The Wisdom Of Visionaries: With the public sector facing an increasingly likely sequestration, including furloughs and decreased training resources, and with those within the private sector having to navigate the rough waters surrounding President Obama's far reaching Patient Protection and Affordable Care Act (ACA), it is important to reflect upon the wisdom bestowed by Katherine Nordal at this year's exciting State Leadership Conference. Proclaiming to her 500+ colleagues in attendance: "The clock is ticking towards full implementation of the law [ACA] and January 1, 2014 is coming quickly. ButJanuary 1st is really just a mile maker 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. Many of our practitioners increasingly will need to promote the value and quality they can contribute to emerging models of care. These are factors that create 'value-add' for psychologists on health care teams and in integrated, interdisciplinary systems of care. No one else is fighting the battles for psychology… and don't expect them to." Public service colleagues do bring "value-add" to those whom they serve. Now we must collectively educate those who establish our nation's health policies and advocate for appropriate recognition. We must also be willing to aggressively embrace change.
This summer, I was invited to participate in the Canadian Psychological Association's 74th annual convention in which CPA President Jennifer Frain passionately urged her colleagues to take control of their own professional destiny by becomingpersonally involved in the public policy/political process with her inspirational opening address "Supporting Canadian Psychology: Advocacy Required." The following day, the Honorable Justice Edward F. Ormston, of the Consent and Capacity Board (an independent body created by the provincial government of Ontario to conduct public hearing under the Mental Health Act), similarly invoked "A Call to Arms: A Discussion of Why the Timing is Right to Reclaim the Role of Psychologists in Treating Mental Illness and to Access Public Health Funding." The political and health care structure of Canada is without question considerably different than that of the United States. However, the needs of our clients and the potential contributions of our profession are strikingly similar and challenging.
It was back in 1974 that the Canadian Minister of National Health and Welfare, Marc Lalonde, visionarily proclaimed: "For these environmental and behavioural threats to health, the organized health care system can do little more than serve as a catchment net for the victims. Physicians, surgeons, nurses and hospitals together spend much of their time in treating ills caused by adverse environmental factors and behavioral risks…. While it is easy to convince a person in pain to see a physician, it is not easy to get someone not in pain to moderate insidious habits in the interests of future well-being…. It is therefore necessary for Canadians themselves to be concerned with the gravity of environmental and behavioural risks before any real progress can be made." Our nation's mental (i.e., behavioral) health care providers of all disciplines must come to appreciate that what our visionary colleagues to the North are calling for is, in essence, our training and clinical expertise. We must now make sure that society appreciates the significant "value-add" of our perspective and expertise. Hope springs eternal and we were very pleased to learn from APA's Heather Kelly that the SPSSI Policy Workshop, which is being cosponsored by APA and a number of divisions, was "over-applied for by paying participants by a couple of hundred young graduate students and early career psychologists! And there is space for only 40… wow. There will be lots of young people there."
This June, I also was invited to attend the 3rd annual NUKA System of Care Conference sponsored by Southcentral Foundation (SCF) of Anchorage, Alaska. SCF is an Alaskan Native owned, nonprofit health care organization serving nearly 60,000 Alaska Native and American Indian people living in Anchorage, Matanuska-Susitna Valley, and 60 rural villages in the Anchorage Service Unit. It is built around the value of shared responsibility; ensuring systems are respectful and culturally appropriate and strive to achieve excellence in "customer-owner" satisfaction, connecting the Native Community with services that benefit everyone. By accepting clinical and financial responsibility from the Indian Health Service for serving its beneficiaries, SCF obtained the necessary flexibility to craft clinical services that would be most cost-effective. Their inpatient utilization rate has dramatically declined, while "owner" (i.e., patient) satisfaction and health status indicator measures impressively improved. SCF has also been able to develop innovative training programs; their dental extender model (which was subject to litigation by the ADA) was included in the ACA and their Traditional Healing Clinic and Family Wellness Warriors initiatives wonderfully reflect the patient-centered holistic ideals of President Obama's vision. The underlying NUKA system is both a capitated system (i.e., bundled reimbursement), as well as possessing the ability to obtain fee-for-service reimbursement. Their experience has been that to truly provide quality care, they cannot let short term financial rewards override long term wellness initiatives which ultimately contain costs. One concrete example which is particularly relevant to the Alaskan Native and Native Hawaiian populations: A provider can be reimbursed for providing a child with an audiology evaluation and referral; however, if there are no speech therapists available, what has really been accomplished?
At the conference there were health leaders from around the country (including several from other nations), and an impressive presence from the VA. Don Berwick, former Acting Administrator of the Centers for Medicare and Medicaid Services (CMS), was the keynote speaker. He presented a vision of how dramatically our nation's health care system was changing. Unprecedented change is clearly inevitable and, as Katherine keeps emphasizing, will be unsettling, if not downright painful for many. One of his most memorable slides graphically depicted how an extraordinary weather event had destroyed almost all of the bridges in a small rural nation, except one built by the U.S. government. Very impressive. However, the river had significantly modified its course, so it no longer was flowing under the still standing bridge. Over and over the underlying message presented was that for acute health care needs (such as immediately following an automobile accident), we have the best health care system in the world. However, for the 80+% of health care needs, it is the patient (in SCF's case, the "owner") who really determines the course of care. Accordingly, the relationship between patients and providers is critical to ensuring quality health care. Providers have to be willing to give up their historical "hero" roles and become educators/coaches if they want to be effective. They have to learn to listen to the patient's journey and accept them where they are. Systems have to continuously seek and respond to owner feedback. For most health care providers and training institutions this is a fundamentally new perspective. The senior leadership from the VA clearly listened. We shall see if they can ultimately make a real difference for our nation's veterans who really do "own" the VA. SCF received the well-deserved 2011 Malcolm Baldrige National Quality Award for performance excellence; an honor which was established by the Congress in 1987 in memory of the late Department of Commerce Secretary as the highest level of national recognition for performance excellence.
What's Past May Well Be Prologue: During the late 1970s, following up on impressive testimony by former APA President Nick Cummings and Joan Willens, the Senate Finance Committee seriously explored including psychology under the "physician" definition of Medicare and developing a process by which those mental health services which would eventually met the Food and Drug Administration standard (i.e., were safe, effective, and appropriate) would be fully reimbursed. Recently, APS's Alan Kraut, along with Steve Breckler and Lynn Bufka of APA, participated in discussions chaired by the leadership of the NIMH regarding the possibility of an Institute of Medicine (IOM) study on the now apparently timely topic of psychotherapy standards, efficacy, effectiveness, etc. The ACA calls for health care delivery system reforms and innovations that rely heavily upon incorporating health (including behavioral and mental health) services within budgeted (i.e., "closed") systems such as Accountable Care Organizations and Medical Homes, as well as utilizing electronic health records (EHRs) which ultimately will allow cross-population and cross-provider comparisons. At the same time, mental health parity is expected to be provided. Reflections of the current thinking by senior health policy experts:
Without traditional fee-for-service transactions to keep track of utilization and access, these newly developing systems of care will rely on performance measurement to monitor how patients are treated and require objective outcome successes (such as lowered blood pressure readings, successful diabetes management, etc.). Accountability will increasingly take the form of linking performance measures to economic rewards such as shared savings. Behavioral health performance related to pharmacological management of patients is simpler and better developed than is the measurement of psychosocial treatments. As a result, treatment has increasingly shifted away from psychosocial care possibly to the detriment of patient well-being. Unfortunately, the mental health field has lagged behind in the development of measures to allow one to track whether the content of provided psychosocial treatment is consistent with evidence-based treatment and what clinical science has shown to work. It is critical therefore to develop better ways to promote effective psychosocial therapies to counter the pressures to limit access to these types of care and to develop better ways to monitor the quality of care being provided through psychosocial services.
The process by which psychosocial therapies are currently validated and coverage determinations are made is highly variable based largely on policies developed by payers, including private insurers, and public payers such as CMS, the VA, state Medicaid programs, etc. In addition, there are a wide range of disciplines and levels of training that claim to provide effective psychosocial treatments. Variation exists in the levels of scientific evidence used to make coverage determinations, the types of studies and outcome measures used, and the evidence needed to determine the necessary dose and duration of treatments under differing conditions. Further, there are no standards in place to ensure treatment fidelity based, for example, on providers' training or performance metrics for providers. How does one know what actually transpired during therapy? As a result, it is difficult for consumers and payers to understand what they are buying. This uncertainty reasonably creates skepticism regarding the value of the average psychosocial service. By default, this reinforces a traditional "medical model" of care which many non-physician providers feel is simply inappropriate. This inherent skepticism is likely to be especially present within the newly proposed ACA organizations that must manage care under a finite budget.
The Mental Health Parity and Addiction Equity Act was intended to address special limits on access to behavioral health care services. However, without accepted and endorsed quality standards for psychosocial care, emerging health care systems may be highly reluctant to promote appropriate use of these treatments. To facilitate a balanced approach to care that is consistent with the mental health parity directive and to track its effect on access to care and appropriate utilization of services, the quality standards developed must feed into existing accountability arrangements, including the quasi-public entities that have already demonstrated leadership on endorsing, reporting, and maintaining performance measures (for example, the National Quality Forum, the National Committee for Quality Assurance, etc.).
The IOM has an impressive record of addressing complex health policy issues such as this in an open, transparent, and interdisciplinary manner. The leadership of the NIMH similarly has an outstanding history of looking to the future. Addressing the controversy surrounding the publication of the new DSM V, the NIMH Director and the President-Elect of the American Psychiatric Association jointly stated: "What may be realistically feasible today for practitioners is no longer sufficient for researchers. Looking forward, laying the groundwork for a future diagnostic system that more directly reflects modern brain science will require openness to rethinking traditional categories…. This is the focus of the NIMH's Research Domain Criteria (RDoC) project. RDoC is an attempt to create a new kind of taxonomy for mental disorders by bringing the power of modern research approaches in genetics, neuroscience, and behavioral science to the problem of mental illness." The contemplated IOM study could represent a very important step in this process -- perhaps as was envisioned in the late 1970s. The 21st century will be an era of provider accountability. Aloha,
Pat DeLeon, former APA President – Division18 – July, 2013
