As Steve Ragusea recently pointed out when agreeing to reinvigorate the Florida Psychological Association (FPA) prescriptive authority initiative (RxP), it has been quite a while since one of our state psychological associations successfully enacted RxP legislation. Over the past decade a number of states have made considerable progress with both Hawaii and Oregon getting as far as having their bill ultimately vetoed by their Governor. This year Illinois and New Jersey have made considerable progress, each having passed one of the Houses of their respective legislatures, and with both of their efforts remaining alive in their two year legislative cycles. Patience, persistence, and personal presence will always be the key to ultimate success. Collectively, how do we encourage our colleagues to keep inching forward at the state level until the next generation of psychologists believes that their profession has "always prescribed," as it has clearly been in the best interests of its patients? Merely writing e-mails to each other simply does not work.
Prescribing colleagues in the Department of Defense (DoD) and the U.S. Public Health Service (particularly, the Indian Health Service) have clearly demonstrated that psychologists can learn this clinical skill and can apply it admirably. And, it would be quite helpful in convincing those in administrative and policy positions to expand these important initiatives if our research colleagues would take a closer look at what has been accomplished, including the extent to which behavioral approaches might have been superior to utilizing medication. For example, research in psychotherapeutic techniques has repeatedly shown Panic Attacks can be successfully treated in less than 10 sessions. If prescribing psychologists are eliminating the long term costs of anxiolytics and antidepressants by using cognitive behavioral therapy, the monetary savings and reduction in human suffering would be demonstrably substantial. Bob McGrath, head of the Fairleigh Dickinson psychopharmacology training program, estimates that there are currently 1750 psychologists who have completed their advanced RxP training and with 60 percent of psychotropic medications currently being ordered by primary care providers, there is a pressing societal need. Incidentally, Bob was just voted Psychologist of the Year by his New Jersey colleagues – a well-deserved honor.
The Department of Veterans Affairs (VA) is the largest employer of psychologists and Advance Practice Nurses (APNs). Obtaining RxP authority within the VA would be a major breakthrough for psychology. The VA serves approximately 49.3 million beneficiaries, constituting 15.5 percent of the nation. It operates the largest Federal health care delivery system in the country, with 152 hospitals, 107 domiciliary residential rehabilitation treatment programs, 133 nursing homes, 300 Vet Centers, and 821 outpatient clinics. It is estimated that 6.5 million patients will be treated in the coming year. The VA has proposed utilizing its federal supremacy authority to establish a system-wide, national nurse practice standard which would allow these practitioners to function to the fullest extent of their training, pursuant to recommendations by the Institute of Medicine (IOM). Under the leadership of Cathy Rick, then-Chief Nursing Services Officer, the new VHA [Veterans Health Administration] Nursing Handbook, provides APNs with the authority for independent practice, regardless of individual state licensure limitations, unless an individual VA facility limits their scope within that facility. This visionary document has been "cleared" by the relevant legal authorities who will be reminding hesitant states about the federal government's supremacy powers within federal facilities. Two underlying values enumerated are that the patient owns and drives their care based on the information available and that nursing interventions are based on the best available evidence and accepted standards of practice.
Specifically the handbook proposes: "Clinical nursing practice varies widely among the States. To ensure safe and appropriate health care to the nation's Veterans, VA has standardized the elements of practice, within VA, for clinical nursing practice other than the prescribing of controlled substances, without regard to individual State Practice Acts. This ensures a consistent standard of nursing care throughout VA's national health care system…. Under the Federal Controlled Substances Act… a health care practitioner may prescribe controlled substances only if the practitioner's State license authorizes such prescribing. Accordingly, APRNs, including NPs, may prescribe controlled substances within VA only if they are authorized to do so by their State of licensure or registration and comply with the limitations and restrictions on that prescribing authority. Where VA establishes elements of nursing practice that are more expansive or otherwise inconsistent with State practice standards, VA's practice standards control. VA nurses must follow the VA nursing practice standards established in VA rules, regulations, and policies."
Not surprisingly, medicine (the President-elect of the American Society of Anesthesiologists, who herself possesses a nursing degree and was trained as a nurse anesthetist), has expressed objections, based upon the commonly used "public health hazard" argument. She said of the proposed policy: "This document effectively eliminates the gold standard, physician-led, team-based coordinated care in anesthesiology. The VHA intends this to be the policy for all its hospitals, superseding state law, where currently more than half of states require physician supervision of nurse anesthetists…. (L)ocal chiefs of anesthesiology will no longer have the authority to set policies they deem best for the patients they serve." The proposal policies "raise significant safety concerns in our sickest population." "The length and depth of training are dramatically different. As physician anesthesiologists we trained for 12 to 14 years rather than 5 to 7. Nursing education and training did not prepare me for the level of care needed in the perioperative environment when seconds matter." Despite her statement, all of the objective evidence that we have seen over the years indicates that nurse anesthetists are extraordinarily safe, including a recent review of approximately 500,000 cases. In rural America their services are crucial as they are the primary provider of anesthesia.
We were very pleased to learn that Heather Kelly, who for the past 15 years has addressed legislative and administrative issues for the Science Directorate regarding the importance of psychological research at the VA, NSF, and DoD, has now become the APA point person on their team effort on all military and veteran-related issues, including the clinical portfolio. Obtaining RxP for interested VA employees will become one of her agendas. Accordingly, the research that Steve Ragusea has proposed would indeed be most timely, as well as extraordinarily useful to Heather, in countering medicine's ongoing emotional "public health hazard" arguments against the expansion of non-physician scopes of practice and particularly, against RxP. And, we should remember that obtaining RxP provides clinicians with the authority to modify or stop ineffective medication decisions. Fred Frese, a longtime advocate for individuals challenged by chronic mental health issues, reports on a 7-year follow-up study published in JAMA-Psychiatry finding that individuals with schizophrenia who are on reduced or no doses of anti-psychotic medications do better than those on medications. Other research Fred has highlighted suggests that those on antipsychotic medications live 15 to 25 years less than would be normally expected.
The Alliance for Health Reform: One of the most enjoyable aspects of having retired from the U.S. Senate staff after 38+ years is that I have the time (and willing friends) to host a psychology-nursing health policy seminar at the Uniformed Services University of the Health Sciences (USUHS) (DoD). Each week we invite a colleague who is, or has been, active within the public policy process to discuss their personal journey. Recently Toni Zeiss addressed the class (generally 7 to 10 students and faculty) about her experience serving as the first woman and first non-physician to be appointed as Chief Consultant for Mental Health Services at the VA Central Office. At our annual APA convention in Honolulu, President Don Bersoff presented her with a special Lifetime Achievement Award. A previous guest was twice former VA Secretary Tony Principi.
Ed Howard, another speaker, and I used to work together when he was on the staff of then-Representative Spark Matsunaga, who was elected to the U.S. Senate in 1977. Ed is currently the Executive Vice President of the bipartisan Alliance for Health Reform, which is chaired by Senators Jay Rockefeller and Roy Blunt. Ed suggested that our nation's health policy experts might finally be appreciating the importance of mental health care to our nation's overall health care system and our citizens' quality of life. Interestingly, Ken Pope has shared a similar view noting that in 2009, public and private mental health spending totaled approximately $150 billion, more than double its level in inflation-adjusted terms in 1986. The Accountable Care Act (ACA) will provide the largest expansion of mental health and substance use disorder coverage in a generation, with 32.1 million Americans gaining access to these services, while another 30.4 million currently with some coverage will gain federal parity protection.
Highlights of the information which Ed presented: *An estimated 26.2 percent of Americans ages 18 and older – about one in four adults – suffer from a diagnosable mental disorder in a given year. * In 2008, just over half (58.7 percent) of adults in the U.S. with a serious mental illness received treatment for a mental health problem. * Approximately 38,000 people committed suicide in 2010. * Over 8.9 million individuals have co-occurring mental illness and substance use disorders. Only 7.4 percent of these individuals receive treatment for both disorders, while 55.8 percent receive no treatment at all. Minorities with mental health disorders have less contact with specialists. More than half of disabled Medicaid enrollees with psychiatric conditions also had claims for diabetes, cardiovascular disease, or pulmonary disease. People with mental illnesses and addiction disorders are at much greater risk than the general public for homelessness, poverty, poor nutrition, and lack of health care.
The All Important "Bigger Picture": Community Health -- David Derauf, Executive Director of the Kokua Kalihi Valley (KKV) Community Health Center in Honolulu, Hawaii, recently shared with us the cogent observations of one of his medical colleagues: "A few months ago, I was sitting across from Dr. Robert Jesse, Principal Deputy Under Secretary for Health in the VA, in a meeting when he asked a provocative question, 'Why is it when we talk about personalized medicine, we only talk about genetics? Why wouldn't we talk about a patient's social circumstances and how we can 'personalize' medical care for them?' He is totally right. In this country, 50 million people are hungry, while 26 million have heart disease and 26 million have diabetes. Those numbers cannot be mutually exclusive. Many people with heart disease and diabetes must be hungry at some point each month, which has been shown to result in worse health and higher rates of health care utilization.
"Yet despite this knowledge, we do not typically 'personalize' healthcare to ask patients a simple two-question scale validated by Children's HealthWatch to detect food insecurity, even when we know they are at a higher risk based on their zip code and where they receive their health care. Think for a second about the inefficiency of a doctor asking a woman to come back to the hospital each month to check her blood pressure when that woman regularly skips meals, worries about paying bills and potentially cuts her pills in half since she can't afford them? Before we progress to expensive genetic testing to see if a patient processes drugs differently, wouldn't it be more 'personalized' and more effective to screen for a common modifiable factor like hunger, and then make sure eligible patients are getting all the food subsidy programs for which they are eligible?
"In many ways the VHA, the Nation's largest integrated health care system, already 'personalizes' its care in important ways. It pays for Supportive Services for Veteran Families (SSVF), including help with job training and childcare, and it has begun to bring legal services onsite at VA facilities as part of medical-legal partnerships [such as with the University of Hawaii William S. Richardson School of Law] to address many civil legal needs that interfere with getting and staying healthy. I look forward to a future when 'personalized medicine' means less high tech care, and more 'patient centered' inter-professional teams addressing the full spectrum of social determinants of health."
A "Retiree's" Journey – "A long time ago, ten years ago, I retired from the VA. And time and technology are passing by me so quickly. I can see it in my grandchildren, now starting college, who know so much more and can access so many things so quickly – compared to what I was like when I was graduating from high school. I was typing only 40 words a minute by the time I left high school, compared to two of my grandchildren, one still in high school, who repair computers and design software and create computer systems for their prep-schools. I stand in complete awe, as I work with Student Veterans, returning home from war, now enrolling in college. How outstanding they were in combat and now how outstanding they are in college. Like, what's happening now, as I consult with the Office of the Dean of Students at the University of Texas at Austin, in the Student Veterans Center. I see first-hand the mastery of so many skills, so that Student Veterans are achieving so much…. Reminds me of my days as a teenager, attending a residential prep-school, adjacent to the UT Austin campus, 1947-1953. I was awed by World War II combat veterans enrolling in college, worked with them as we nailed up signs for Lyndon Baines Johnson (LBJ) running for the U.S. Senate in the Democratic primaries of 1948. World War II Student Veterans were awesome then, as OIF/OEF/OND Student Veterans are so now! Plus, older veterans – Korean and Vietnam era – are retiring and returning to school! There is so much more we must do to help veterans return to school.
"Sad, now, that political leadership has changed so much in Texas. LBJ filled his politics with Pro-Life for living, improving education, enhancing health, helping businesses change from war to peace…. Nowadays, though, current Texas politicians are practicing Pro-Death. Refusing federal dollars for healthcare already paid for by Texas tax-payers; refusing federal dollars for Education already paid for by Texas tax-payers, etc., etc. It's Pro-Death in Texas and Pro-Life in Massachusetts… and all you have to do is compare the life expectancies in the State of Texas with that of the Commonwealth of Massachusetts. Citizens are living much longer in Pro-Life Massachusetts than in Pro-Death Texas. Similarly, it's not just life expectancies being shorter in Texas, it's also Infant Mortality is higher in Texas. And, it's not only due to lack of healthcare in Texas… some portion of the higher death rate may be associated with greater use and excellent aims in using firearms and weapons here in Texas. Sad. But we can not focus on what is Wrong. We must aspire to doing what is Right… [Walter Penk]."
A Personal Perspective – It is important for psychology remember its history as we focus on future agendas. The Center for the History of Psychology, located at the University of Akron in Akron, Ohio, is a unique institution that cares for, provides access to, and interprets the historical record of psychology and related human sciences. Under the leadership of David Baker, the Center houses a museum of psychology as well as the Archives of the History of American Psychology and provides a variety of educational programs for the public. The Center houses and makes available the personal papers of more than 200 psychologists. The collections include personal and professional correspondence, sound recording and moving images, artifacts, photographs, unpublished papers and presentations, and other kinds of material that tell the story of psychology. The Center, a 501(c) 3 organization, is supported primarily through gifts from visitors, foundations, and other donors. The gifts provide support for processing collections, creating exhibits, and providing public programming. Individuals interested in donating materials should contact Cathy Fay [cfaye@uakron.edu]. Aloha,
Pat DeLeon, former APA President – Division 55 – September, 2013
