system, and legally challenge inappropriate insurance practices and parity violations. The new OHCF was created to augment those efforts, and will work in close partnership with Katherine and APAPO, although it will be housed in APA's Executive Office. Getting included as providers in all primary care and integrated care settings, playing a key role in inter-professional treatment teams, participating in Accountable Care Organizations (ACOs), etc., are all necessary, but not sufficient, steps to insuring our future. For example, if you (or your institution) are not being reimbursed for your services in the existing fee-for-service (FFS) system or in the newer care delivery models, you are at risk of being replaced by those who are reimbursable, or by lower cost providers.
"The AMA Strategy: Our strategy is to directly target this issue in the most critical national venues where financing policies and mechanisms are translated into actual reimbursement realities. The American Medical Association (AMA) is one of those venues, so a primary activity of the new OHCF for the immediate future is to coordinate and expand APA's involvement with the AMA. Their processes play a very direct and powerful role in shaping this country's health care financing policies and provider reimbursement levels – in both the public sector and the private health care market. The Center for Medicare and Medicaid Services (CMS) uses the AMA's recommendations to set the fees paid in Medicare. And, these Medicare fees become the benchmark for reimbursements in other federal programs such as TriCare (DoD) and Medicaid and, very importantly, the commercial insurance market.
"So how does the AMA influence the public and private reimbursement system throughout the country? The AMA owns and runs the confidential and proprietary process through which all health care procedures in the U.S. are described and then assigned a billing code (which is then used for reimbursement in virtually all payment systems), known as the Current Procedural Terminology (CPT) system. APA is a player at the AMA CPT Committee, and was represented there by Tony Puente from 1994-2008. In 2009, Tony became the first psychologist elected as a voting member of its governing body, the AMA CPT Editorial Panel. Since then, Neil Pliskin has represented APA at CPT. The AMA also owns and controls the highly confidential process by which 'work values' are determined for all CPT codes; i.e., for all health care procedures from surgery to psychotherapy and beyond. That committee is known as the Resource-Based Relative Value Update Committee or 'RUC.' Jim Georgoulakis is the APA representative to the AMA RUC, and has held that seat for a decade and a half.
"So the AMA defines the procedure codes used by all health care providers, including psychologists, and also assigns a valuation ('RVU') to each procedure. CMS bases its fees on the RUV recommendations of the AMA, so this is where 'value' translates to reimbursement dollars. Commercial carriers and other federal programs then use the CMS fee schedule as a benchmark in setting their rates.
"APA's Game Plan: As I noted, APA has been a player for many years at the AMA CPT and RUC through our volunteer representatives. But with pressures to transform the health care system accelerated by President Obama's ACA, it is critical for APA to kick its CPT and RUC involvement up a notch to be at the table even more actively. And while these processes are central to maintaining the existing fee-for-service (FFS) system in health care, the move to newer financing models such as 'bundling' and 'global payments' will still rely on current fees as the building blocks to value the contribution of individual team members. So psychology cannot afford to neglect this arena for both the present and the future.
"To that end, we are working very intensively at the CPT and RUC with colleagues Tony, Jim, and Neil on issues that affect both 1) mental health services by psychologists and 2) the delivery of psychological services in physical health and integrated care settings. The immediate priorities of the OHCF in each of those two domains are: Mental Health Codes -- * Complete the AMA RUC survey process for the three remaining CPT codes in the new mental health CPT code set that went into effect January 1st for the entire public and private mental health system. CMS is using an interim fee schedule, and will not release its final fees for all mental health codes until that survey work is completed. * Work with the AMA and the other mental health societies to develop an 'extended service' psychotherapy code for trauma, PTSD, and other treatments that extend beyond 60 minute sessions, because there is no code available in the new mental health code set. Codes for Integrated Care -- * Lobby CMS for permission to re-survey (through the RUC system) the existing Health and Behavior CPT codes, used for psychological treatments associated with physical disorders. Those codes are currently valued at 30-40% below the comparable mental health codes. * Participate in the AMA's ongoing development of reimbursement codes for care coordination, transitional care, team conferences, etc. Psychologists are currently not reimbursable for these activities, and are not yet at the AMA table where they are being developed."
Health Resources and Services Administration (HRSA): Having finally completed deliberations on its very contentious Fiscal Year 2013 budget, the Administration recently submitted its request for Fiscal Year 2014. Administrator Mary Wakefield, who has participated in Cynthia Belar's Education Directorate Advocacy Breakfast: "Thanks to ACA, HRSA has an even broader role. Combined with first of its kind initiatives like the National HIV/AIDS strategy, HRSA's mandate continues to grow. Working with our DHHS partners, HRSA is responsible for 50 individual provisions in the health care law. These generally fall into three major categories. * Expanding the primary care safety net for all Americans – especially those who are geographically isolated, economically disadvantaged or medically vulnerable – for example, through expansion of the Health Center program. * Training the next generation of primary care professionals, while improving the diversity of the workforce and re-orienting it toward interdisciplinary, patient-centered care. HRSA does this through targeted support to students and clinicians and grants to colleges, universities and other training institutions. * Working with its partner agencies, HRSA is expected to greatly expand prevention and public health efforts to catch patients' health issues early – before they require major intervention; to improve health outcomes and quality of life; and to help contain health care costs in the years ahead. Our FY 2014 budget request places a strong emphasis on investing in programs that improve access to health care in underserved areas and allows the Health Resources and Services Administration to take important steps towards implementing healthcare reform and improving healthcare access for underserved populations. We are determined to work with our DHHS and other healthcare partners to assure the health of the Nation."
As a result of the continuing diligent efforts by Cynthia Belar and Nina Levitt, the HRSA budget request includes $2,892,000 for the Graduate Psychology Education (GPE) program, which was the level provided in FY 2012 (with a slight increase in FY 2013). This APA sponsored program funds accredited health profession schools, universities, and other public or private nonprofit entities to plan, develop, operate, or maintain doctoral psychology schools and programs and programs in mental and behavioral health practice to train psychologists to work with underserved populations. The program is designed to foster an integrated and interprofessional approach to addressing access to behavioral health care for vulnerable and underserved populations. Fifty-five percent of graduates were underrepresented minorities and/or from disadvantaged backgrounds and 29% report practicing in a medically underserved area. In support of the program, HRSA noted that mental disorders rank in the top five chronic illnesses in the U.S. and that the National Alliance on Mental Illness reported approximately 6%, or one in 17 Americans suffers from a serious mental illness. Serious mental illnesses cost society approximately $193.2 billion in lost earnings per year. Individuals suffering from a serious mental illness earned at least 40% less than people in good mental health, confirming that mental disorders contribute to significant losses of human productivity. Over the years, we have come to appreciate that the federal government is much more sympathetic to paying for clinical services rendered by practitioners when it has supported their training.
The Office for the Advancement of Telehealth (OAT) would receive $11.5 million, which was also its level in FY 2012. Funds would be provided for two grants under the Licensure Portability Grant Program, as well as associated technical assistance and evaluation activities. OAT anticipates that 204 communities will have access to adult mental health services and 239 communities will have access to pediatric and adolescent mental services by FY 2014. The OAT programs are viewed as an integral component of the overall DHHS Improve Rural Health Care Initiative to expand the use of telecommunications technologies that increase access to and improve the quality of health care provided to rural and underserved populations. Telehealth programs strengthen partnerships among rural health care providers, recruit and retain rural health care professionals, and modernize the health care infrastructure in rural areas.
Very Timely Steps -- Division 31: "APA Division 31 and Division 42 received a CODAPAR grant to create a specific digest of the laws of each State, and then create State specific electronic health record (EHR) templates. All APA member psychologists will have access to the laws and templates. It should assist in the implementation of the ACA provisions that will require EHR use among integrated healthcare professionals. Check the Division's website for the grant proposal and additional information. To gain access, go directly to:http://www.apadivisions.org/division-31/membership/health-record-templates.aspx. The State specific EHR templates comply with the laws of each jurisdiction. The States have had an opportunity to have their digests and the templates reviewed through the volunteer efforts of their member experts on the ethics/law. Each State's vetted materials are now posted at the Division 31 Community website so that all APA members will have access to these free resources [Andy Benjamin, Division 31 Past-President]."
Intriguing Incremental Steps: Those involved in shaping APA's Guidelines for the Practice of Telepsychology, which is a collaborative effort by APA governance entities, the Insurance Trust, and the Association of State and Provincial Psychology Boards (ASPPB), have taken notice of the parallel evolution of the notion of an "E. Passport" by ASPPB. This would address a number of issues surrounding interjurisdictional telepsychology practice and ASPPB is currently seeking public comment on their preliminary proposal. "The primary objective of every regulator within the field of occupational regulation should be public protection. Regulators typically achieve public protection by establishing licensing standards, engaging in complaint resolution, and by facilitating education. A central consideration in evaluating the effectiveness of any proposed Telepsychology standard, guideline, or regulatory language is its ability to ensure that the practice of psychology is done competently and at the minimum standard of acceptable and prevailing practice. In essence, by asking, 'Will this solution to Telepsychology protect the recipients of the psychological services?'" The ASPPB Telepsychology Task Force is considering the E. Passport proposal as such a mechanism to monitor and regulate interjurisdictional telepsychology practice. This goes directly to the underlying issue of licensure mobility which, with the advent of technology and integrated health systems, must be effectively addressed in a timely manner ifpsychology is to remain competitive within the global health care environment.
Clinical Pharmacy: "Reciprocity of pharmacy licensure is 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 agreements between pharmacists and physicians, nurse practitioners, and other prescribers, Collaborative drug therapy management facilitates pharmacists' patient management activities which include the initiation, modification, and cessation of medication (June, 2011)." Pharmacy's visionary approach proactively addresses the complex issues surrounding providing telehealth services by their profession. Aloha,
Pat DeLeon, former APA President – Division 42 – June, 2013
